High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review

Methodology and development of a machine learning probability calculator: Data heterogeneity limits ability to predict recurrence after arthroscopic Bankart repair

PURPOSE

The aim of this study was to develop and train a machine learning (ML) algorithm to create a clinical decision support tool (i.e., ML-driven probability calculator) to be used in clinical practice to estimate recurrence rates following an arthroscopic Bankart repair (ABR).

METHODS

Data from 14 previously published studies were collected. Inclusion criteria were (1) patients treated with ABR without remplissage for traumatic anterior shoulder instability and (2) a minimum of 2 years follow-up. Risk factors associated with recurrence were identified using bivariate logistic regression analysis. Subsequently, four ML algorithms were developed and internally validated. The predictive performance was assessed using discrimination, calibration and the Brier score.

RESULTS

In total, 5591 patients underwent ABR with a recurrence rate of 15.4% (n = 862). Age <35 years, participation in contact and collision sports, bony Bankart lesions and full-thickness rotator cuff tears increased the risk of recurrence (all p < 0.05). A single shoulder dislocation (compared to multiple dislocations) lowered the risk of recurrence (p < 0.05). Due to the unavailability of certain variables in some patients, a portion of the patient data had to be excluded before pooling the data set to create the algorithm. A total of 797 patients were included providing information on risk factors associated with recurrence. The discrimination (area under the receiver operating curve) ranged between 0.54 and 0.57 for prediction of recurrence.

CONCLUSION

ML was not able to predict the recurrence following ABR with the current available predictors. Despite a global coordinated effort, the heterogeneity of clinical data limited the predictive capabilities of the algorithm, emphasizing the need for standardized data collection methods in future studies.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Results After Arthroscopic Bankart Repair in Contact Athletes Should Not Be Reported Globally Because of the High Variability in Recurrences Among the Different Contact or Collision Sports: A Systematic Review

PURPOSE

To describe and compare the recurrence rates in contact or collision (CC) sports after arthroscopic Bankart repair (ABR) and to compare the recurrence rates in CC versus non-collision athletes after ABR.

METHODS

We followed a prespecified protocol registered with PROSPERO (registration No. CRD42022299853). In January 2022, a literature search was performed using the electronic databases MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials), as well as clinical trials records. Clinical studies (Level I-IV evidence) that evaluated recurrence after ABR in CC athletes with a minimum follow-up period of 2 years postoperatively were included. We assessed the quality of the studies using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, and we described the range of effects using synthesis without meta-analysis and described the certainty of the evidence using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations).

RESULTS

We identified 35 studies, which included 2,591 athletes. The studies had heterogeneous definitions of recurrence and classifications of sports. The recurrence rates after ABR varied significantly among studies between 3% and 51% (I2 = 84.9%, 35 studies and 2,591 participants). The range was at the higher end for participants younger than 20 years (range, 11%-51%; I2 = 81.7%) compared with older participants (range, 3%-30%; I2 = 54.7%). The recurrence rates also varied by recurrence definition (I2 = 83.3%) and within and across categories of CC sports (I2 = 83.8%). CC athletes had higher recurrence rates than did non-collision athletes (7%-29% vs 0%-14%; I2 = 29.2%; 12 studies with 612 participants). Overall, the risk of bias of all the included studies was determined to be moderate. The certainty of the evidence was low owing to study design (Level III-IV evidence), study limitations, and inconsistency.

CONCLUSIONS

There was high variability in the recurrence rates reported after ABR according to the different types of CC sports, ranging from 3% to 51%. Moreover, variations in recurrence among CC sports were observed, with ice hockey players being in the upper range but field hockey players being in the lower range. Finally, CC athletes showed higher recurrence rates when compared with non-collision athletes.

LEVEL OF EVIDENCE

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

Surgical Intervention Following a First Traumatic Anterior Shoulder Dislocation Is Worthy of Consideration

Up to 60% of patients experience recurrence after a first traumatic anterior shoulder dislocation (FTASD), which is often defined as having experienced either dislocation or subluxation. Thus surgical intervention after FTASD is worthy of consideration and is guided by the number of patients who need to receive surgical intervention to prevent 1 redislocation (i.e., number needed to treat), (subjective) health benefit, complication risk, and costs. Operative intervention through arthroscopic stabilization can be successful in reducing recurrence risk in FTASD, as has been shown in multiple randomized controlled trials. Nevertheless, there is a large "gray area" for the indication of arthroscopic stabilization, and it is therefore heavily debated which patients should receive operative treatment. Previous trials showed widely varying redislocation rates in both the intervention and control group, meta-analysis shows 2% to 19% after operative and 20% to 75% after nonoperative treatment, and redislocation rates may not correlate with patient-reported outcomes. The literature is quite heterogeneous, and a major confounder is time to follow-up. Furthermore, there is insufficient standardization of reporting of outcomes and no consensus on definition of risk factors. As a result, surgery is a reasonable intervention for FTASD patients, but in which patients it best prevents redislocation requires additional refinement.

High variability in what is considered important to report following instability surgery: a Delphi study among Dutch shoulder specialists

Background

Standardized reporting leads to high-quality data and can reduce administration time. The aim of this study was to (1) get an insight into the variability of what is considered important to report in the surgical report following shoulder instability surgery and (2) determine which elements should be included in the surgical report following shoulder instability surgery according to Dutch surgeons using a Delphi method.

Methods

Dutch orthopedic shoulder surgeons were included in a panel for a Delphi study consisting of 3 rounds. Importance of the elements was rated on a 9-point Likert scale. High variability was defined as an element that received at least 1 score between 1 and 3 and 1 score between 7 and 9 in round 3. Consensus was defined as ≥80% of the panel giving a score of 7 or more.

Results

Seventeen shoulder specialists completed all 3 rounds and identified a total of 82 elements for the arthroscopic Bankart repair and 60 for the open Latarjet. High variability was observed in 57 (70%) and 52 (87%) of the elements, respectively. After round 3, the panel reached consensus on 27 and 11 elements that should be mentioned in the surgical report following arthroscopic Bankart repair and open Latarjet.

Conclusion

There is high variability in what shoulder specialists regard essential to report. Consensus was reached on 27 and 11 elements to be reported following arthroscopic Bankart repair and open Latarjet, respectively. Future studies on an international scale can further improve data collection and communication between specialists.

A modified Delphi study to identify which items should be evaluated in shoulder instability research: a first step in developing a core outcome set

Background

The aim of this study was to identify items that healthcare providers and/or patients consider important to include in a questionnaire for clinical trials and cohort studies in shoulder instability research. This could serve as a basis to develop a core outcome set for shoulder instability research.

Methods

Healthcare providers and patients were included in a panel for a modified Delphi consensus study. The study consisted of three rounds, comprising (1) identifying items, (2) rating the importance of the items, and (3) rating the importance again after seeing a summary of the results of round two. Importance was rated on a 9-point Likert scale. Consensus was defined as ≥ 80% of the panel giving a score of 7 or higher.

Results

In total, 44 healthcare providers and 30 patients completed all three rounds. Round one identified 54 items. After round three, the panel reached a consensus on 11 items that should be included in a questionnaire, comprising re-dislocation (99%), instable feeling of the shoulder (96%), limitations during sport (93%), patient satisfaction with the shoulder (93%), fear/anxiety for re-dislocation (91%), range of motion (88%), return to old level of functioning (85%), performing daily activities (85%), return to sport (82%), return to work (82%), and trusting the shoulder (81%).

Conclusion

Healthcare providers and patients reached a consensus on 11 items that should be included in a questionnaire for shoulder instability research. These items can facilitate design and development of future clinical trials and form the basis for the development of a core outcome set.

Patient perceptions after the operative and nonoperative treatment of shoulder instability: A qualitative focus group study

Background

Little evidence is available regarding patient perceptions of the treatment of shoulder instability. The aim of this study is to investigate patient perceptions regarding the operative and nonoperative treatment of anterior shoulder instability.

Methods

Patients who presented to the emergency department or outpatient clinic between 2016 and 2020 were retrospectively selected using diagnosis and procedure codes. Online focus groups and semistructured interviews were conducted, systematically recorded and subsequently transcribed to MaxQDA 2007 for qualitative analysis. Coded transcripts of all focus groups were subjected to a grounded theory-based analysis.

Results

Six focus groups and two semistructured interviews were hosted with 35 included patients. The mean age of included patients was 34.1 years (±11.5). Eight patients were female (23%), and 27 patients were male (77%). Fear of (recurrent) dislocation, preoperative counseling, communication between surgeon and physiotherapists and need for a consistent postoperative rehab protocol turned out to be important patient perceptions. The most crucial factor for discontent was a lack of communication from the surgeon.

Discussion

This patient-centered focus group study revealed that fear of (recurrent) dislocation, preoperative counseling, communication between surgeons and physiotherapists and the need for a consistent postoperative rehabilitation protocol was the most frequently discussed themes.

"Nearly off-track lesions" or a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track does not seem to be accurate in predicting recurrence after an arthroscopic Bankart repair in a military population: a case-control study

BACKGROUND

On-track lesions with a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track (nearly off-track) may predispose recurrence after arthroscopic Bankart repair (ABR) in the general population. The aim of this study was to determine if a shorter distance between the medial edge of the Hill-Sachs lesion and the medial edge of the glenoid track could accurately predict recurrence after an ABR in a high-demand military population. It was hypothesized that a shorter distance would not accurately predict recurrence.

MATERIALS AND METHODS

A retrospective monocenter case-control study was performed at the Dutch Central Military Hospital. Patients with an on-track Hill-Sachs lesion who underwent a primary ABR between 2014 and 2019 with a minimal follow-up of 2 years and a preoperative magnetic resonance imaging (MRI) assessment received a questionnaire. The primary outcome was recurrence, defined as a complete dislocation or subluxation. Glenoid bone loss was assessed using a linear-based method on MRI. The distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track was defined as the distance to dislocation (DTD). A receiver operating characteristic curve was created to determine the predictive value of the DTD for recurrence. Logistic regression was used to determine preoperative risk factors that predispose recurrence. Covariates were selected based on univariable analysis and included gender, body mass index, age at surgery and first dislocation, laterality, smoking habits, overhead shoulder activity during work, preoperative dislocations, sports type and level, bony or labral lesions on MRI, and DTD.

RESULTS

In total, 80 patients with an average follow-up of 4.8 ± 1.9 years completed the questionnaire and were included in the analyses. Seventeen patients (21%) experienced recurrence at the final follow-up. No difference in DTD was observed among patients who experienced recurrence (9 ± 4 mm) compared with patients who did not (9 ± 5 mm; P = .81). The receiver operating characteristic curve demonstrated no predictive power of DTD for recurrence (area under the curve = 0.49). Smoking at the time of surgery (odds ratio: 3.9; confidence interval: 1.2-12.7; P = .02) and overhead shoulder movement during work (odds ratio: 9.3; confidence interval: 1.1-78.0; P = .04) were associated with recurrence according to the logistic regression analysis.

CONCLUSION

A shorter DTD demonstrated no accuracy in predicting recurrence in a military population. Smoking at the time of surgery and overhead shoulder activity during work were associated with recurrence; however, these analyses were underpowered to draw valid conclusions.

Development and training of a machine learning algorithm to identify patients at risk for recurrence following an arthroscopic Bankart repair (CLEARER): protocol for a retrospective, multicentre, cohort study

INTRODUCTION

Shoulder instability is a common injury, with a reported incidence of 23.9 per 100 000 person-years. There is still an ongoing debate on the most effective treatment strategy. Non-operative treatment has recurrence rates of up to 60%, whereas operative treatments such as the Bankart repair and bone block procedures show lower recurrence rates (16% and 2%, respectively) but higher complication rates (<2% and up to 30%, respectively). Methods to determine risk of recurrence have been developed; however, patient-specific decision-making tools are still lacking. Artificial intelligence and machine learning algorithms use self-learning complex models that can be used to make patient-specific decision-making tools. The aim of the current study is to develop and train a machine learning algorithm to create a prediction model to be used in clinical practice-as an online prediction tool-to estimate recurrence rates following a Bankart repair.

METHODS AND ANALYSIS

This is a multicentre retrospective cohort study. Patients with traumatic anterior shoulder dislocations that were treated with an arthroscopic Bankart repair without remplissage will be included. This study includes two parts. Part 1, collecting all potential factors influencing the recurrence rate following an arthroscopic Bankart repair in patients using multicentre data, aiming to include data from >1000 patients worldwide. Part 2, the multicentre data will be re-evaluated (and where applicable complemented) using machine learning algorithms to predict outcomes. Recurrence will be the primary outcome measure.

ETHICS AND DISSEMINATION

For safe multicentre data exchange and analysis, our Machine Learning Consortium adhered to the WHO regulation 'Policy on Use and Sharing of Data Collected by WHO in Member States Outside the Context of Public Health Emergencies'. The study results will be disseminated through publication in a peer-reviewed journal. No Institutional Review Board is required for this study.

Bony reconstruction after failed labral repair is associated with higher recurrence rates compared to primary bony reconstruction: a systematic review and meta-analysis of 1319 shoulders in studies with a minimum of 2-year follow-up

BACKGROUND

There is uncertainty with regard to the optimal revision procedure after failed labral repair for anterior shoulder instability. An overview of outcomes of these procedures with quantitative analysis is not available in literature. The aim of this review is (1) to compare recurrence rates after revision labral repair (RLR) and revision bony reconstruction (RBR), both following failed labral repair. In addition, (2) recurrence rates after RBR following failed labral repair and primary bony reconstruction (PBR) are compared to determine if a previous failed labral repair influences the outcomes of the bony reconstruction.

METHODS

Randomized controlled trials and cohort studies with a minimum follow-up of 2 years and reporting recurrence rates of (1) RBR following failed labral repair and PBR and/or (2) RLR following failed labral repair and RBR following failed labral repair were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics.

RESULTS

Thirteen studies met the inclusion criteria and comprised 1319 shoulders. Meta-analyses showed that RBR has a significantly higher recurrence rate than PBR (risk ratio [RR] 0.51, P < .008) but found no significant difference in the recurrence rates for RLR and RBR (RR 1.40, P < .49). Also, no significant differences were found between PBR and RBR in return to sport (RR 1.07, P < .41), revision surgery (RR 0.8, P < .44), and complications (RR 0.84, P < .53). Lastly, no significant differences between RLR and RBR for revision surgery (RR 3.33, P < .19) were found.

CONCLUSION

The findings of this meta-analyses show that (1) RBR does not demonstrate a significant difference in recurrence rates compared with RLR and that (2) RBR has a significantly higher recurrence rate than PBR.

Clinical Outcomes of Arthroscopic Bony Bankart Repair for Anterior Instability of the Shoulder: A Systematic Review

BACKGROUND

Individual studies reporting the clinical outcomes of arthroscopic bony Bankart repair for anterior shoulder instability have reported excellent results but have been limited by their small sample sizes. No systematic review of the literature has been performed examining the clinical outcomes of arthroscopic bony Bankart repair.

PURPOSE

To provide a systematic review of the literature to examine the functional outcomes, recurrence rate, and return to sports rate after arthroscopic bony Bankart repair for anterior instability of the shoulder.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted using the Cochrane Database of Systematic Reviews, Ovid/Embase, PubMed, and Web of Science. Studies that examined clinical outcomes after arthroscopic bony Bankart repair for anterior shoulder instability were included. Data pertaining to study characteristics and design, patient demographic characteristics, and clinical results, including functional outcomes, recurrence rate, and return to sports, were collected. The results from the studies were pooled, and weighted means and overall rates were calculated.

RESULTS

In total, 21 studies with 769 patients were included for analysis. Most patients were male (91.7%), the mean age was 26.7 years (range, 12-71 years), and the mean follow-up was 42.7 months (range, 6-120 months). The most commonly reported functional outcome score was the Rowe score (12 studies), which improved on average from 41.9 preoperatively to 90.8 postoperatively. The rate of recurrent instability was reported by all 21 studies, and the overall recurrence rate was 11.9% (88/738). Return to sports after arthroscopic bony Bankart repair was reported by 11 studies, with a pooled return to sports rate of 91.0% (264/290).

CONCLUSION

Arthroscopic bony Bankart repair for anterior shoulder instability resulted in improvements in functional outcomes, a low rate of recurrent instability, and a high rate of return to sports. Although these findings are extremely promising, future prospective studies with larger sample sizes are needed to further evaluate the clinical outcomes of arthroscopic bony Bankart repair.