The supine apprehension test helps predict the risk of recurrent instability after a first-time anterior shoulder dislocation

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

Background

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

Methods

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

Results

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

Conclusion

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

Developing a Rehabilitation Guideline (REGUIDE) for Patients Undergoing an Arthroscopic Bankart Repair After Traumatic Anterior Shoulder Dislocation, Focusing on Managing Apprehension: An International Delphi-Based Consensus Study

OBJECTIVE: We aimed to develop a consensus-based rehabilitation guideline specifically designed to reduce apprehension following arthroscopic Bankart repair after traumatic anterior shoulder dislocation. DESIGN: Delphi-based consensus. METHOD: A comprehensive list of interventions for potential inclusion in a postoperative rehabilitation guideline was developed. American and European physiotherapists and orthopedic surgeons were invited to participate in a Delphi panel, engaging in 3 survey rounds. The health professionals were surveyed about their level of agreement on both initially listed and newly suggested interventions. Consensus was established when a "critical-to-include" rating was given in ≥70% of all responses. Ten former patients were consulted to identify the intervention during standard care rehabilitation that had the most impact on reducing postoperative apprehension following ABR. Any interventions not initially listed in the first round were added to the second survey round of the Delphi process. RESULTS: Forty-four health professionals reached consensus on a set of 27 interventions for managing apprehension after arthroscopic Bankart repair. New interventions included gradual exposure to shoulder positions eliciting apprehension, training in anterior stability-provoking positions, and education addressing the impact of psychosocial factors. Former patients identified specific interventions that were effective in reducing postoperative apprehension following ABR. These interventions encompassed medicine ball throws, active-assisted wall slides, and kinetic chain exercises in anterior stability-provoking positions. CONCLUSION: Our Delphi process informed expert recommendations for various interventions aimed at addressing apprehension associated with ABR. The recommendations were the foundation for developing a rehabilitation guideline (REGUIDE). The REGUIDE integrates principles from cognitive-behavioral therapy to improve rehabilitation and mitigate apprehension. J Orthop Sports Phys Ther 2024;54(5):1-13. Epub 20 March 2024. doi:10.2519/jospt.2024.12106.

At long-term follow-up many first-time male traumatic shoulder dislocators remain symptomatic

OBJECTIVES

To assess the status at 13 to 17 years follow-up of a cohort of young male traumatic shoulder dislocators.

STUDY DESIGN

Prospective cohort study.

METHODS

A prospective study of first-time young male traumatic shoulder dislocators, began in 2004. Subjects were evaluated by the apprehension test after completing rehabilitation 6 to 9 weeks post dislocation. Between March 2021 and July 2022, a telephone questionnaire was administered to ascertain their current shoulder status. Subjects were questioned about avoidance of activities of daily living and sport, participation in sports, current instability, and self-assessed shoulder function by the SANE score.

RESULTS

50/53 (94.3%) of the study subjects, mean age 20.4 years, completed a mean follow-up of 181.8 ± 12 months. The non-redislocation survival was 13% for those with a positive apprehension test and 49% for those with a negative test (p = 0.007). SANE scores were 64.3 ± 23.7 for those with a positive apprehension test and 83.7 ± 19.7 for those with a negative test (p = 0.001). In the year before the follow-up, 33.3% of those treated conservatively and 42.9% treated surgically experienced subluxation (p = 0.5). Fifty-seven percent of those who were treated conservatively and 56% of those who underwent surgery avoided some ADL or sports because of their shoulder.

CONCLUSIONS

For young male first time traumatic shoulder dislocators a positive apprehension test after rehabilitation is associated with a high risk for reoccurrence and poorer long-term results. Most subjects were still dealing with shoulder symptoms at long-term follow-up.

Operative Versus Nonoperative Treatment Following First-Time Anterior Shoulder Dislocation

BACKGROUND

There is an ongoing debate about whether to perform operative or nonoperative treatment following a first-time anterior dislocation or wait for recurrence before operating. The aim of this systematic review is to compare recurrence rates following operative treatment following first-time anterior dislocation (OTFD) with recurrence rates following (1) nonoperative treatment (NTFD) or (2) operative treatment after recurrent anterior dislocation (OTRD).

METHODS

A literature search was conducted by searching PubMed (Legacy), Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics from 1990 to April 15, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The revised tool to assess risk of bias in randomized trials (RoB 2) developed by Cochrane was used to determine bias in randomized controlled trials, and the methodological index for non-randomized studies (MINORS) was used to determine the methodological quality of non-randomized studies. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach using GRADEpro software.

RESULTS

Of the 4,096 studies for which the titles were screened, 9 comparing OTFD and NTFD in a total of 533 patients and 6 comparing OTFD and OTRD in a total of 961 patients were included. There is high-quality evidence that OTFD is associated with a lower rate of recurrence (10%) at >10 years of follow-up compared with NTFD (55%) (p < 0.0001). There is very low-quality evidence that patients receiving OTFD had a lower recurrence rate (11%) compared with those receiving OTRD (17%) (p < 0.0001).

CONCLUSIONS

There is high-quality evidence showing a lower recurrence rate at >10 years following OTFD compared with NTFD (or sham surgery) in young patients. There is evidence that OTFD is more effective than OTRD, but that evidence is of very low quality.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Shoulder Pain and Disability Index: Italian cross-cultural validation in patients with non-specific shoulder pain

BACKGROUND

Health-related patient reported outcome measures are considered essential to determine the impact of disease on the life of individuals. Aim of this study is to culturally adapt the Italian version of the Shoulder Pain and Disability Index (SPADI). The secondary aim is to evaluate psychometric proprieties in patients with non-specific shoulder pain.

METHODS

The current study is an analysis of a sample of 59 adult patients with non-specific shoulder pain. The SPADI was translated and cross-culturally adapted, and then psychometric properties were tested. Participants completed the Shoulder Pain and Disability Index-Italian (SPADI-I), 36-item short form health survey, the Oxford Shoulder Score, the Disability of Arm, Shoulder, and Hand scale and a pain intensity visual analogue scale.

RESULTS

SPADI-I included two domains. Internal consistency analysis showed good values for total (α = 0.84) and subscales (α = 0.94 and α = 0.76). For construct validity, there was good correlation between the visual analogue scale, the Oxford Shoulder Score, the DASH and the SPADI-I total score and subscales. Standard error of measurement and minimally detectable change were calculated.

CONCLUSIONS

The SPADI-I was culturally adapted into Italian. SPADI-I is centred on pain and disability of the shoulder only and can be considered as a useful tool in daily clinical practice for assessing musculoskeletal non-specific shoulder pain because of its good internal consistency and validity. Further studies should focus on other psychometric proprieties such as test re-test reliability, responsiveness and clinical interpretability to improve the available clinimetrics of the tool.

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.

Predicting Recurrent Instability of the Shoulder (PRIS): A Valid Tool to Predict Which Patients Will Not Have Repeat Shoulder Instability After First-Time Traumatic Anterior Dislocation

OBJECTIVE

To assess the sensitivity, specificity, and validity of the Predicting Recurrent Instability of the Shoulder (PRIS) tool in people with a first-time traumatic anterior shoulder dislocation.

DESIGN

Prospective cohort study.

METHODS

People with first-time traumatic anterior shoulder dislocation (n = 85), aged 16 to 40 years, were recruited within 12 weeks of their shoulder dislocation and followed prospectively for 1 year post injury. We calculated the sensitivity, specificity, negative predictive value, and positive predictive value of the PRIS tool.

RESULTS

Of the 75 participants available for 1-year follow-up, 57 (76%) did not have recurrent shoulder instability. With the PRIS tool cut point set at 0.895, the tool's sensitivity was 39% (95% confidence interval [CI]: 17.3%, 64.3%) and its specificity was 95% (95% CI: 85.4%, 98.9%). The area under the curve was 0.69 (95% CI: 0.55, 0.84; P = .01). The PRIS tool correctly identified 54 of the 57 (95%) who did not have recurrent instability (accuracy, 81%; 95% CI: 70.7%, 89.4%). Negative and positive predictive values were 83% (95% CI: 77.2%, 87.7%) and 70% (95% CI: 40.2%, 89.0%), respectively.

CONCLUSION

The PRIS tool can predict those who will not have further shoulder instability in the year following first-time traumatic anterior shoulder dislocation. The PRIS tool cannot accurately predict those who will have recurrent shoulder instability. J Orthop Sports Phys Ther 2020;50(8):431-437. doi:10.2519/jospt.2020.9284.

Translational movement within the glenohumeral joint at different rotation velocities as seen by cine MRI

BACKGROUND

The glenohumeral joint is subjected to opposing forces when the direction of shoulder motion is changed, accelerating and decelerating to make the movements. The influence of motion velocity or acceleration on translation of the humeral head has not been evaluated although direction and distance of humeral head translation has been analyzed in real time in normal shoulders. We hypothesized that, in a normal shoulder, the humeral head does not deviate significantly or suddenly during active shoulder rotation regardless of motion velocity. The purpose of this study was to clarify normal intraarticular kinematics of humeral head position and translation during axial shoulder rotation with the arm by the side of the body at different rotational velocities using cine magnetic resonance imaging (MRI).

METHODS

Both shoulders of ten healthy adults (mean age group between 27.80 ± 6.05 years) were used in this study. Prior to MRI scan, dynamic glenohumeral stability was confirmed by physical examination. The glenohumeral joint was scanned during active shoulder rotation at three angular velocities (low, medium and high velocities), with the arm by the side of the body by real-time cine MRI while recording with the help of a video camera. Translation of the humeral head and rotation angles on MR imaging and video camera were measured to match shoulder rotational positions.

RESULTS

There were no statistical differences of the humeral head position and translation among three rotation velocities (p > 0.05). Translation of the humeral head was distributed from 1.44 ± 2.45 mm anteriorly to 0.65 ± 1.84 mm posteriorly at low velocity, from 0.74 ± 1.92 mm anteriorly to 0.75 ± 2.17 mm posteriorly at medium velocity, and from 2.62 ± 2.19 anteriorly to 1.17 ± 1.44 mm posteriorly at high velocity.

CONCLUSIONS

Translation of the humeral head was shown to undergo no significant change throughout the ranges of internal and external rotation, or among different rotational velocities in dynamic stability of the glenohumeral joint.

Effect of Arthroscopic Stabilization on In Vivo Glenohumeral Joint Motion and Clinical Outcomes in Patients With Anterior Instability

BACKGROUND

Glenohumeral joint (GHJ) dislocations are common, and the resulting shoulder instability is often treated with arthroscopic stabilization. These procedures result in favorable clinical outcomes, but abnormal GHJ motion may persist, which may place patients at risk for developing osteoarthritis. However, the effects of shoulder instability and arthroscopic stabilization on GHJ motion are not well understood.

HYPOTHESIS

GHJ motion is significantly influenced by anterior instability and arthroscopic stabilization, but postsurgical measures of GHJ motion are not different from those of control subjects.

STUDY DESIGN

Controlled laboratory study.

METHODS

In vivo GHJ motion was measured by applying a computed tomographic model-based tracking technique to biplane radiographic images acquired during an apprehension test in healthy control subjects (n = 11) and anterior instability patients (n = 11). Patients were tested before surgery and at 6 months after surgery. Control subjects were tested once. Shoulder strength, active range of motion (ROM), and the Western Ontario Shoulder Instability (WOSI) index were also measured.

RESULTS

Before surgery, the humerus of the instability patients during the apprehension test was located significantly more anteriorly on the glenoid (7.9% of glenoid width; 2.1 mm) compared with that of the controls (P = .03), but arthroscopic stabilization moved this joint contact location posteriorly on the glenoid (4.7% of glenoid width; 1.1 mm; P = .03). After surgery, GHJ excursion during the apprehension test was significantly lower (14.7% of glenoid width; 3.6 mm) compared with presurgical values (19.4% of glenoid width; 4.7 mm; P = .01) and with that of the controls (22.4% of glenoid width; 5.7 mm; P = .01). The external and internal rotation strength of patients was significantly lower than that of the controls before surgery (P < .05), but differences in strength did not persist after surgery (P > .17). External rotation ROM in patients was significantly lower than that in control subjects both before and after arthroscopic stabilization (P < .01). The WOSI score improved significantly, from 48.3 ± 13.1 presurgery to 86.3 ± 16.5 after surgery (P = .0002).

CONCLUSION

In patients with anterior instability, arthroscopic stabilization significantly improves measures of strength, ROM, and clinical outcome. However, GHJ excursion is not fully restored to levels seen in the control subjects.

CLINICAL RELEVANCE

Although arthroscopic stabilization satisfactorily restores most clinical outcome measures, GHJ excursion and external rotation ROM remain compromised compared with healthy control subjects and may contribute to the development of osteoarthritis in patients with anterior instability.