Single Assessment Numeric Evaluation for instability as an alternative to the Rowe score

Latarjet procedure restores range of motion at 6 months postoperatively: a prospective cohort study using motion capture analysis

BACKGROUND

There is a common concern that range of motion (ROM) is negatively affected by the Latarjet procedure. We hypothesize that the Latarjet procedure results in full recovery of ROM postoperatively and significantly improved patient-reported outcome measures.

METHODS

Patient data were prospectively collected from a randomized controlled trial to analyze outcomes after open Latarjet procedure. Inclusion criteria involved a minimum follow-up of 6 months and unilateral shoulder instability. Study outcome was assessed by postoperative ROM at 6 months postoperatively and compared to the preoperative ROM of the ipsilateral shoulder as well as the ROM of the unaffected contralateral shoulder. All ROM measurements were performed using a motion capture system to ensure consistent and reliable measurements.

RESULTS

The study included a total of 84 patients. ROM was measured in external rotation with the shoulder adducted (ER1), external rotation with the shoulder abducted 90° (ER2), internal rotation with the arm abducted 90° (IR2), and active forward elevation (AE). The mean difference in ROM between the operated arm vs. the contralateral healthy arm at 6 months postoperatively was 3.4° in ER1 (P = .19), 4.2° in ER2 (P = .086), 2.2° in IR2 (P = .36), and 2.4° in AE (P = .045). Subanalysis of patients with and without sling use revealed no significant difference in ROM between the operated shoulder and the contralateral shoulder at 6 months in either group, with the exception of ER2 in the sling group. In this latter group, ROM was 71° in the operated arm and 79° in the contralateral arm (P = .0094). Mean preoperative pain score was 25.7 (95% CI 21.4-30.1) vs. 13.0 postoperatively at 6 months (95% CI 9.50-16.5) (P < .00001). Mean preoperative Single Assessment Numeric Evaluation instability was 42.9 (95% CI 38.4-47.3) vs. 86.2 postoperatively at 6 months (95% CI 83.6-88.7) (P < .00001). Mean preoperative Rowe score was 38.5 (95% CI 34.3-42.7) vs. 84.3 at postoperative month 6 (95% CI 81.1-87.4) (P < .00001).

CONCLUSIONS

Latarjet procedure performed for anterior instability using a capsular repair results in complete ROM recovery in ER1, ER2, and IR2 at 6 months postoperatively, with only a slight discrepancy in active elevation. Sling use after the Latarjet procedure results in no benefit over postoperative recovery without the use of a sling. Sling use negatively affects the ROM in ER2, taking as reference the contralateral arm of the same patient, when compared to patients who did not use a sling postoperatively.

Good clinical outcomes and low recurrence rate in patients undergoing arthroscopic revision Latarjet for failed arthroscopic Bankart repair

BACKGROUND

The role of arthroscopic Latarjet stabilization after failed arthroscopic Bankart repair has yet to be definitively established and merits further investigation.

OBJECTIVE

To assess clinical and radiological outcomes after arthroscopic Latarjet stabilization as a revision procedure for failed Bankart repair, as well as the return to athletic activity and complication rates.

METHODS

Between 2009 and 2020, patients with a previous failed arthroscopic Bankart repair who were treated with an arthroscopic Latarjet were retrospectively evaluated. Clinical outcomes at a minimum of 24 months postoperatively included the Rowe score, Western Ontario Shoulder Instability Index, Constant-Murley Shoulder Outcome score, and Single Assessment Numeric Evaluation. Dislocations, subluxations, complications, pre- and postoperative levels of activity, and degree of osteoarthritis were also assessed.

RESULTS

A total of 77 patients, with a mean age at revision surgery of 31.2 ± 9.1 years and with either 1 (n = 59), 2 (n = 13), or 3 (n = 4) previous arthroscopic stabilizations, who underwent revision surgery using an arthroscopic Latarjet procedure were studied. Postoperatively, the mean Rowe and Constant-Murley Shoulder Outcome scores increased from 41.8 ± 16 to 90.7 ± 14.3 (P < .001) and from 50.5 ± 13.8 to 90.5 ± 10.3 (P < .001), respectively. Western Ontario Shoulder Instability Index decreased from 1247 ± 367.6 to 548.9 ± 363 at the final follow-up (P < .001). After a mean follow-up of 39.6 ± 23.1 months, 64 shoulders (83.1%) were subjectively graded as good to excellent using the Single Assessment Numeric Evaluation score. Grade 1, 2, and 3 osteoarthritis, according to Ogawa et al, was found in 18 (23.4%), 6 (7.8%), and 3 (3.9%) shoulders, respectively. Six (7.8%) dislocations after revision surgery were reported. In 4 failed cases, an Eden-Hybinette procedure was conducted, and in the remaining 2 patients, an arthroscopic extra-articular anterior capsular reinforcement was performed. A significantly decreased level of athletic activity was observed postoperatively (P = .01).

CONCLUSIONS

Arthroscopic Latarjet for the revision of failed arthroscopic Bankart repair provides satisfactory patient-reported subjective outcomes with a low rate of recurrences and complications. However, a decreased level of athletic activity is expected.

Arthroscopic Bankart repair versus arthroscopic Latarjet for anterior shoulder instability in adolescents

Aims

The Bankart and Latarjet procedures are two of the most common surgical techniques to treat anterior shoulder instability with satisfactory clinical and functional outcomes. However, the outcomes in the adolescent population remain unclear, and there is no information regarding the arthroscopic Latarjet in this population. The purpose of this study was to evaluate the outcomes of the arthroscopic Bankart and arthroscopic Latarjet procedures in the management of anterior shoulder instability in adolescents.

Methods

We present a retrospective, matched-pair study of teenagers with anterior glenohumeral instability treated with an arthroscopic Bankart repair (ABR) or an arthroscopic Latarjet (AL) procedure with a minimum two-year follow-up. Preoperative demographic and clinical features, factors associated with dislocation, and complications were collected. Recurrence, defined as dislocation or subluxation, was established as the primary outcome. Clinical and functional outcomes were analyzed using objective (Rowe), and subjective (Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE)) scores. Additionally, the rate of return to sport was assessed.

Results

A total of 51 adolescents were included, of whom 46 (92%) were male, with 17 (33%) in the Latarjet group and 34 (66%) in the Bankart group. The mean age at time of surgery was 18 years (15 to 19). There were no intraoperative complications. At a median follow-up of nine years (IQR 2 to 18), recurrence was observed in 12 patients in the Bankart group (35.3%) and one patient in the Latarjet group (5.9%) (p = 0.023). Satisfactory postoperative outcomes were obtained, with mean Rowe, WOSI, and SANE scores noted at 95 (10 to 100), 325 (25 to 1,975), and 87.5 (10 to 100), respectively. Most patients (29 in the Bankart group (85.3%) and 16 in the Latarjet group (94.1%)) were able to return to sport (p = 0.452).

Conclusion

The ABR and AL procedures both obtain satisfactory clinical and functional outcomes in the treatment of anterior glenohumeral instability in adolescents with a low complication rate. However, the ABR is associated with a significantly higher recurrence rate.

Clinical outcomes of a novel 'all-suture' fixation for valgus-impacted proximal humeral fractures

Background

Conventional techniques for the fixation of displaced proximal humeral fractures include the use of locking plates, intramedullary nailing, hemiarthroplasty and reverse shoulder replacement. Valgus-impacted fractures are a common subtype of proximal humeral fracture, but there are few publications concerning the outcomes of treatment. This study aims to review outcomes following an 'all-suture' technique for this fracture subtype without the use of transosseous sutures.

Methods

All patients over the age of 18 who presented with 3- or 4-part valgus-impacted proximal humeral fractures and who underwent 'all-suture' repair at our centre were included. We reviewed their post-operative imaging and collected data on post-operative complications and patient-reported outcome measures.

Results

We identified 15 patients who had undergone all-suture fixation. The cohort's mean age was 56. Eleven patients were female. Eight patients had 3-part fractures and seven patients had 4-part fractures. There were no major post-operative complications. All fractures united. The mean Oxford Shoulder Score was 43.7 and the mean Single Assessment Numerical Evaluation score was 85.9 at the final follow-up.

Discussion

Our results suggest that all-suture fixation of proximal humeral fractures presents an attractive alternative to conventional techniques, whilst avoiding complications relating to metalwork implantation.

Are Psychological Variables and Time Since Surgery Related to Rotator Cuff Strength and Functional Performance in Cadets After Shoulder Stabilization Surgery?

BACKGROUND

Traumatic shoulder instability is a common injury in the general population and the military. Surgical stabilization surgery reduces recurrence rates compared with nonsurgical management. Time since surgery is generally the primary measure of return to sport. There is a gap in knowledge on psychological variables and time since surgery and their relationship to rotator cuff strength and functional performance.

HYPOTHESIS

It was hypothesized that, after shoulder stabilization surgery, psychological factors and time since surgery will be associated positively with objective physical performance tests, that physical performance will differ significantly between postsurgery cadets and healthy controls, and that surgical stabilization of the nondominant arm will demonstrate greater range of motion deficits than surgical intervention on the dominant arm.

STUDY DESIGN

Case-control study.

LEVEL OF EVIDENCE

Level 4.

METHODS

The 52 participants (26 postsurgical [6-24 months after surgery] and 26 healthy controls) were all military cadets. Outcome measures were patient-reported outcomes, range of motion, isometric strength, and functional performance.

RESULTS

No significant relationships existed between time since surgery and psychological factors to rotator cuff strength or functional performance. Significant differences were found between groups in self-reported outcomes, including the Shoulder Instability Return to Sport After Injury scale, Single Assessment Numeric Evaluation, Numeric Pain Rating Scale, quickDASH, flexion and external rotation (ER), and ER limb symmetry. Those who received dominant-sided shoulder surgery demonstrated a greater mean active range of motion deficit than those who received nondominant-sided surgery. Both groups demonstrated a significant loss in ER, but dominant-sided surgical participants also demonstrated significant flexion loss.

CONCLUSION

Time since surgery and psychological variables did not demonstrate a relationship to rotator cuff strength and functional performance. Significant differences existed between the stabilization surgical participants and healthy controls in all patient-reported outcomes. Surgical participants with dominant-sided shoulder surgery demonstrated a greater mean motion deficit when compared with those who received nondominant-sided surgery.

Measure what matters: Single Assessment Numeric Evaluation (SANE) score as the critical measure for shoulder outcomes

BACKGROUND

Implementation of a system anchored in patient outcomes is challenged to gain widespread adoption required to demonstrate the value of care provided for shoulder conditions. This is in large part because of the administrative burden created by current tools and clinical implementation barriers that limit practical use and therefore leave most clinicians, administrators, payers, and patients without a measure of what matters most: Are patients improving? Thus, we must ask ourselves, How do we accurately and efficiently measure and report quality of care in a simple, reliable, and easily communicated manner? We propose that the Single Assessment Numeric Evaluation (SANE) score is the best solution to measure patient improvement and can be used universally for all shoulder conditions. The measure is simple, valid, reliable, and sensitive to change and has the lowest implementation barrier compared with all other outcome measures.

METHODS

We synthesized the available literature (11 studies) that demonstrates strong psychometrics comparable to legacy measures across >4000 patients with a wide range of shoulder conditions.

RESULTS

SANE scores range from 40% to 60% at baseline for most patients before treatment and range from 75% to 85% at 1 year after therapy depending on the condition, similar to legacy scores such as the American Shoulder and Elbow Surgeons score. Additionally, the SANE score shows similar baseline and post-care measures across conditions that can be used to guide clinical care. This finding shows that the observed baseline and improvement scores can provide valuable patient assessment and can be used in aggregate for quality improvement and other value-based purposes.

CONCLUSION

We strongly recommend the SANE score as the primary patient outcome measure for patients with all shoulder conditions, given the value of measuring every patient's progress and growing pressure to quantify patient outcomes.

Postoperative Shoulder Function Assessment: Proposing the Concept of "Forgotten Shoulder" Over "Normal Shoulder" as the New Standard in Single Assessment Numerical Evaluation

A major limitation of Patient-Reported Outcomes Measures (PROMs) postoperatively is the ceiling effect, where patients report the maximum score, making it difficult to differentiate between different conditions. Our findings regarding the SSV-Sport reveal a significant ceiling effect post-surgery, indicating the need for improvements in PROMs, including the Single Assessment Numerical Evaluation (SANE). One of the problems with SANE is scoring a 'normal' joint as the maximum. Patients might tolerate some subtle imperfections in their recovery and still consider their joint 'normal'. Proposing the concept of a 'forgotten' joint into the SANE could be a more accurate assessment tool and c which could diminish the ceiling effect. We suggest a shift from 'normal joint' to 'forgotten joint' as a standard for evaluating postoperative recovery and function in SANE.

A Comprehensive Review of Proximal Humerus Fractures: From Epidemiology to Treatment Strategies

This comprehensive review delves into the intricate landscape of proximal humerus fractures (PHFs), exploring their epidemiology, historical evolution, contemporary classification systems, treatment strategies, and outcome measures. PHFs present a complex orthopedic challenge, necessitating a nuanced understanding of their multifaceted dimensions. Despite their clinical significance, PHFs remain relatively understudied in population-based epidemiology. This review critically examines existing literature to uncover the incidence, prevalence, and demographic patterns associated with these fractures. A foundational understanding of the epidemiological landscape is crucial for effective preventive strategies and optimized fracture management. Tracing back to historical records, the review explores the evolution of diagnostic and therapeutic approaches for PHFs. From ancient treatment modalities documented on the Edwin Smith papyrus to contemporary X-ray-based classifications such as Neer and AO/OTA, a historical context is provided to understand the journey of managing these fractures. Navigating through a spectrum of treatment strategies, the review contrasts nonoperative approaches with various surgical interventions. The challenges and outcomes associated with conservative management are juxtaposed against methods like open reduction internal fixation and tension band osteosynthesis. Evidence synthesis guides clinicians in making informed decisions based on patient characteristics and fracture complexities. Central to assessing PHF management are patient-reported outcome measures. The review explores the significance of instruments such as the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Constant-Murley score in evaluating treatment success. The shift toward subjective measures is discussed, considering their correlation with patient experiences and the concept of minimal clinically important difference. The impact of demographic factors, including age and gender, on PHFs is scrutinized. The association between these fractures and osteoporosis is highlighted, emphasizing the crucial role of bone health in fracture prevention and management. Through this comprehensive exploration, the review provides a robust foundation for understanding, evaluating, and advancing the management strategies for PHFs. The synthesis of historical perspectives, contemporary classifications, and treatment modalities serves as a valuable resource for the orthopedic community, fostering improved clinical decision-making and patient outcomes.

Subjective Shoulder Value for Sport Is a Simple, Reliable, and Valid Score to Assess Shoulder Function in Athletes

PURPOSE

To validate the subjective shoulder value for sport (SSV-Sport) by measuring its correlation with existing patient-reported outcome measures (PROMs) and defining its psychometric properties.

METHODS

Between May 2021 and May 2022, we established 2 patient groups. Group 1 included those (1) aged 18 years or older, who were (2) consulting for the first time for any shoulder condition, (3) regularly participated in sports, and were capable of accessing a questionnaire independently. There were asked to rate their SSV and SSV-Sport at admission and 2 weeks later; they also were asked to answer a questionnaire including other PROMS. Group 2 comprised patients who had (1) undergone shoulder stabilization surgery and had (2) a minimum follow-up period of 6 months.

RESULTS

For the shoulder disability patients (group 1, n = 62), there was a strong and significant correlation between SSV-Sport and other PROMs: Quick Disabilities of the Arm, Shoulder and Hand Sport (r = 0.84), Walch-Duplay (r = 0.65), Rowe (r = 0.74), Western Ontario Shoulder Instability (r = 0.78), and SSV (r = 0.75) (P = .0001). The SSV-Sport was reliable at baseline and 2 weeks after (0.91, 95% confidence interval 0.85-0.94), and was responsive to change (P < .001). For the anterior instability patients (group 2, n = 83), SSV was on average 50 points greater than SSV-Sport (29.2 vs 79.4, P < .001) for preoperative values. In both groups, the values of SSV were constantly and significantly higher than the values of SSV-Sport (81.9 ± 21.3 vs 54.8 ± 30.9; P < .001).

CONCLUSIONS

The SSV-Sport is an easily administered, reliable, responsive, and valid measure of shoulder function in athletes that is highly correlated with other PROMs. SSV-Sport is better adapted than SSV to quantify pre- and postoperative shoulder deficiency in athletes.

LEVEL OF EVIDENCE

Level III, cohort study (diagnosis).

The association of ICUC trauma score and quick DASH in a distal radius fracture cohort

BACKGROUND

This study evaluates the association between ICUC trauma and short-form Disabilities of the Arm, Shoulder, and Hand Questionnaire (Quick DASH) scores among patients who underwent surgery for distal radius fractures.

METHODS

This research gathered patient-reported outcomes (PROs) from patients registered in the ICUC database at a single trauma center. The study involved 76 adult patients who underwent surgical treatment for distal radius fractures before 2023. These patients received a volar locking plate for their distal radius fracture. The research utilized two different PROs to evaluate the patients' conditions. The ICUC trauma score measures functional impairment and pain through two 5-point scale questions, allowing patients to self-assess these aspects. The Quick DASH, comprising 11 questions, was used to evaluate symptoms and functionality of the upper extremity.

RESULTS

For patients aged 55.9 ± 15.3 years and 4.6 ± 3.9 years post-op follow-up, the ICUC trauma score was 0.70 ± 0.95, and Quick DASH was 6.07 ± 10.35. A strong correlation between ICUC and Quick DASH was identified (r = 0.71, P < 0.01). The interaction between the ICUC trauma score and age at the surgery to Quick DASH revealed a significant unstandardized partial regression coefficient of 0.19 (95% confidence interval 0.08-0.31; P < 0.01).

CONCLUSION

This study demonstrated a strong correlation between the ICUC trauma score and the Quick DASH among patients, especially the elderly. It was noted that an elevation in the ICUC trauma score is linked to a more marked increase in the Quick DASH score, particularly in older patients. Given its simplicity and efficacy, the ICUC trauma score may be a viable alternative to the Quick DASH for assessing the patient's clinical outcomes.

Reconsidering "Critical" Bone Loss in Shoulder Instability: 17-Year Follow-Up Study following Arthroscopic Bankart Repair

Background

Glenoid bone loss is a risk factor leading to the failure of arthroscopic Bankart repair. While 20-25% glenoid bone loss has long been considered the level to necessitate bony augmentation, recent studies indicate that 13.5% has a "subcritical" glenoid bone loss level, which is associated with decreased short- and medium-term functional scores. Few researchers worked on the long-term effect of "subcritical" or even less severe degrees of glenoid bone loss on redislocation rates and functional outcomes after arthroscopic Bankart repair. This study aimed to evaluate the effect of subcritical or less severe glenoid bone loss on redislocation rates and function after arthroscopic Bankart repair.

Methods

A patient cohort who had undergone computed tomography (CT) of glenoid bone loss and arthroscopic Bankart repair over 15 years ago was reviewed. Western Ontario Shoulder Instability (WOSI) score, Single Assessment Numeric Evaluation (SANE) score, redislocation after operation, mechanism of recurrence, and revision details were reviewed.

Results

Seventy-five patients were reassessed 17.6 ± 1.9 years following initial surgery. The age at enrolment was 26.8 ± 8.3 years. Twenty-two (29%) patients of the 75 patients had a redislocation on long-term follow-up, though this was not related to glenoid bone loss severity. The impaired functional score was found in patients with initial glenoid bone loss of 7% or more on long-term follow-up: WOSI (physical symptoms): 0.98 ± 2.00 vs 2.25 ± 4.01, p=0.04 and WOSI (total): 0.79 ± 1.43 vs 1.88 ± 3.56, p=0.04.

Conclusions

At a mean of 17.5 years following arthroscopic Bankart repair, redislocation occurs in over a quarter of 75 patients, and they are not related to initial glenoid bone loss severity. Impaired functional outcome is apparent in patients with initial glenoid bone loss of >7%, though this impairment does not seem sufficiently severe to warrant an alternative treatment approach.

Outcomes of Arthroscopic Latarjet as a Revision Surgery After Failed Arthroscopic Bankart Repair

BACKGROUND

The role of arthroscopic Latarjet as a revision surgery after failed arthroscopic Bankart repair has yet to be established.

PURPOSE

To compare clinical outcomes, recurrences, and complication rates of arthroscopic Latarjet as a revision procedure after failed arthroscopic Bankart repair versus arthroscopic Latarjet as a primary procedure.

DESIGN

Cohort study; Level of evidence, 3.

METHODS

This is a retrospective study of prospectively collected data of patients who were diagnosed with anterior shoulder instability and underwent arthroscopic Latarjet stabilization between 2009 and 2018. Patients were separated into 2 groups depending on whether Latarjet was performed after a previous instability surgery (revision) or as a primary surgery (primary). Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome (CMSO) score, and Single Assessment Numeric Evaluation (SANE) were assessed pre- and postoperatively with a minimum 24 months of follow-up. In addition, pre- and postoperative levels of sports activity, dislocations, subluxations, and complications were assessed.

RESULTS

A total of 97 patients (n = 62 revision; n = 35 primary), with a mean age of 31.0 ± 8.8 and 29.4 ± 7.6 years old in the revision and primary Latajet group, respectively, met the inclusion criteria. The mean follow-up in the revision group was 32 months (24-53) and 35.5 months (27.7-42.2) in the primary Latarjet group. No significant differences between groups were observed in Rowe score (revision = 91.4, primary = 94.1; P = .223), CMSO score (revision = 90.7, primary = 94; P = .105), and SANE (revision = 85.8, primary = 87.3; P = .683) postoperatively. However, the postoperative difference in the WOSI score between the revision and primary Latarjet groups was nearly significant (510 ± 334 vs 403 ± 343, respectively; P = .05). Four (6.4%) postoperative dislocations were reported in the revision and 1 (2.8%) in the primary Latarjet group (P = .14). Patients in the revision group had a lower return to the previous level of sports participation (P = .008) and decreased external rotation with the arm by the side compared with the primary Latarjet group (P = .000).

CONCLUSION

Arthroscopic Latarjet as a revision surgery is a reasonable surgical option in failed Bankart repair cases. The decision to perform arthroscopic Latarjet stabilization as a revision surgery should not be influenced by the potential risk of future complications as it provides comparable clinical outcomes to the primary Latarjet procedure with a low postoperative recurrence rate. However, a decreased level of postoperative sports participation and external rotation with the arm by the side can be expected.

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.

Functional and Sport-Specific Outcome Following Traumatic First-Time Shoulder Dislocation and Arthroscopic Surgical Repair in Rock Climbers

INTRODUCTION

Traumatic shoulder dislocations rank among the most common shoulder injuries in climbers, with rising numbers over the last years. The objective of this study was to analyze the outcome following traumatic first-time shoulder dislocation and subsequent surgical treatment in this population.

METHODS

In a retrospective study, climbers who experienced a traumatic shoulder dislocation were treated with an arthroscopic repair of the labrum-ligament complex (LLC). The functional outcome was assessed with a standardized questionnaire and clinical examination, including the Constant Murley and Single Assessment Numeric Evaluation scores. The sport-specific outcome was analyzed using the Union Internationale des Associations d'Alpinisme (UIAA) scale of difficulty and a sport-specific outcome score.

RESULTS

The functional and sport-specific outcome for 27 climbers (20 men; 7 women; 3 with bilateral injuries; age, 34±11 [17-61] y; data presented as mean±SD [range]) was assessed 53±29 (12-103) mo after surgery. The postoperative Constant Murley score was 95±8 (67-100) points. At follow-up, 93% (n=25) of patients had started climbing again. Twenty-one climbers (78%) reached a climbing level within the range of ±0.33 UIAA grades of their initial capability or even exceeded their preinjury grade. Only 7% (n=2) of the patients had a recurrent shoulder dislocation, leading to a secondary surgery, and, therefore, required ongoing postoperative treatment at the time of follow-up.

CONCLUSIONS

Arthroscopic repair of the LLC following first-time traumatic shoulder dislocation in climbers shows a good outcome and a low recurrence rate. After surgery, most patients are able to regain a high level of rock-climbing ability.

The single assessment numeric evaluation correlates with the western ontario rotator cuff score in non-traumatic shoulder disease

Patient-reported outcome measures (PROMs) are essential clinical instruments used for assessing patient function and assisting in clinical decision making. The Western Ontario Rotator Cuff (WORC) index is the PROM for shoulder pathology with the most psychometric properties but is very time consuming. The Single Assessment Numeric Evaluation (SANE) method is a PROM that takes less time to answer and to analyze. The aim of the study is to evaluate the intra- class correlation between these two outcome scores in establishing shoulder function in patients with non-traumatic rotator cuff pathologies. Fifty five subjects of both genders and different ages presenting with non-traumatic shoulder pain for more than 12 weeks had a physical examination and ultrasound as well as MRI arthrogram scan findings that were consistent of a non-traumatic rotator cuff (RC) based pathology. On the same moment a WORC index and a SANE score questionnaire were filled in by the subject. The intra class correlation of both PROMs was statistically analyzed. The WORC index score and the SANE score show a moderate correlation with an Intra Class Coefficient (ICC) of r = 0.60 (95% CI:0.40-0.75). This study demonstrates a moderate correlation between the WORC index score and the SANE score in rating the disability of patients with atraumatic RC disease. The SANE score is applicable in research and clinical practice and is for the patient and the researcher an almost no time consuming PROM.

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.

Is sling immobilization necessary after open Latarjet surgery for anterior shoulder instability? A randomized control trial

BACKGROUND

There is a current lack of knowledge regarding optimal rehabilitation and duration of sling immobilization after an open Latarjet procedure. A shift towards immediate self-rehabilitation protocols in shoulder surgery is observed to avoid postoperative stiffness and fasten return to sport. Avoiding sling immobilization could further simplify rehabilitation and provide an even faster return to activities of daily living and enhance patient satisfaction.

METHODS

This study is a single-center, randomized control trial. Sixty-eight patients will be instructed with the same standardized immediate postoperative self-rehabilitation protocol. Patients will be allocated 1:1 between a sling immobilization group for the first three postoperative weeks and no sling group without postoperative immobilization. The primary endpoint will be functional outcome at 6 months postoperative evaluated by the disease-specific Rowe score. Secondary endpoints will include baseline, 1.5-, 6-, and 12-month single assessment numeric evaluation (SANE) of instability score and visual analog pain scale (VAS). At the 6-month time point, graft bony union and position will be assessed by computed tomography. Motion capture technology will evaluate the baseline and 6-month postoperative range of motion. Finally, time to return to work and sport during the first postoperative year, along with patient satisfaction at one postoperative year, will also be recorded.

DISCUSSION

This study will allow further insights into the optimal rehabilitation protocol after open Latarjet surgery and enhance patient care by helping identify rehabilitation and coracoid graft-related factors influencing functional outcomes, bony union, range of motion, and patient satisfaction.

TRIAL REGISTRATION

The protocol was approved by the ethical committee board (CCER 2019-02,469) in April 2020 and by ClinicalTrials.gov (Identifier: NCT04479397 ) in July 2020.

Microinstability characterised by small and easily overlooked anterior labral or Hill-Sachs lesions can be managed with arthroscopic anterior labral repair

PURPOSE

Some young individuals present with shoulder pain without a definite history or complaint of instability. However, careful history taking, physical examination, and high-quality magnetic resonance imaging may reveal evidence of instability of which the patient is unaware. Therefore, a clearer definition of these ambiguous patients is needed. This study aimed to report the characteristics and surgical outcomes of patients with microinstability compared to those of patients with classic recurrent anterior shoulder instability.

METHODS

From 2005 to 2018, 35 patients with microinstability (group M) underwent arthroscopic anterior labral repair (AALR) and were compared to 35 sex- and age-matched patients with classic recurrent anterior shoulder instability (group C) who also underwent AALR. Baseline characteristics, preoperative apprehension test findings, preoperative imaging for the presence of anterior labral and Hill-Sachs lesions, preoperative and postoperative (over 2 years) range of motion (ROM) and functional scores, final complications, and patient satisfaction were analysed.

RESULTS

The most common chief complaints in groups M and C were pain (29/35) and both pain and instability (27/35), respectively. Only pain during the apprehension test was predominant in group M (M vs. C, 27 vs. 1, p < 0.001). High incidence of chronic repetitive injuries (26/35) and acute trauma (28/35) were observed in groups M and C, respectively. Over half of the patients in group M showed anterior labral lesions on magnetic resonance arthrography (MRA, 18/35), and 21 patients had Hill-Sachs lesions on MRA/three-dimensional computed tomography. Finally, 29 patients showed either anterior labral or Hill-Sachs lesions on preoperative imaging. The lesion severity was higher in group C than that in group M. All patients underwent AALR with/without the remplissage procedure, with no significant differences in final clinical outcomes, complications, and patient satisfaction between the groups.

CONCLUSIONS

Microinstability is diagnostically challenging and can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability. Pain on anterior apprehension test and subtle labral and/or Hill-Sachs lesion on imaging study could be diagnostic clues. This condition can be managed with arthroscopic anterior labral repair with or without the remplissage procedure. The possibility of microinstability in young patients with shoulder pain should always be considered, and small anterior labral or Hill-Sachs lesions should be closely monitored.

LEVEL OF EVIDENCE

III.

Glenoid microfracture in active-duty military patients: minimum 5-year follow-up demonstrates 75% survival

Background

To present midterm patient-reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid.

Methods

All consecutive patients from January 2013 through December 2016 who underwent glenoid microfracture for full-thickness cartilage injuries with complete outcome scores were identified. Twenty patients met the final inclusion criteria for the study, and all were active-duty military at the time of surgery. A separate subgroup analysis was performed to determine if dominant-shoulder involvement portends worse outcomes.

Results

The mean follow-up was 81.45 ± 19.43 months (range, 60-108). Of the 20 patients, 5 required a secondary surgical procedure within 5 years of their index procedure, with an average time to failure of 45.6 ± 13.15 months. For the 15 patients who did not fail, there was a statistically significant increase in the mean American Shoulder and Elbow Surgeons score (57.20 vs. 88.27, P < .0001) and Single Assessment Numeric Evaluation (45.00 vs. 86.33, P < .0001). Mean pain decreased significantly as measured by the pain visual analog scale (5.40 vs. 1.37, P < .0001). Range of motion in forward elevation, external rotation, and internal rotation did not change significantly postoperatively (P = .4528, .4810, and .1919, respectively). Concomitant procedures did not predict changes in pain, American Shoulder and Elbow Surgeons, or Single Assessment Numeric Evaluation scores. A majority of patients (13/20, 65%) were able to remain on unrestricted military active-duty service, but 7 (35%) underwent medical discharge, including the 5 patients who had experienced treatment failure, plus 2 additional patients.

Conclusion

Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at 5 years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.

Arthroscopic Posterior Labral Repair in Active-Duty Military Patients: A Reliable Solution for an At-Risk Population, Regardless of Anchor Type

BACKGROUND

Active-duty servicemembers are a population at risk for the development of posterior shoulder instability. While short-term outcomes after arthroscopic posterior labral repair for posterior shoulder instability are promising, there is a paucity of longer term follow-up data for this procedure.

PURPOSES

The primary purpose was to report midterm outcomes after arthroscopic posterior labral repair in active-duty military patients for posterior shoulder instability without bone loss. The secondary purpose was to determine if outcomes varied between anchor types used.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Preoperative and postoperative outcomes, with a minimum 3-year follow-up, for a visual analog scale for pain, the Single Assessment Numeric Evaluation (SANE), the American Shoulder and Elbow Surgeons (ASES) score, and the Rowe score were collected and analyzed. A separate subgroup analysis was performed comparing the outcomes of patients who underwent repair with biocomposite anchors versus those who underwent repair with all-suture anchors.

RESULTS

A total of 73 patients with a mean follow-up of 82.55 ± 24.20 months met the inclusion criteria and were available for analysis. As a whole, the cohort demonstrated statistically and clinically significant improvements in outcome scores at final follow-up. Preoperative and postoperative range of motion did not vary significantly. While the difference in final outcome scores between the 2 anchor types did not reach statistical significance, a statistically significantly larger proportion of patients who underwent repair with all-suture anchors versus those who underwent repair with biocomposite anchors met the Patient Acceptable Symptom State for the SANE (97.14% vs 78.95%, respectively; P = .0180) and the ASES score (88.57% vs 68.42%, respectively; P = .0171). The proportion of patients who achieved the substantial clinical benefit or surpassed the minimal clinically important difference, however, did not vary by anchor type. Overall, 70 patients (95.89%) remained on active duty and were able to return to preinjury work and recreational activity levels. There were 3 patients (4.11%) who had recurrent posterior instability.

CONCLUSION

This population of active-duty servicemembers undergoing posterior labral repair for posterior labral instability without bone loss demonstrated a statistically and clinically significant improvement in midterm outcomes, a low recurrence rate, and a rate of return to active duty of 95.89%, regardless of the anchor type used.

Biceps Tenodesis Combined With Arthroscopic Posterior Labral Repair for Type VIII SLAP Lesions in Active-Duty Military Patients Yields Excellent Return to Military Duty

PURPOSE

To report short-term outcomes following biceps tenodesis combined with arthroscopic posterior labral repair of type VIII SLAP lesions in active-duty military patients.

METHODS

All consecutive patients from January 2012 through December 2018 who underwent biceps tenodesis combined with arthroscopic posterior labral repair of type VIII SLAP tears performed by the senior surgeon with complete outcome scores and minimum 2.5 years follow-up were identified. Exclusion criteria included concomitant glenoid microfracture, rotator cuff repair, or other capsulolabral repair. Outcome measures were completed by patients within 7 days before surgery and at latest follow-up. Biceps tenodesis performed was a mini-open, through a subpectoral approach, using a double-loaded 2.9mm suture-anchor.

RESULTS

Thirty-two patients met the inclusion criteria for the study. All patients were active-duty military at time of surgery. Average follow-up was 73.53 ± 22.37 months. Thirty-one patients achieved the minimal clinically important difference, 30 of 32 reached the substantial clinical benefit, and 31 of 32 met the patient acceptable symptomatic state, as defined for the American Shoulder and Elbow Surgeons Shoulder Score. Similarly, 30 of 32 patients reached the minimal clinically important difference, 29 of 32 achieved the substantial clinical benefit, and 32 of 32 met the patient acceptable symptomatic state for the Single Assessment Numeric Evaluation. There were no significant changes in forward flexion, external rotation, or internal rotation between pre- and postoperative measurements. Three patients reported postoperative complications and 1 patient progressed to further surgery. Thirty (93.75%) patients remained on active-duty military service and were able to return to preinjury levels of activity.

CONCLUSIONS

Active-duty military patients with type VIII SLAP tears had statistically and clinically significant increases in outcome scores, marked improvement in pain, and high rates of return to unrestricted active-duty following mini-open subpectoral biceps tenodesis combined with posterior labral repair.

LEVEL OF EVIDENCE

IV, retrospective case series.

Rates of Return to Manual Labor After Arthroscopic Rotator Cuff Repair

BACKGROUND

Rotator cuff tears represent a significant cause of shoulder pain and dysfunction in the United States. The development of these injuries is associated with older patient age and higher levels of physical activity; however, data regarding the rate of return to work after arthroscopic rotator cuff repair in patients older than 50 years of age who have physically strenuous jobs is inconclusive.

PURPOSE/HYPOTHESIS

The purpose of this study was to report short term outcomes and return to work rates after arthroscopic rotator cuff repair in a cohort of patients aged 50 to 60 years working in manual labor jobs. It was hypothesized that arthroscopic rotator cuff repair would result in good functional outcomes for these patients and allow for return to work rates in excess of 80%.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Preoperative and final evaluations including the pain visual analog scale (VAS), the Single Assessment Numeric Evaluation (SANE), and the American Shoulder and Elbow Surgeons (ASES) Shoulder Score were collected. A total of 73 patients were screened for inclusion. Nineteen patients were outside of the inclusion age range, 2 underwent exclusionary concomitant procedures, and 4 patients were lost to follow up, leaving a total of 48 patients with a mean follow up of 34.02 months (range, 24-67 months) available for analysis. None of the patients were involved in a workers' compensation claim. Subgroup analysis was performed to determine if arm dominance or tear size affected surgical outcomes or return to work rates.

RESULTS

After arthroscopic rotator cuff repair, 43 of 48 patients (89.6%) were able to return to manual labor positions. Tears were classified using the Southern California Orthopaedic Institute Classification at the time of repair as massive (C4) in 9 patients (18.75%), large (C3) in 13 patients (27.08%), medium (C2) in 21 patients (43.75%), and small (C1) in 5 patients (10.42%). At latest follow up, the mean VAS decreased from 8.0 ± 1.81 to 0.46 ± 1.20, the average SANE increased from 47.50 ± 18.59 to 91.88 ± 12.30, and the average ASES score improved from 39.58 ± 10.71 to 93.44 ± 11.97 (P < .0001). Outcomes did not differ between patients who underwent surgery on their dominant shoulder and those who underwent surgery on their nondominant shoulder. The overall postoperative complication rate was 8.33%.

CONCLUSION

Arthroscopic rotator cuff repair portended favorable outcomes and high rates of return to work in this cohort of manual laborers, with 89.6% of patients able to return to work.

Double-Pulley Remplissage in Active-Duty Military Population With Off-Track Anterior Shoulder Instability Results in Improved Outcomes and Low Recurrence at Minimum 4-Year Follow-Up

PURPOSE

To report mid-term outcomes of active-duty patients with anterior shoulder instability following our technique for double-pulley remplissage (DPR) with concomitant anterior labral repair.

METHODS

All consecutive patients from 1/2010 through 12/2016 that underwent DPR by the senior surgeon with complete outcome scores were identified. All patients had experienced a shoulder dislocation following a traumatic event, and had subsequent instability recalcitrant to conservative management. Patients were excluded if they were lost to follow-up (3) of if they underwent stabilization procedures other than DPR (148). Outcome measures were completed by patients within 1 week prior to surgery and at latest follow-up. Twenty-four patients met the inclusion criteria for the study, and all were active-duty military at the time of surgery.

RESULTS

20/24 (83.3%) patients met the patient acceptable symptomatic state (PASS), while 21/24 (87.5%) achieved substantial clinical benefit (SCB) and 22/24 (91.7%) exceeded the minimal clinically important difference (MCID) for their operative shoulder, as determined by the American Shoulder and Elbow Surgeons (ASES) Score. 21/24 (87.5%) patients met the PASS, while 19/24 (79.2%) achieved SCB and 20/24 (83.3%) exceeded the MCID for their operative shoulder, as determined by the single assessment numeric evaluation (SANE). In addition, 23/24 (95.8%) patients exceeded the MCID for their operative shoulder, as determined by the Rowe Instability score. Preoperative and postoperative range of motion did not vary significantly. All patients had decreased pain postoperatively (P < .0001); 22/24 (91.67%) of patients remained on active-duty status. Failure rate, defined as recurrent subluxation or dislocation, was 4.2%.

CONCLUSIONS

Mid-term outcomes in this population of active-duty patients undergoing DPR for shoulder instability without glenoid bone loss demonstrate a statistically and clinically significant improvement in patient-reported outcomes, a significant decrease of pain and an overall return to active-duty rate of 91.67%.

LEVEL OF EVIDENCE

IV, therapeutic case series.

Outcomes of Arthroscopic Latarjet Procedure for Anterior Glenohumeral Instability in Patients With Epilepsy: A Case-Control Study

BACKGROUND

Unacceptably high rates of redislocation, reoperation, osteoarthritis, and coracoid nonunion have been reported in patients with a seizure disorder after surgery for shoulder instabilitiy.

PURPOSE

To evaluate the objective and subjective functional and radiologic results of the arthroscopic Latarjet procedure for anterior shoulder instability in patients with epilepsy and compare them with the results of patients without epilepsy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective and comparative case-control analysis of patients operated for shoulder instability with arthroscopic Latarjet was conducted. Nineteen patients (21 unstable shoulders) with a seizure disorder (epilepsy group) were matched with 21 patients without a history of seizure (control group). Demographics, surgical indications, and imaging data were collected. Clinical outcomes at a minimum 2 years of follow-up (range, 2-9 years) postoperatively included Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome (CMSO) score, and Single Assessment Numeric Evaluation (SANE). The incidence of complications, recurrent instability, redislocation, revision surgery, repeated seizure(s), and presence of osteoarthritis, coracoid nonunion, and osteolysis were also examined.

RESULTS

After a mean follow-up of 4.5 years, no significant differences in functional results were found between patients with and without epilepsy on the average Rowe (P = .917), WOSI (P = .621), CMSO (P = .600), and SANE (P = .859) scores. A total of 5 patients (7 shoulders) continued to have seizures postoperatively, but no seizure-related glenohumeral instability was documented. One dislocation and 1 subluxation were documented while participating in sports in each study group, comprising a recurrence rate of 9.5%, but no significant differences were found at comparison (P = .605). A bone defect did not influence the results, as no significant difference was found between the 2 groups. Osteoarthritic changes of the glenohumeral joint were observed in 5 shoulders (23.8%) in the epilepsy group and in 3 (14.3%) in the control group (P = .451). No case of coracoid nonunion or osteolysis was recorded. There was no statistically significant difference in postoperative athletic activity (P = .660). However, patients with epilepsy had significantly lower pre- and postoperative sports participation (P < .001).

CONCLUSION

Arthroscopic Latarjet stabilization can lead to improved functional and subjective outcomes and should be considered in patients with epilepsy with recurrent anterior glenohumeral instability. These results can be achieved regardless of the presence of bone defect and the postoperative control of seizures and are similar to those in patients without epilepsy.

Team Approach: Treatment of Shoulder Instability in Athletes

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Shoulder instability is a complex problem with a high rate of recurrence in athletes. Treatment of a first-time subluxation or dislocation event is controversial and depends on patient-specific factors as well as the identified pathology.

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Athletic trainers and physical therapists are an integral part of the treatment team of an in-season athlete who has experienced a shoulder instability event. Through comprehensive physiological assessments, these providers can effectively suggest modifications to the patient's training regimen as well as an appropriate rehabilitation program.

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Surgical intervention for shoulder stabilization should use an individualized approach for technique and timing.

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A team-based approach is necessary to optimize the care of this high-demand, high-risk population.