Open shoulder stabilization: current trends and 1-year postoperative complications

Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes

The shoulder, being the most mobile joint in the human body, is often susceptible to dislocations and subluxations more so than other joints. As such, shoulder instability constitutes a common complaint among patients worldwide, especially those who are young, participate in contact sports, and have increased innate flexibility in their joints. Management options in the setting of instability vary between conservative and surgical options that aim to mitigate symptoms and allow return of function. Surgical options can be arthroscopic and open, with a general shift among surgeons towards utilizing arthroscopic surgery in the past several decades. Nevertheless, open procedures still play a role in managing shoulder instability patients, especially those with significant bone loss, recurrent instability, coexisting shoulder pathologies, and high risk of failure with arthroscopic surgery. In these clinical settings, open procedures, like the Latarjet procedure, open Bankart repair, glenoid bone augmentation using iliac crest autograft or distal tibial allograft, and salvage options like glenohumeral arthrodesis and arthroplasty may show good clinical outcomes and low recurrence rates. Each of these open procedures possesses its own set of advantages and disadvantages and entails a specific set of indications based on published literature. It is important to cater treatment options to the individual patient in order to optimize outcomes and reduce the risk of complications. Future research on open shoulder stabilization procedures should focus on the long-term outcomes of recently utilized procedures, investigate different graft options for procedures involving bone augmentation, and conduct additional comparative analyses in order to establish concrete surgical management guidelines.

Risk for recurrent instability and reoperation following arthroscopic and open shoulder stabilization in a large cross-sectional population

Background

Recurrent shoulder instability is an orthopedic problem with potentially long-term functional ramifications. Although arthroscopic stabilization has become increasingly utilized over open stabilization, optimal surgical intervention to minimize recurrent instability remains controversial.

Methods

The PearlDiver Mariner database was queried for all cases of open and arthroscopic shoulder stabilization from 2010 to 2019. Utilization trends were aggregated after identifying cohorts of 107,210 and 13,217 patients who respectively underwent arthroscopic or open stabilization using Current Procedural Terminology codes. Subsets from those cohorts with laterality-specific International Classification of Diseases, Tenth Revision codes for shoulder instability were used to evaluate 2-year rates of recurrent instability (presence of shoulder dislocation or revision open or arthroscopic stabilization). Linear regression and chi-squared analysis were used to analyze utilization trends and to compare recurrent instability.

Results

Arthroscopic stabilization comprised 90% of all stabilization procedures with annual utilization continuing to increase into 2019. Latarjet utilization increased from 15% to 42% of all open stabilization procedures while open Bankart repair utilization decreased from 56% to 35%. The rate of recurrent instability was 10.2% after arthroscopic stabilization and 12.3% after open stabilization (P = .01). Rates of redislocation (4.0% vs. 2.6%, P < .01), conversion to shoulder arthroplasty (1.2% vs. 0.4%, P < .01), and revision open stabilization (6.8% vs. 2.3%, P < .01) after index open stabilization were significantly higher than after index arthroscopic stabilization. There was no difference in revision stabilization or dislocation rates between open procedures.

Conclusion

Despite increasing utilization of coracoid transfer, arthroscopic stabilization is still the dominant modality used for surgical treatment of shoulder instability and in our analysis, showed lower 2-year rates of dislocation, revision open stabilization, and conversion to shoulder arthroplasty.

Trends in utilization and patient demographics for shoulder instability procedures from 2010 to 2019

BACKGROUND

Improved techniques and increased surgeon experience have optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there are limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographic characteristics (age and sex) from 2010 to 2019 for 4 shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR).

METHODS

We identified >87,000 patients using an all-payer claims database. The utilization rate was defined as the number of cases of a procedure divided by the total number of surgical cases for shoulder instability for any given year. Age was divided into 3 groups: <25 years, 25-35 years, and >35 years. Trends were reported in terms of the compounded annual growth rate (CAGR).

RESULTS

Although ABR was the most common shoulder instability procedure overall (91% utilization rate), the LP had the greatest increase in utilization from 2010 to 2019 (2.0% to 4.5%; CAGR, +9.8%). In comparison, the utilization of ABB procedures increased by 4.3% annually whereas that of OBR declined by 6.9% annually. The utilization of ABR showed minimal change. Notably, the LP was performed more frequently in younger patients over time. The percentage of patients aged < 25 years who underwent the LP increased from 30% to 41% from 2010 to 2019 (CAGR, +3.4%). There was a trend toward the performance of more LPs in men than in women (+1.2% vs. -3.5%, P < .05), although most cases (68%) were still performed in men.

CONCLUSION

ABR continues to account for most shoulder instability procedures. The LP had the greatest increase in the utilization rate from 2010 to 2019 and has now surpassed OBR in the utilization rate. ABB procedures are also being more frequently performed but only represent a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedures were male individuals and were aged < 25 years.

Open Stabilization Procedures of the Shoulder in the Athlete: Indications, Techniques, and Outcomes

Shoulder instability is a relatively common injury especially in the young athletic population and its surgical management continues to remain a controversial topic in sports medicine orthopedics. Anterior instability is the most common type encountered and is estimated to have an incidence rate of 0.08 per 1000 person-years in the general population; however, this figure is likely higher in the young athletic population. While in recent practice, arthroscopic surgery has become the new gold standard for management, reported failure rates as high as 26% and high recurrence rates in specific subpopulations such as young men in high collision sports have led to the consideration of alternative open procedures such as open Bankart repair, Latarjet, capsular shift, and glenoid bone grafting. These procedures may be preferred in specific patient subgroups such as young athletes involved in contact sports and those with Hill-Sachs defects and multidirectional instability, with postoperative recurrence rates of instability as low as 10%. The purpose of this review is to provide an overview of different open surgical techniques in the management of shoulder instability and summarize patient outcomes including recurrence rates for shoulder instability, return to sport, range of motion (ROM), muscle strength, and complications either individually by procedure or in comparison with other techniques, with special focus on their impact in the athletic population.

The Influence of Exposure in Training to the Open Bankart on the Declining Current Use of the Procedure

OBJECTIVE

The purpose of this study was to assess the influence of exposure to the open Bankart during residency and fellowship on the trend toward obsolescence of the procedure. Our hypothesis was that the open Bankart would be used with decreasing frequency and that this would be related to lack of exposure to the procedure during training.

METHODS

A survey consisting of 10 questions about their experience with the open Bankart procedure in residency, fellowship, and practice, as well as their current usage of it and other operations, was sent to members of the American Shoulder and Elbow Surgeons. Respondents were divided into groups based on the year of completion of training.

RESULTS

Statistical analysis of the responses revealed a notable trend of progressively diminished use of the open Bankart by those trained before 2000 compared with those completing training between 2001 and 2017. Ancillary findings included more surgeons using the open Bankart for revision cases than as a primary procedure and many using the Latarjet for patients with less than 15% or even no glenoid bone loss.

CONCLUSION

We concluded that a statistically notable trend of the decreasing use of the open Bankart was observed despite excellent reported outcomes and that its current role is most likely as a revision procedure. Lack of exposure to the operation in training is a major factor in its decline, and this decreasing exposure is self-perpetuating.

LEVEL OF EVIDENCE

Survey.

Are Patients Who Undergo the Latarjet Procedure Ready to Return to Play at 6 Months? A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group Cohort Study

BACKGROUND

The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss.

PURPOSE

(1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports.

RESULTS

Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) (P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02).

CONCLUSION

A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.