Painful posterior shoulder instability: Anticipating and preventing failure. A study in 25 patients

Arthroscopic Posterior Bankart Repair Using the Wilmington Portal to Facilitate Suture Anchor Implantation

Posterior shoulder instability (PSI) accounts for 2% to 10% of all shoulder instability, with recurrent posterior subluxation being the most common type. One of the most important risk factors is the presence of an anterior humeral notch (so-called reverse Hill-Sachs lesion), and the most common lesion in PSI is a posterior labral lesion. When conservative treatment fails, surgery is recommended to provide long-term stability, manage pain, and enable a return to previous activity levels. Most posterior labral tears are treated by an arthroscopic posterior Bankart procedure. Visualization of the posterior aspect of the glenohumeral joint is technically challenging in this procedure. The instrumental portal is also a matter of concern because there is no rotator interval posteriorly for cannula placement. The purpose of this article is to propose a technique using a secondary posterolateral Wilmington instrumental portal to perform easy and reproducible placement of the posterior suture anchor at a 45° angle to the glenoid rim. We recommend implementing this technique in patients with painful PSI or with a type B2 lesion according to the Moroder classification.

The Cartilage Wear Index: A new evaluation method to improve patient selection in surgical treatment of recurrent posterior glenohumeral instability

Background

The purpose of this study was to validate glenoid cartilage lesions as a negative prognostic factor and to define a new image-based preoperative evaluation method to identify surgical candidates for arthroscopic labral refixation with suture anchors in posterior shoulder instability.

Methods

Twenty-six patients who underwent arthroscopic posterior labral repair for shoulder instability were evaluated. Only patients with structural dynamic posterior instability were included. We evaluated on preoperative magnetic resonance arthrogram: glenoid version, humeral head subluxation, type of capsular insertion, and the cartilage lesions using the new Cartilage Wear Index (CWI). Two subgroups were analyzed with regard to the preoperative CWI and shoulder outcome scores: Single Assessment Numerical Evaluation (SANE) and Western Ontario Shoulder Instability Index (WOSI).

Results

The median age at operation was 28 (interquartile range = 21-33) years. Median overall postoperative outcome assessment demonstrated a SANE of 90 and a WOSI of 385. The median CWI was 1.02. Subgroup analysis revealed worse median WOSI and SANE scores in patients with a CWI >1.02 and a strong correlation between a high preoperative CWI and a higher postoperative WOSI score (R = 0.58; P = .038).

Conclusion

The CWI can be useful to identify patients who might obtain better outcomes when treated with arthroscopic labral repair in posterior shoulder instability.

Posterior glenoid bone block transfer for posterior shoulder instability: a systematic review

BACKGROUND

The purpose of this study is to systematically review the literature and evaluate patient-reported outcomes and complication/revision rates of bone block augmentation in the treatment of posterior shoulder instability (PSI).

METHODS

PubMed was searched according to PRIMSA guidelines to find clinical studies evaluating patient-reported outcomes, revision, and complication rates in posterior bone block for PSI. A literature search of MEDLINE, EMBASE, and the Cochrane Library was performed based on the PRISMA guidelines. Clinical studies reporting on the complications following posterior bone block were included.

RESULTS

Overall, 11 studies (level of evidence [LOE] III: 2, LOE IV: 9) met inclusion criteria, with 225 shoulders. Recurrent instability after the posterior bone block was found to be 9.8%. The overall complication rate was 13.8%, with 0.89% having graft complications, 11.1% having hardware complications, 0.4% having wound complications, 0.4% having nerve complications, and 0.89% having other complications. Residual pain was found in 11.6% of shoulders operated on. Patient-reported outcomes were evaluated most commonly by Rowe (81.4%), Constant (84.6%), and Walch-Duplay scores (81.6%).

CONCLUSION

There is a moderate rate of recurrence following posterior bone block for PSI. However, the patient-reported outcomes are high despite there being commonly reported persistent shoulder pain postoperatively.

Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis

Background:

The glenohumeral joint is one of the most frequently dislocated joints in the body, particularly in young, active adults.

Purpose:

To conduct a systematic review and meta-analysis to evaluate and compare outcomes between anterior versus posterior shoulder instability.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed using the PubMed, Cochrane Library, and MEDLINE databases (from inception to September 2019) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they were published in the English language, contained outcomes after anterior or posterior shoulder instability, had at least 1 year of follow-up, and included arthroscopic soft tissue labral repair of either anterior or posterior instability. Outcomes including return-to-sport (RTS) rate, postoperative instability rate, and pre- and postoperative American Shoulder and Elbow Surgeons (ASES) scores were recorded and analyzed.

Results:

Overall, 39 studies were included (2077 patients; 1716 male patients and 361 female patients). Patients with anterior instability had a mean age of 23.45 ± 5.40 years (range, 11-72 years), while patients with posterior instability had a mean age of 23.08 ± 8.41 years (range, 13-61 years). The percentage of male patients with anterior instability was significantly higher than that of female patients (odds ratio [OR], 1.36; 95% CI, 1.04-1.77; P = .021). Compared with patients with posterior instability, those with anterior instability were significantly more likely to RTS (OR, 2.31; 95% CI, 1.76-3.04; P < .001), and they were significantly more likely to have postoperative instability (OR, 1.53; 95% CI, 1.07-2.23; P = .018). Patients with anterior instability also had significantly higher ASES scores than those with posterior instability (difference in means, 6.74; 95% CI, 4.71-8.77; P < .001). There were no significant differences found in postoperative complications between the anterior group (11 complications; 1.8%) and the posterior group (3 complications; 1.6%) (OR, 1.12; 95% CI, 0.29-6.30; P = .999).

Conclusion:

Patients with anterior shoulder instability had higher RTS rates but were more likely to have postoperative instability compared with posterior instability patients. Overall, male patients were significantly more likely to have anterior shoulder instability, while female patients were significantly more likely to have posterior shoulder instability.

Acceptable Long-Term Outcomes of Arthroscopic Bone Grafting for Recurrent Posterior Shoulder Instability: Minimum Follow-Up of 5 Years

PURPOSE

To examine the long-term clinical outcome associated with arthroscopically placed autologous iliac crest bone graft (ICBG) for recurrent posterior shoulder instability.

METHODS

From January 2008 to December 2013, patients treated with posterior ICBG and a minimum follow-up of 5 years were included. Clinical outcome of patients operated with a posterior ICBG was analyzed with multiple patient-reported outcome measures included Constant (CS), American Shoulder and Elbow Surgeons (ASES), Walch-Duplay, and Rowe scores, shoulder subjective value, and pain visual analog score. Patient satisfaction was assessed by asking the patients their overall level of satisfaction at last follow-up on a 1 to 10 scale.

RESULTS

In total, 18 patients (19 shoulders) were included. At a mean follow-up of 7.3 years (range, 5-10 years), patients had significant improvements in their mean CS from 63 (standard deviation [SD] 18) to 80 (SD 18; P = .005), ASES from 57 (SD 18) to 81 (SD 18; P = .003), Walch-Duplay from 34 (SD 31) to 79 (SD 22; P < .001), and Rowe score from 37 (SD 23) to 79 (SD 24; P < .001). Pain level decreased from 5.6 (SD 2.5) preoperative to 2.3 (SD 2.3; P < .001) and shoulder subjective value improved 58 (SD 20) to 76 (SD 24; P = .002). Global satisfaction with the procedure was 8.4 (SD 2.1). Clinical significance was met or exceeded by 84% for CS and 89% of the patients for ASES and 95% met or exceeded satisfaction threshold for CS. There were 7 shoulders (37%) reoperated for symptomatic screw irritation.

CONCLUSIONS

This series reporting on the long-term follow-up after arthroscopic posterior ICBG for recurrent posterior shoulder instability demonstrates, despite a high number of reoperations for symptomatic screw irritation, its effectiveness with acceptable clinical outcomes and satisfied patients.

LEVEL OF EVIDENCE

IV, therapeutic case series.

Return to Play After Arthroscopic Stabilization for Posterior Shoulder Instability-A Systematic Review

Purpose

To ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after arthroscopic posterior shoulder stabilization.

Methods

Medline, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies on arthroscopic posterior shoulder stabilization. Studies were included if they reported RTP data or rehabilitation protocols and excluded if concomitant procedures influenced the rehabilitation protocol. Rate and timing of RTP, along with rehabilitation protocols, were assessed.

Results

This review found 25 studies, including 895 cases, meeting the study’s inclusion criteria. The majority of patients were male (82.7%), with an age range of 14 to 66 years and a follow-up range of 4 to 148.8 months. The overall RTP rate ranged from 62.7% to 100.0%, and 50.0% to 100.0% returned to the same level of play. Among collision athletes, the overall rate of RTP was 80.0% to 100.0%, with 69.2%-100.0% returning to the same level of play. In overhead athletes, the overall rate of RTP was 85.2% to 100.0%, with 55.6% to 100.0% returning to the same level of play. Four studies (128 patients) specifically addressed the timing of RTP, and the range to RTP was 4.3 to 8.6 months. Specific RTP criteria were reported in a majority of studies (60%), with the most reported item being restoration of strength (44%).

Conclusion

There is a high rate of return to sport after arthroscopic posterior shoulder stabilization, ranging from 4.3 to 8.6 months after surgery. Return to preinjury level is higher for collision athletes compared with overhead athletes. However, there is inadequate reporting of RTP criteria in the current literature, with no clear timeline for when it is safe to return to sport.

Level of Evidence

IV, systematic review of level II to IV studies

Posterior shoulder instability: a systematic review

INTRODUCTION

This review aims to provide information on outcomes of surgical procedures for soft tissue or bony glenoid and/or humeral abnormalities in case of posterior shoulder instability.

SOURCE OF DATA

A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'posterior instability', 'dislocation', 'reversed bony bankart', 'reversed Hill Sachs', and 'capsulolabral' was performed.

AREAS OF AGREEMENT

A total of 847 shoulders in 810 patients were included. A redislocation event occurred in 33 (8.7%) of 411 shoulders with soft tissue abnormalities and in 12 (9.1%) of 132 shoulders with bony abnormalities of the glenoid, humeral head or both.

AREAS OF CONTROVERSY

The optimal treatment modalities for posterior shoulder dislocation remain to be defined.

GROWING POINTS

Operative stabilization for posterior shoulder instability should be lesion-specific and should correct all components of the posterior instability.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for posterior shoulder instability.

No difference in outcomes of surgical treatment for traumatic and atraumatic posterior shoulder instability

BACKGROUND

Posterior shoulder instability is a rare pathology and accounts for 2-10% of all shoulder instabilities. The purpose of this study was to compare pain and functional scores following surgical treatment of traumatic and atraumatic PSI.

HYPOTHESIS

The authors hypothesize that patients with traumatic PSI are at greater risks of residual pain and recurrent subluxation.

MATERIAL AND METHODS

The records of 150 patients operated for PSI between 2000 and 2015 at 10 different centers were analysed. Inclusion criteria were symptomatic PSI (subluxation and/or pain) with radiographic signs of posterior glenoid erosion or fracture, posterior labral tears, or reverse Hill Sachs lesions. One hundred and seventeen patients were eligible, of which 84% presented symptoms of subluxation and/or dislocation, and 16% were painful without clinical symptoms of subluxation and/or dislocation. Patients were evaluated at 48±33months (range: 12-159) using the Constant, Walch-Duplay and Rowe scores, with pain on Visual Analogic Scale (pVAS).

RESULTS

Compared to atraumatic PSI, traumatic PSI was more prevalent in men (84.4% vs 61.9%, p=0.031), and tended to have fewer pain symptoms (15.8% vs 23.8%, n.s). Atraumatic PSI was more likely to affect the dominant arm, although the difference was not significant (81.0% vs 59.4%, n.s.). Traumatic PSI did not differ from atraumatic PSI in terms of preoperative lesional characteristics, procedures performed, or postoperative pain and instability. Although these differences were not statistically significant, it is worth noting that traumatic PSI patients experienced more recurrence of instability (15.6% vs 4.8%, p=0.298), and lower pain on VAS (1.5±2.3 vs 2.6±3.0, n.s.) compared to atraumatic PSI.

DISCUSSION

Functional scores did not significantly differ between traumatic and atraumatic PSI after surgery, although traumatic PSI patients tended to have a higher recurrence of instability, while atraumatic PSI patients tended to remain more painful.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Glenoid Cartilage Lesions Compromise Outcomes of Surgical Treatment for Posterior Shoulder Instability

Background:

Posterior shoulder instability is associated with nonspecific symptoms, including pain, subluxation, and functional impairment, which complicate its diagnosis and management. Owing to the rarity of the condition, there are no present decision tools for its diagnosis and treatment.

Purpose:

To investigate demographic, lesional, and surgical factors that influence functional outcomes in patients treated for posterior shoulder instability.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We analyzed the clinical and radiographic records of 150 patients treated surgically for isolated posterior shoulder instability at 10 centers between 2000 and 2015, of which 144 were eligible for inclusion: 114 men (79%) and 30 women (21%) (mean ± SD age, 28.7 ± 9.6 years). The mean time between onset of symptoms and surgery was 66 ± 75 months. Shoulder instability was of traumatic origin in 115 patients (80%). The primary treatment was bone-block procedures for 65 patients (45%), posterior Bankart repair for 67 (47%), and capsular plication for 12 (8%). Patients were assessed with the Constant and Walch-Duplay scores at a mean follow-up of 51 ± 32 months (range, 12-159 months). Uni- and multivariable regression analyses were performed to determine associations between clinical scores and sex, age, traumatic origin, type of lesion, type of procedure, and follow-up.

Results:

At final follow-up, subluxations or dislocations recurred in 24 patients (17%). The overall Constant score was 86.2 ± 14.5, with a pain component of 12.6 ± 3.5. The Walch-Duplay score was 79.8 ± 24.2. Multivariable regressions revealed that the presence of a glenoid cartilage lesion was the only factor associated with worse Constant score (beta = –10; P = .013) and Walch-Duplay score (beta = –16.7; P = .024) across all subcomponents.

Conclusion:

The only factor that jeopardized functional outcomes of posterior instability surgery was the presence of glenoid cartilage lesions. Knowing that shoulders with glenoid cartilage lesions are at greater risk of residual pain or instability could help manage patient expectation and justify faster intervention before lesions deteriorate.