Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Long-term Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13-Year Follow-up

Biomechanical comparison shows increased stability of an arthroscopic subscapular sling procedure compared to an open Latarjet reconstruction for anterior shoulder instability in specimens with major glenoid bone defect

Purpose

Recurrent anterior glenohumeral instability (RASI) is commonly treated with arthroscopic techniques, though their effectiveness in providing stability may diminish in cases of critical glenoid bone loss. This study aimed to compare the stability outcomes and range of motion (ROM) associated with an arthroscopic subscapular sling procedure (SSP), first introduced in 2015.

Methods

Sixteen fresh-frozen human cadaveric shoulder specimens were biomechanically evaluated in four conditions: native, injured, post-SSP and post-LP. Glenohumeral translations were measured under anterior, anteroinferior and inferior loading, while external rotation ROM was assessed in neutral and abducted positions. Testing was conducted using a robotic system for precise force and torque application. Specimens were prepared with a 20% glenoid bone defect and subjected to stability testing sequentially.

Results

The SSP significantly reduced glenohumeral translations compared to LP, particularly under anterior loading in neutral (p < 0.001), external rotation (p = 0.007) and abduction (p < 0.001) positions. Although the SSP demonstrated superior stability in these key positions, it did not consistently outperform the LP across all scenarios, as stability was similar between the two in the abducted and rotated position under anterior loading (p = 0.379). Under anteroinferior loading, the SSP showed comparatively better stability at neutral (p = 0.003) and abduction (p < 0.001), whereas the LP led to greater anteroinferior translations in these same positions (p = 0.002 and p = 0.014, respectively). The SSP outperformed the LP under inferior loading in neutral (p = 0.005) and abduction (p = 0.02) positions, though it did not fully restore stability to native shoulder levels. The SSP maintained ROM similar to native shoulders. LP allowed greater ROM, potentially compromising stability.

Conclusion

The SSP provided greater stability than the open Latarjet in most positions and did not limit ROM, suggesting it could be a viable, less invasive option for managing shoulder instability.

Level of Evidence

Not applicable.

The New Double-row Bankart Repair Recovered Shoulder Stability without Excessive Motion Limitation: A Case-Control Study with Single-row Bankart Repair

OBJECTIVES

Bankart lesion is one of the most common lesions of the glenohumeral joint. Several double-row suture methods were reported for Bankart repair, which could provide more stability, yet more motion limitation and complications. Therefore, we introduced a new double-row Bankart repair technique, key point double-row suture which used one anchor in the medial line. The purpose of this article is to investigate the clinical outcomes of this new method and to compare it with single-row suture.

METHODS

Seventy-eight patients receiving key point double-row suture or single-row suture from October 2010 to June 2014 were collected retrospectively. The basic information including gender, age, dominant arm, and number of episodes of instability was collected. Before surgery, the glenoid bone loss was measured from the CT scan. The visual analogue scale, American shoulder and elbow surgeons, the University of California at Los Angeles shoulder scale, and subjective shoulder value were valued before surgery and at the last follow-up.

RESULTS

Forty-four patients (24 patients receiving single-row suture and 20 patients receiving key point double-row suture) were followed up successfully. The follow-up period was 9.2 ± 1.1 years (range, 7.8-11.4 years). At the last follow-up, no significant differences were detected for any of the clinical scores. The recurrence rate was 12.5% for the single-row group and 10% for the double-row group, respectively (p = 0.795) 14 patients (31.8%) in the single-row group and nine patients (26.5%) in the double-row group were tested for active range of motion. A statistically significant difference was found only for the internal rotation at 90° abduction (48.9° for single-row and 76.7° for key point double-row, p = 0.033).

CONCLUSION

The key point double-row sutures for Bankart lesions could achieve similar long-term outcomes compared with single-row suture, and one medial anchor did not result in a limited range of motion. The low recurrence rate and previous biomechanical results also indicate the key point double-row suture is a reliable method.

Arthroscopic Labral Reconstruction With a Modified Inferior Capsular Shift Allows Return to Sport and Excellent Outcomes in Contact and Noncontact Athletes With Anterior Shoulder Instability at Minimum 5-Year Follow-Up

PURPOSE

To compare return to sport, functional outcomes, recurrence of instability, and osteoarthritis (OA) between collision/contact and limited/noncontact athletes following arthroscopic labral reconstruction with a modified inferior capsular shift for anterior shoulder instability.

METHODS

Athletes underwent an arthroscopic labral reconstruction with a modified inferior capsular shift by the senior author between 1999 and 2018. Inclusion criteria were labral stripping from 12 (just beyond the biceps anchor) to 6 o'clock, less than 20% glenoid bone loss, active sports participation, and no previous surgery. Athletes were divided into collision/contact and limited/noncontact groups. Outcome measures, physical examination, and radiographic evaluation were collected at a minimum 5-year follow-up. Reoperations or any subjective laxity were considered failures. Radiographs were analyzed for OA using the Samilson-Prieto Radiological Classification.

RESULTS

Ninety-two patients underwent arthroscopic labral reconstruction with a modified inferior capsular shift. Sixty-four met the inclusion criteria. Thirty-eight (age = 26.0 ± 8.0 years) participated in at least 1 collision/contact sport, and 26 (age = 38.0 ± 9.0 years) participated in limited/noncontact sports. Two (5%) collision/contact and 3 (12%) limited/noncontact athletes had traumatic reinjury requiring revision surgery. Of the remaining athletes (59/64), minimum 5-year follow-up was obtained on 54 (92%), with a mean follow-up of 12 ± 4 years (range 5-23 years). All athletes returned to their original sport at the same level. There was no significant difference between collision/contact and limited/noncontact athletes in timing of return to sports (5.2 ± 1.9 and 6.0 ± 3.1 months, respectively; P = .389). There were no significant differences between groups on any outcomes scores.

CONCLUSIONS

Arthroscopic labral reconstruction with a modified inferior capsular shift addressed anterior instability with return to sport for both collision/contact and limited/noncontact athletes with excellent functional and clinical outcomes, full shoulder range of motion, and a low prevalence of advanced OA at minimum 5-year follow-up. This modified technique resulted in a low failure rate in both limited/noncontact and collision/contact athletes.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Knotless Bioabsorbable Anchors Placed on the Glenoid Face for Arthroscopic Bankart Repair

BACKGROUND

Quantitative analysis of the glenoid face knotless-type anchor placement for arthroscopic Bankart repair has not been reported.

PURPOSE

To evaluate the clinical and radiologic outcomes after arthroscopic Bankart repair using knotless bioabsorbable anchors depending on the anchor location.

STUDY DESIGN

Case series, Level of evidence, 4.

METHODS

A total of 124 patients (113 men and 11 women; age, 25.6 ± 7.5 years; follow-up time, 46.5 ± 18.2 months [range, 6.2-75.5 months]) who underwent arthroscopic Bankart repair with the bioabsorbable knotless anchor between 2017 and 2021 were included in this study. Among them, 118 patients were observed for >2 years (mean, 48.2 ± 16.8 months [range, 24-75.5 months]) and were analyzed for final clinical and radiologic outcomes. Using postoperative 6-month magnetic resonance imaging, remnant glenoid (%) and labral height were measured. Shoulder range of motion (ROM), radiographic osteoarthritic change, dislocation, apprehension test, and return to sports were recorded. Three groups were established based on the remnant glenoid, which represented the percentage of the exposed glenoid anteroposterior diameter to the original diameter using the best-fit circle method-group A: lower quartile; group B: interquartile; and group C: upper quartile-and variables were analyzed.

RESULTS

Overall, the remnant glenoid was 57% ± 6.4% (range, 41.5%-75%) after the surgery. Osteoarthritic change, dislocations, and positive apprehension tests were observed in 5 (4.2%), 4 (3.4%), and 12 (10.2%) patients, respectively. A total of 34 (28.8%) and 64 (54.2%) patients could return to sports without and with restrictions, respectively. Comparing groups A, B, and C, postoperative labral height (7 ± 1, 7 ± 2, and 7 ± 1 mm; P = .623), final osteoarthritic change (1, 4, and 0; P = .440), positive apprehension tests (5, 5, and 2; P = .387), and return to sports (complete/restricted/unable, 6/18/5, 19/29/11, 9/17/4; P = .769) were not different. All ROM were similar across the groups (all P > .054), except for external rotation (ER) at postoperative 6 months (41.3°± 12.8°; 50.2°± 18.5°; and 49.8°± 15.2°; P = .050). However, ER after 1 year was similar across the groups (all P > .544). In further analysis, patients with positive apprehension tests had lower labral height compared with others (5 [4-6] mm and 7 [6-8] mm; P < .001).

CONCLUSION

In arthroscopic Bankart repair, the placement of knotless bioabsorbable anchors on the glenoid face, combined with the remplissage procedure or rotator interval closure, resulted in a low recurrence rate and moderate return to sports. However, most patients had some restrictions in returning to sports. Moreover, this technique was not associated with postoperative arthritis and shoulder stiffness, including ER deficit, which was not affected by the position of the anchor on the glenoid face for a minimum 2-year follow-up.

Outcomes of total shoulder arthroplasty in patients with prior anterior shoulder instability: minimum 5-year follow-up

BACKGROUND

Patients with a history of anterior shoulder instability (ASI) commonly progress to glenohumeral arthritis or even dislocation arthropathy and often require total shoulder arthroplasty (TSA). The purposes of this study were to (1) report patient-reported outcomes (PROs) after TSA in patients with a history of ASI, (2) compare TSA outcomes of patients whose ASI was managed operatively vs. nonoperatively, and (3) report PROs of TSA in patients who previously underwent arthroscopic vs. open ASI management.

METHODS

Patients were included if they had a history of ASI and had undergone TSA ≥5 years earlier, performed by a single surgeon, between October 2005 and January 2017. The exclusion criteria included prior rotator cuff repair, hemiarthroplasty, or glenohumeral joint infection before the index TSA procedure. Patients were separated into 2 groups: those whose ASI was previously operatively managed and those whose ASI was treated nonoperatively. This was a retrospective review of prospective collected data. Data collected was demographic, surgical and subjective. The PROs used were the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score. Failure was defined as revision TSA surgery, conversion to reverse TSA, or prosthetic joint infection. Kaplan-Meier survivorship analysis was performed.

RESULTS

This study included 36 patients (27 men and 9 women) with a mean age of 56.4 years (range, 18.8-72.2 years). Patients in the operative ASI group were younger than those in the nonoperative ASI group (50.6 years vs. 64.0 years, P < .001). Operative ASI patients underwent 10 open and 11 arthroscopic anterior stabilization surgical procedures prior to TSA (mean, 2 procedures; range, 1-4 procedures). TSA failure occurred in 6 of 21 patients with operative ASI (28.6%), whereas no failures occurred in the nonoperative ASI group (P = .03). Follow-up was obtained in 28 of 30 eligible patients (93%) at an average of 7.45 years (range, 5.0-13.6 years). In the collective cohort, the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score significantly improved, with no differences in the postoperative PROs between the 2 groups. We found no significant differences when comparing PROs between prior open and prior arthroscopic ASI procedures or when comparing the number of prior ASI procedures. Kaplan-Meier analysis demonstrated a 79% 5-year survivorship rate in patients with prior ASI surgery and a 100% survivorship rate in nonoperatively managed ASI patients (P = .030).

CONCLUSION

At mid-term follow-up, patients with a history of ASI undergoing TSA can expect continued improvement in function compared with preoperative values. However, TSA survivorship is decreased in patients with a history of ASI surgery compared with those without prior surgery.

Patients Have a 15% Redislocation Rate After Arthroscopic Bankart Repair With a Knotless Technique

Purpose

To evaluate the redislocation rate after arthroscopic Bankart repair (ABR) with a standardized knotless anchor technique in a consecutive series of patients with anterior glenohumeral instability.

Methods

Inclusion criteria were patients who underwent ABR by a single surgeon between January 2008 and December 2018 with a minimum follow up of 2 years. We collected data through phone interviews, Western Ontario Shoulder Instability Index, and review of patient records. The primary outcome was redislocation and secondary outcomes were recurrent subluxations, reoperation, postoperative complications, patient satisfaction, and functional outcomes. We also performed survival analysis and risk factor analysis.

Results

Of 88 patients (91 shoulders) who underwent ABR during the inclusion period, 70 patients (73 shoulders) were included (follow-up rate 80%). The mean follow-up was 7.5 years (range 2-12 years). Redislocation occurred in 15% (95% confidence interval [CI] 7.8%-25.4%) of patients at a mean of 41 months after surgery (range 6-115 months). The reoperation rate for recurrent redislocation was 4.1%. Overall, 90.4% reported being currently satisfied with their shoulder and the mean Western Ontario Shoulder Instability Index score at follow-up was 73.8% (range 8.3%-99.9%). Patients with redislocation were younger at primary operation than patients with no redislocation (mean 21 years vs 28 years; P = .023) and adjusted hazard ratio for age was 0.86 (95% CI 0.74-0.99; P = .033). It was more common to have less than 3 anchors in patients with redislocation (P = .024), but adjusted hazard ratio was 4.42 (95% CI 0.93-21.02; P = .061).

Conclusions

The redislocation rate after ABR with a standardized knotless anchor technique in a consecutive series of patients with anterior glenohumeral instability was found to be 15% after a minimum 2-year follow-up (mean 7.5).

Level of Evidence

Level IV, therapeutic case-series.

Intra-articular soft arthroscopic Latarjet technique as a Bankart-plus procedure for type V superior labrum anterior-posterior lesion: lower rate of instability recurrence and better functional outcomes of a prospective cohort study

BACKGROUND

Intra-articular soft arthroscopic Latarjet technique (in-SALT) involves augmentation of arthroscopic Bankart repair (ABR) with soft tissue tenodesis of long head of biceps to upper subscapularis. This study was conducted to investigate superiority of outcomes of in-SALT-augmented ABR over those of concurrent ABR and anterosuperior labral repair (ASL-R) in management of type V superior labrum anterior-posterior (SLAP) lesion.

METHODS

This prospective cohort study (conducted between January 2015 and January 2022) included 53 patients with arthroscopic diagnosis of type V SLAP lesion. Patients were allocated into 2 consecutive groups: group A of 19 patients managed with concurrent ABR/ASL-R and group B of 34 patients managed with in-SALT-augmented ABR. Outcome measurements included 2-year postoperative pain, range of motion, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Rowe instability scores. Failure was defined as frank/subtle postoperative recurrence of glenohumeral instability or objective diagnosis of Popeye deformity.

RESULTS

The statistically matched studied groups showed significant postoperative improvement in outcome measurements. However, group B demonstrated significantly better 3-month postoperative visual analog scale score (3.6 vs. 2.6, P = .006) and 24-month postoperative external rotation at 0° abduction (44° vs. 50°, P = .020) and ASES (84 vs. 92, P < .001) and Rowe (83 vs. 88, P = .032) scores. Rate of postoperative recurrence of glenohumeral instability was relatively lower in group B (10.5% vs. 2.9%, P = .290). No Popeye deformity was reported.

CONCLUSION

For management of type V SLAP lesion, in-SALT-augmented ABR yielded a relatively lower rate of postoperative recurrence of glenohumeral instability and significantly better functional outcomes compared with concurrent ABR/ASL-R. However, currently reported favorable outcomes of in-SALT should be validated via further biomechanical and clinical studies.

Artificial Intelligence Can Define and Predict the "Optimal Observed Outcome" After Anterior Shoulder Instability Surgery: An Analysis of 200 Patients With 11-Year Mean Follow-Up

Purpose

The purpose of this study was to use unsupervised machine learning clustering to define the "optimal observed outcome" after surgery for anterior shoulder instability (ASI) and to identify predictors for achieving it.

Methods

Medical records, images, and operative reports were reviewed for patients <40 years old undergoing surgery for ASI. Four unsupervised machine learning clustering algorithms partitioned subjects into "optimal observed outcome" or "suboptimal outcome" based on combinations of actually observed outcomes. Demographic, clinical, and treatment variables were compared between groups using descriptive statistics and Kaplan-Meier survival curves. Variables were assessed for prognostic value through multivariate stepwise logistic regression.

Results

Two hundred patients with a mean follow-up of 11 years were included. Of these, 146 (64%) obtained the "optimal observed outcome," characterized by decreased: postoperative pain (23% vs 52%; P < 0.001), recurrent instability (12% vs 41%; P < 0.001), revision surgery (10% vs 24%; P = 0.015), osteoarthritis (OA) (5% vs 19%; P = 0.005), and restricted motion (161° vs 168°; P = 0.001). Forty-one percent of patients had a "perfect outcome," defined as ideal performance across all outcomes. Time from initial instability to presentation (odds ratio [OR] = 0.96; 95% confidence interval [CI], 0.92-0.98; P = 0.006) and habitual/voluntary instability (OR = 0.17; 95% CI, 0.04-0.77; P = 0.020) were negative predictors of achieving the "optimal observed outcome." A predilection toward subluxations rather than dislocations before surgery (OR = 1.30; 95% CI, 1.02-1.65; P = 0.030) was a positive predictor. Type of surgery performed was not a significant predictor.

Conclusion

After surgery for ASI, 64% of patients achieved the "optimal observed outcome" defined as minimal postoperative pain, no recurrent instability or OA, low revision surgery rates, and increased range of motion, of whom only 41% achieved a "perfect outcome." Positive predictors were shorter time to presentation and predilection toward preoperative subluxations over dislocations.

Level of Evidence

Retrospective cohort, level IV.

Arthroscopic Bankart repair versus conservative treatment for first-time traumatic anterior shoulder dislocation: a systematic review and meta-analysis

BACKGROUND

Shoulder is vulnerable to dislocation owing to its anatomical structure and the increasing popularity of contact sports in young population. The management of first-time anterior shoulder dislocation in this group is still controversial and the prognosis are varied. This review aimed to compare the results of arthroscopic Bankart repair and conservative management for first-time traumatic anterior shoulder dislocation in young active patients.

METHODS

Databases were searched till November 2021, and comparative studies between arthroscopic Bankart repair and conservative management for first-time traumatic anterior shoulder dislocation in young population were selected. Methodological quality of the studies was assessed according to the Cochrane Back Review Group 12-item scale. Outcome measures included recurrence of instability, return to play, subsequent instability surgery, and shoulder functional scores.

RESULTS

The search returned 12 eligible trials with 786 participants. All the trials were of prospective design. After arthroscopic Bankart repair, patients experienced significantly less re-dislocation (7.5% vs. 53.0%, p < 0.00001, I² = 0%), subluxation (3.1% vs. 24.2%, p < 0.0001, I² = 0%), positive apprehension test (7.3% vs. 25.8%, p = 0.002, I² = 11%), and subsequent surgical treatment for instability (5.6% vs. 37.8%, p < 0.00001, I² = 0%) when compared with those underwent conservative management. And more patients returned to play (83.5% vs. 66.0%, p = 0.03, I² = 81%) after arthroscopic Bankart repair. Outcomes regarding the functional scores did not reach a significant difference between the two cohorts.

CONCLUSIONS

Arthroscopic Bankart repair showed superiority over conservative management in terms of recurrence, return to play, and subsequent instability surgery during the follow-up in young active patients that encountered first episode of dislocation. As long-term prognosis is comparable, an immediate surgical stabilization might not be suitable for everyone.

Predictors of Bone Loss in Anterior Glenohumeral Instability

BACKGROUND

Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis.

HYPOTHESIS/PURPOSE

The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects.

RESULTS

Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher.

CONCLUSION

An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes.

REGISTRATION

NCT02075775 (ClinicalTrials.gov identifier).

Fourteen years of follow-up after first arthroscopic Bankart repair in athletes: functional outcomes and magnetic resonance imaging findings

BACKGROUND

The arthroscopic Bankart procedure is the most performed surgery for shoulder stabilization. Short-term to midterm results are well studied; however, long-term results over 10 years are rare.

PURPOSE

This study evaluates the long-term results and magnetic resonance imaging (MRI) findings in athletes at a mean follow-up of 14 years after an arthroscopic Bankart stabilization as well as risk factors for osteoarthritis.

METHODS

A total of 63 athletes had an arthroscopic Bankart repair between 2001 and 2008, of whom 46 patients (73.0%) participated in the final follow-up. The Constant, Rowe, and Western Ontario Shoulder Instability Index (WOSI) score and the rate of return to sports were evaluated. Glenohumeral osteoarthritis was assessed using the Samilson-Prieto classification. Known risk factors for osteoarthritis were analyzed. MRI findings (bone marrow edema, cysts, and joint effusion) were analyzed.

RESULTS

The average follow-up was 14 years. Assessment was performed on 46 athletes with an average age of 21.6 at the time of surgery. The overall redislocation rate was 21.7%. The Constant score was 96.7, the Rowe score was 83.4, and the Western Ontario Shoulder Instability Index score was 90.7 out of 100. A total of 84.8% of the athletes returned to their initial sports level. Glenohumeral osteoarthritis occurred in 28.1%. Known risk factors for osteoarthritis were confirmed. Further MRI findings were rare.

CONCLUSIONS

Arthroscopic Bankart repair in athletes shows good long-term clinical results. However, this is only in patients without osteoarthritis, which was rare, but was confirmed as a risk factor. We assume that resorption of anchors differs in patients. If it does have an impact on developing arthrosis, this should be confirmed in further studies.

The arthroscopic Bankart operation: a 10-year follow-up study

INTRODUCTION

Traumatic shoulder instability most frequently occurs in young people often during sports events. Currently, the arthroscopic Bankart repair is the therapy of choice in the absence of extensive glenoid bone loss and has proved to be a safe and effective procedure. Nevertheless, we see recurrence of instability-especially if new trauma happens-and further data are needed to guide the right decision-making for these often young patients. The purpose of this study was to determine the long-term outcome 10 years after arthroscopic Bankart operation in terms of satisfaction of the patient, functional result, complications, recurrent instability, and development of osteoarthritis, and to look after possible risk factors for recurrence of instability and statistical proof of these.

MATERIALS AND METHODS

Thirty-nine out of 49 patients underwent physical examination of both shoulders. We could perform a postoperative shoulder a-p X-ray in 28 patients. According to Samilson, [24] the extent of osteoarthritis was measured. The Constant score and the postoperative ROWE score were determined for both shoulders as well as the WOSI Score. In 25 cases, we calculated the ISIS Score.

RESULTS

We could reach out to 89.6% of patients and 79.6% could be physically examined. The vast majority of 95.5% are either very satisfied or satisfied with the result at the time we ended the follow-up. The mean Constant score of 95.5 reflects this result. In contrast to this, we found at the same time in 15.3% ongoing clinical signs of instability of the concerning shoulder, even though 9.1% had to be re-operated for recurrent instability in between the follow-up timeline and we found in the X-rays (57.1% of all patients) in 35.7% at least moderate and in 10.7% severe signs of osteoarthritis. The Constant score but not the ROWE score differed significantly in patients with no or mild compared to those with moderate-to-severe osteoarthritis.

CONCLUSIONS

The arthroscopic Bankart stabilization procedure showed after 10 years to be a very safe operation and to be able to produce a satisfying and functional very good long-term result-reflected by the Constant score. We assume that the extent of osteoarthritis seems to be the determining factor of the very good functional result, even though ongoing instability was present in 15.3% of the patients.

Glenohumeral Arthropathy After Arthroscopic Surgery for Shoulder Instability: Outcomes at 16-Year Follow-up

Background

Glenohumeral arthropathy after surgery for traumatic shoulder instability is a condition whose etiology and long-term course are still unknown.

Purpose

To evaluate the risk factors for the onset of arthropathy and to assess the relationship between the degree of arthropathy and final outcomes.

Study Design

Case series; Level of evidence, 4.

Methods

We included patients who underwent surgery for a shoulder instability at a single institution between 2000 and 2004. The following variables were studied for relationship with functional outcomes: sex, age, body mass index, smoking at the time of surgery, number of episodes of shoulder dislocation, and time from first dislocation to surgery. The number of anchors used and their position were also evaluated. Functional outcomes were assessed using the Constant-Murley, Western Ontario Shoulder Instability Index, and Rowe scores, and results were compared with the onset of arthropathy according to Buscayret classification. Spearman and Pearson correlations were performed for the association between glenohumeral arthritis (Buscayret grade) and the study variables, the Mann-Whitney U test and Student t test were used to compare outcome scores with the study variables, and the Kruskal-Wallis test was used to compare Buscayret grade and outcome scores.

Results

A total of 26 shoulders in 25 patients were analyzed, finding a high rate (54%) of arthropathy at a minimum follow-up of 16 years. Patients with Buscayret grade 4 had the worst functional results (P = .007). However, 80% of patients with Buscayret grade ≤3 had excellent Constant-Murley scores. A significant relationship was found between degree of arthropathy and patients who were smokers before surgery (P < .01). No relationship was found between the onset of arthropathy and the other variables analyzed.

Conclusion

Postinstability glenohumeral arthropathy was not correlated with functional outcomes except in those patients with advanced arthroplasty (Buscayret grade 4). A direct relationship was found between smoking before surgery and the onset of glenohumeral arthropathy.

The Effect of Glenoid Version on Glenohumeral Instability

In recent years, an appreciation for the dynamic relationship between glenoid and humeral-sided bone loss and its importance to the pathomechanics of glenohumeral instability has substantially affected modern treatment algorithms. However, comparatively less attention has been paid to the influence of glenoid version on glenohumeral instability. Limited biomechanical data suggest that alterations in glenoid version may affect the forces necessary to destabilize the glenohumeral joint. However, this phenomenon has not been consistently corroborated by the results of clinical studies. Although increased glenoid retroversion may represent an independent risk factor for posterior glenohumeral instability, this relationship has not been reliably observed in the setting of anterior glenohumeral instability. Similarly, the effect of glenoid version on the failure rates of surgical stabilization procedures remains poorly understood.

Impact of Prior Anterior Instability on Shoulder Arthroplasty Outcomes: A Systematic Review

Background

Anterior shoulder instability (ASI) is a frequently encountered pathology. Patients with a history of ASI have an increased rate of developing glenohumeral osteoarthritis and becoming candidates for shoulder arthroplasty. This systematic review aims to synthesize outcomes for patients undergoing shoulder arthroplasty with a history of ASI.

Methods

A comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, OVID Medline, Scopus, CINAHL, Web of Science, and Cochrane databases for studies evaluating the impact of prior ASI on total shoulder arthroplasty (TSA), reverse TSA, and/or hemiarthroplasty outcomes, with a minimum follow-up of 12 months. Studies were graded by level of evidence and data concerning patient demographics and outcomes were extracted.

Results

Sixteen articles met the inclusion criteria, including 596 patients (413 male, 181 female). The average age of the control and prior ASI groups were 57.5 and 57.0 years, respectively. Overall, 251 patients were treated operatively, 132 nonoperatively, and 213 were controls without a history of prior ASI. Shoulder arthroplasty techniques included TSA (436 shoulders), reverse TSA (130 shoulders), and hemiarthroplasty (14 shoulders). Prior anterior stabilization management included soft tissue repair, bony augmentation, and nonoperative treatment. Almost all studies reported no significant difference in subjective and functional arthroplasty outcomes between control and prior ASI groups, or between patients with prior ASI treated nonoperatively vs. surgically.

Conclusion

Shoulder arthroplasty in the setting of prior ASI results in improved subjective and functional outcome scores that are comparable to patients without a history of instability.

Prevalence of and factors associated with osteoarthritis and pain in retired Olympians compared with the general population: part 2 - the spine and upper limb

OBJECTIVES

(1) To determine the prevalence of spine and upper limb osteoarthritis (OA) and pain in retired Olympians; (2) identify risk factors associated with their occurrence and (3) compare with a sample of the general population.

METHODS

3357 retired Olympians (44.7 years) and 1735 general population controls (40.5 years) completed a cross-sectional survey. The survey captured demographics, general health, self-reported physician-diagnosed OA, current joint/region pain and significant injury (lasting ≥1 month). Adjusted ORs (aORs) compared retired Olympians and the general population.

RESULTS

Overall, 40% of retired Olympians reported experiencing current joint pain. The prevalence of lumbar spine pain was 19.3% and shoulder pain 7.4%, with lumbar spine and shoulder OA 5.7% and 2.4%, respectively. Injury was associated with increased odds (aOR, 95% CI) of OA and pain at the lumbar spine (OA=5.59, 4.01 to 7.78; pain=4.90, 3.97 to 6.05), cervical spine (OA=17.83, 1.02 to 31.14; pain=9.41, 6.32 to 14.01) and shoulder (OA=4.91, 3.03 to 7.96; pain=6.04, 4.55 to 8.03) in retired Olympians. While the odds of OA did not differ between Olympians and the general population, the odds of lumbar spine pain (1.44, 1.20 to 1.73), the odds of shoulder OA after prior shoulder injury (2.64, 1.01 to 6.90) and the odds of cervical spine OA in female Olympians (2.02, 1.06 to 3.87) were all higher for Olympians compared with controls.

CONCLUSIONS

One in five retired Olympians reported experiencing current lumbar spine pain. Injury was associated with lumbar spine, cervical spine and shoulder OA and pain for Olympians. Although overall OA odds did not differ, after adjustment for recognised risk factors, Olympians were more likely to have lumbar spine pain and shoulder OA after shoulder injury, than the general population.

Patient Age and Surgical Intervention as Risk Factors for the Development of Osteoarthritis After Posterior Shoulder Instability: A Population-Based Study

Background

Diagnosis and treatment of posterior shoulder instability (PSI) has improved with advances in imaging and surgical technique. However, the relationship between PSI and osteoarthritis (OA) remains unclear.

Purpose

To evaluate a population-based cohort to (1) determine the rate of symptomatic OA, (2) identify patient characteristic risk factors for OA, and (3) evaluate the effect of posterior capsulolabral repair on OA progression.

Study Design

Case-control study; Level of evidence, 3.

Methods

After review of 324 patient records, we included 115 patients (14 female, 101 male) diagnosed with PSI between January 1994 and July 2012 with an average follow-up of 12.5 years (range, 5-23 years). Medical records were reviewed for patient characteristics, injury characteristics, surgical details (if any), and radiographic progression of OA. Kaplan-Meier survival was used to estimate survival free of OA; characteristics associated with OA progression were determined via univariate Cox regression models, and associated 95% CIs and hazard ratios (HRs) are presented.

Results

Overall, 14% (16/115) of patients had radiographic progression of symptomatic glenohumeral arthritis, with 5-year survival of 88.3% (95% CI, 79.7%-97.3%). Older age at the time of instability diagnosis was associated with arthritis progression (10-year unit HR, 1.95; 95% CI, 1.26-3.03). Patients who underwent surgery demonstrated increased radiographic progression of OA (HR, 4.03; 95% CI, 1.23-13.23). There was a trend of increased OA in patients treated with labral debridement compared with repair despite lower baseline levels of OA; however, this difference was not statistically significant (P = .09).

Conclusion

Symptomatic glenohumeral arthritis is not seen routinely in patients with PSI. Although uncommon, an age of at least 30 years at the time of diagnosis and surgical intervention were identified as risk factors for developing symptomatic arthritis at long-term follow-up.

Long-Term Results of Arthroscopic Bankart Repair for Anterior Glenohumeral Instability: Does Associated Postero-inferior Capsulolabral Repair Still Have a Role?

PURPOSE

To compare the outcomes of arthroscopic anterior Bankart repair with and without associated postero-inferior capsulolabral repair as treatment of anterior glenohumeral instabiliy at minimun 10 year follow-up.

METHODS

A retrospective comparative study including patients who underwent arthroscopic anterior Bankart repair to treat anterior glenohumeral instability with glenoid bone-loss < 15% between January 2000 and February 2010 was performed. Outcomes were reported as recurrence rate, type of recurrence (dislocation or subluxation), need for revision surgery, range of motion, complications, and functional status. Outcomes were compared depending on whether a postero-inferior capsulolabral repair was added to the anterior Bankart repair.

RESULTS

70 shoulders [59 males, mean age 28.2 (range 14-56), mean follow-up 146.1 (range 120-208) months] were included. Recurrence occurred in 9 cases (12.8%), including 3 dislocations and 6 subluxations. Revision surgery was needed in 8 (11.4%). Mean Rowe score improved from 29.7 (11.6) preoperatively to 87.1 (12.3) postoperatively. 83.3% returned to previous sports activities. Mean forward flexion changed from 173.5° (19.2) to 168.4º(10.4) (P < 0.01), external rotation from 81.4° (18) to 75.7° (10.5) (P < 0.01), and internal rotation decreased from 66.2% reaching T12 to 14.1% (P < 0.01). Addition of postero-inferior capsulolabral repair did not influence any of the outcomes significantly.

CONCLUSION

Postero-inferior capsulolabral repair added to anterior Bankart repair as treatment of anterior glenohumeral instability in abscence of significant glenoid bone-loss did not influence the outcomes in terms of recurrence, range of motion, return to sports, or functional status, compared to isolated anterior Bankart repair at 12.2 year follow-up.

LEVEL OF EVIDENCE

Level III.

No Difference Between Anchorless and Traditional Suture Anchors in Arthroscopic Bankart Repair: A Clinical Comparison

Background

Shoulder instability and recurrent dislocations are common problems encountered by orthopedic surgeons and are frequently associated with a Bankart lesion. These are classically treated with either open or arthroscopic repair utilizing traditional suture anchors, though anchorless fixation techniques have recently been developed as an alternate fixation method that reduces native bone loss and has comparable pull-out strength.

Methods

A retrospective review was performed at a single institution for patients who underwent Bankart repair from January 2008 through February 2014. American Shoulder and Elbow Surgeons (ASES) questionnaires were mailed to 35 patients with anchorless fixation and 35 age-, gender-, and surgeon-matched patients with traditional suture anchors. Statistical analysis was performed comparing re-dislocation, additional surgery, and ASES scores with statistical significance set at p < 0.05.

Results

Eleven patients in the anchorless implant group and 15 patients in the anchor group completed the questionnaire. The mean follow-up was 4.1 years in the anchorless group and 5.6 years in the anchor group (p=0.04). The number of implants was 4.82 in the anchorless group and 3.87 in the anchor group (p = 0.04). No difference was found in re-dislocation rates (p = 0.80) or additional surgery on the affected shoulder (p = 0.75). ASES scores were found to have no statistical difference (89.89 for the anchorless group versus 85.37 for the anchor group; p = 0.78).

Conclusion

In patients undergoing arthroscopic Bankart lesion repair with traditional anchors compared to anchorless fixation, there appears to be no difference in shoulder re-dislocation rates, recurrent ipsilateral shoulder surgery, or ASES scores.

Cirurgia de Bankart artroscópica: Resultados clínicos com seguimento mínimo de 10 anos

Objective  To evaluate the functional outcome of patients submitted to arthroscopic Bankart repair in the long-term.

Methods  Retrospective evaluation of 41 patients (45 shoulders) operated between 1996 and 2009 followed-up for a mean period of 14.89 years. Functional scores were analyzed by the University of California, Los Angeles (UCLA) and Carter-Rowe scores, physical examination, and analysis of medical records.

Results  The Carter-Rowe score showed an average improvement of 46.11 points, with a final average of 85.89 points, and the UCLA score showed an average improvement of 31.33 points. Ten patients (22.22%) relapsed, with the number of preoperative dislocations being the most correlated factor.

Conclusion  It was demonstrated that the number of preoperative dislocations negatively influenced the failure rate.

Dynamic Double-Sling Augmentation Prevents Anteroinferior Translation for Recurrent Anteroinferior Shoulder Dislocation With 20% Glenoid Bone Loss: A Cadaveric Biomechanical Study

PURPOSE

To biomechanically compare the dynamic double-sling with single-sling augmentation using the conjoined tendon (CT) with 20% of an anteroinferior glenoid bone defect under the high loads in shoulders.

METHODS

With the shoulder in 60° of glenohumeral abduction and 60° of external rotation, the 12 shoulders stability was tested sequentially in 5 conditions: intact, 20% glenoid bone loss, Bankart repair, single-sling augmentation with the CT, and double-sling augmentation with both the CT and long head of the biceps tendon (LHBT). The anteroinferior humeral head (HH) translation force of 20N, 30N, 40N, 50N, or 60N was applied to determine the shoulder stability in each condition.

RESULTS

The total HH translation over 8.77 mm represented the anteroinferior shoulder instability (95% confidence interval of bone defect: 7.76-8.77 mm). A significant increase in anteroinferior HH translation was demonstrated after the creation of 20% glenoid bone defect under the 20N translational force (10.52 ± 0.71 mm). Structural failure after the Bankart repair and the single-sling augmentation under the 30N (9.84 ± 1.25 mm) and 40N (9.59 ± 0.66 mm) translational forces, respectively, were observed. The double-sling augmentation effectively prevented the anteroinferior HH translation under the translational force of less than 40N, and only half of the augmentation structure (8.25 ± 1.66 mm) had failed under the 50N translational forces.

CONCLUSION

In the absence of any Hill-Sachs lesion and when tested at 60° abduction and external rotation in shoulders with 20% glenoid bone defects, at time-zero, the double-sling augmentation strategy could effectively prevent anteroinferior translation when compared with the Bankart repair or the single-sling augmentation technique under all magnitudes of the translational force in biomechanical simulation. Nevertheless, none of the constructs restored the HH translation to the normal intact state.

CLINICAL RELEVANCE

Double-sling augmentation technique may represent a reliable option for preventing anteroinferior translation.

Dislocation Arthropathy of the Shoulder

Glenohumeral osteoarthrosis (OA) may develop after primary, recurrent shoulder dislocation or instability surgery. The incidence is reported from 12 to 62%, depending on different risk factors. The risk of severe OA of the shoulder following dislocation is 10 to 20 times greater than the average population. Risk factors include the patient’s age at the first episode of instability or instability surgery, bony lesions, and rotator cuff tears. For mild stages of OA, arthroscopic removal of intraarticular material, arthroscopic debridement, or arthroscopic arthrolysis of an internal rotation contracture might be sufficient. For severe stages, mobilization of the internal rotation contracture and arthroplasty is indicated. With an intact rotator cuff and without a bone graft, results for anatomical shoulder arthroplasty are comparable to those following primary OA. With a bone graft at the glenoidal side, the risk for implant loosening is ten times greater. For the functional outcome, the quality of the rotator cuff is more predictive than the type of the previous surgery or the preoperative external rotation contracture. Reverse shoulder arthroplasty could be justified due to the higher rate of complications and revisions of non-constrained anatomic shoulder arthroplasties reported. Satisfactory clinical and radiological results have been published with mid to long term data now available.

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.

Risk factors for recurrence after Bankart repair: a systematic review and meta-analysis

Background

The aim of this literature review was to identify preoperative risk factors associated with recurrent instability after Bankart repair.

Methods

The PubMed, Web of Science, Embase, and Cochrane Library databases were searched for potentially eligible articles. Two reviewers independently screened the titles and abstracts using prespecified criteria. Articles were included if they clearly stated the risk factors for recurrence after Bankart repair. Data on patient characteristics and recurrence rate were collected from each study. A random-effects model was used for the meta-analysis and the statistical analysis was performed using Review Manager 5.4 software.

Results

Nineteen studies that included 2922 participants met the inclusion criteria. The overall pooled prevalence of recurrent instability was 15.3% (range 6.9–42). The mean follow-up duration was 40.5 months (18–108). Twenty-one risk factors were identified, 10 of which were explored quantitatively. Statistically significant risk factors for recurrent instability following a Bankart procedure were age under 20 years (odds ratio [OR] 4.24, 95% confidence interval [CI] 2.8–96.23, p < 0.00001), a Hill-Sachs lesion (OR 3.61, 95% CI 2.06–6.33, p < 0.00001), a glenoid bone lesion (OR 2.8, 95% CI 1.96–4.01, p < 0.00001), shoulder hyperlaxity (OR 4.55, 95% CI 2.19–9.44, p < 0.0001), and an off-track lesion (OR 5.53, 95% CI 2.21–13.86, p = 0.0003). There was moderate evidence indicating that male sex (OR 1.6, 95% CI 1.07–2.37, p = 0.02) and playing contact sports (OR 1.54, 95% CI 0.96–2.45, p = 0.07) were further risk factors. Dominant side, a superior labrum from anterior to posterior (SLAP) lesion, and more than five preoperative dislocations were not found to be risk factors.

Conclusions

Patients younger than 20 years of age, a Hill–Sachs lesion, a glenoid bone lesion, shoulder hyperlaxity, and an off-track lesion appear to be significant predictors of recurrent instability following a Bankart procedure. Factors such as male sex and playing contact sports were associated with recurrent instability. Dominant side, a SLAP lesion, and more than five preoperative dislocations were not significant risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03011-w.

Anchor Arthropathy of the Shoulder Joint After Instability Repair: Outcomes Improve With Revision Surgery

PURPOSE

To report clinical and patient-reported outcome measures (PROMs) in patients undergoing revision surgery after diagnosis of anchor-induced arthropathy.

METHODS

Patients who underwent revision arthroscopic shoulder surgery and were diagnosed with post-instability glenohumeral arthropathy performed from January 2006 to May 2018 were included in the current study. Patients were excluded if they underwent prior open shoulder procedures, if glenoid bone loss was present, or if prerevision imaging and records were incomplete or not available. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, exam findings before revision surgery, and surgical intervention. PROMs were prospectively collected before surgery and at minimum 2-year follow-up.

RESULTS

Fourteen patients were included with a mean (± standard deviation) age at presentation of 35.2 ± 12.1 years (range 16 to 59). The follow-up rate was 86%, with a mean follow-up of 3.8 years (range 1.1 to 10.6). Mean time to development of arthropathy symptoms was 48.2 months (range <1 month to 13.8 years), all presenting with pain and decreased range of motion on exam. At time of revision surgery, all patients underwent either open or arthroscopic removal of previous implants, including anchors and suture material. Six patients underwent additional revision stabilization procedures, 1 underwent total shoulder arthroplasty, and 7 underwent arthroscopic intraarticular debridement, capsular release, and chondroplasty with or without microfracture. Pain significantly improved in 79% of patients (P = .05). Significant improvements in all PROMs were observed, including 12-item Short Form (43.8 to 54.8, P < .01); Disabilities of the Arm, Shoulder, and Hand, shortened version (31.8 to 8.4, P < .01); Single Assessment Numeric Evaluation (47.0 to 84.5, P < .05); and American Shoulder and Elbow Surgeons (61.6 to 92.1, P < .01). Average external rotation significantly improved, from 31° ± 22° to 52° ± 24° (P = .02).

CONCLUSION

Rapid intervention after diagnosis, through either revision arthroscopic or open debridement and stabilization, can lead to significant improvement in range of motion, pain, and overall patient function and satisfaction.

LEVEL OF EVIDENCE

IV, retrospective case series.

Minimum 10-Year Clinical Outcomes After Arthroscopic 270° Labral Repair in Traumatic Shoulder Instability Involving Anterior, Inferior, and Posterior Labral Injury

BACKGROUND

Current literature reports highly satisfactory short- and midterm clinical outcomes in patients with arthroscopic 270° labral tear repairs. However, data remain limited on long-term clinical outcomes and complication and redislocation rates in patients with traumatic shoulder instability involving anterior, inferior, and posterior labral injury.

PURPOSE

To investigate, at a minimum follow-up of 10 years, the clinical outcomes, complications, and recurrent instability in patients with 270° labral tears involving the anterior, inferior, and posterior labrum treated with arthroscopic stabilization using suture anchors.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective outcomes study was completed for all patients with a minimum 10-year follow-up who underwent arthroscopic 270° labral tear repairs with suture anchors by a single surgeon. Outcome measures included pre- and postoperative Rowe score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test, visual analog scale for pain, and Single Assessment Numeric Evaluation (SANE). Western Ontario Shoulder Instability Index (WOSI) scores were collected postoperatively. Complication data were collected, including continued instability, subluxation or dislocation events, and revision surgery. Failure was defined as any cause of revision surgery.

RESULTS

In total, 21 patients (mean ± SD age, 27.1 ± 9.6 years) with 270° labral repairs were contacted at a minimum 10-year follow-up. All outcome measures showed statistically significant improvements as compared with those preoperatively: Rowe (53.9 ± 11.4 to 88.7 ± 8.9; P = .005), ASES (72.9 ± 18.4 to 91.8 ± 10.8; P = .004), Simple Shoulder Test (8.7 ± 2.4 to 11.2 ± 1.0; P = .013), visual analog scale (2.5 ± 2.6 to 0.5 ± 1.1; P = .037), and SANE (24.0 ± 15.2 to 91.5 ± 8.3; P = .043). The mean postoperative WOSI score at minimum follow-up was 256.3 ± 220.6. Three patients had postoperative complications, including a traumatic subluxation, continued instability, and a traumatic dislocation, 2 of which required revision surgery (14.2% failure rate).

CONCLUSION

Arthroscopic repairs of 270° labral tears involving the anterior, inferior, and posterior labrum have highly satisfactory clinical outcomes at 10 years, with complication and redislocation rates similar to those reported at 2 years. This suggests that repairs of extensile labral tears are effective in restoring and maintaining mechanical stability of the glenohumeral joint in the long term.

Postoperative Stiffness and Pain After Arthroscopic Labral Stabilization: Consider Anchor Arthropathy

PURPOSE

To describe the key clinical, imaging, and arthroscopic characteristics of anchor arthropathy after arthroscopic shoulder stabilization procedures and, secondarily, to define risk factors for the development of anchor-induced arthropathy.

METHODS

A total of 23 patients who underwent revision arthroscopic shoulder surgery and were diagnosed with glenohumeral arthropathy were retrospectively identified from prospectively collected data registries between January 2000 and May 2018. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, and examination findings before revision surgery. Pre-revision imaging was used to assess presence of glenohumeral osteoarthritis and chondromalacia, anchors/sutures, loose bodies, and labral pathology. The same parameters were recorded intraoperatively during revision surgery. Descriptive statistics were performed for demographic data and means with standard deviations were calculated for continuous data. A McNemar-Bowker test was used to analyze marginal homogeneity between preoperative imaging and intraoperative findings.

RESULTS

Mean age at presentation was 33.4 ± 11.7 years (range 16-59, 17 male patients; 6 female patients). More than one half (13/23) developed symptoms within 10 months after index arthroscopic procedure (mean 32.2 ± 59.9 months, range <1 to 165.2 months) with 87% presenting with pain and 100% presenting with loss of motion on examination. Plain radiographs demonstrated humeral osteoarthritis in 57% (13/23) of patients, magnetic resonance imaging (MRI) revealed recurrent labral pathology in 19 of 23 (83%) patients, potential proud implants in 12 of 23 (52%), and loose bodies in 12 of 23 (52%). Intraoperatively, all had evidence of osteoarthritis; 22 of 23 (96%) had prominent implants. Humeral head chondromalacia was present in 21 of 23 patients (91%), the majority of which was linear stripe wear, and 6 of 23 (26%) had severe global glenohumeral osteoarthritis. Statistical analysis revealed a 54.5% (95% confidence interval 0.327-0.749) sensitivity of MRI identification of proud implants with a specificity of 100% (95% confidence interval 0.055-1). The ability of MRI to accurately assess chondromalacia of the humeral head (P = .342) or glenoid (P = .685) was not statistically significant.

CONCLUSIONS

Anchor arthropathy is characterized by symptoms of pain and stiffness on examination and in many cases develops early after stabilization surgery (<10 months). Implants were implicated in the majority of cases of humeral head chondromalacia. MRI scans may produce false-negative identification of proud implants and can be a poor predictor of the severity of chondromalacia and intra-articular pathology; thus, a high index of clinical suspicion is necessary in patients with motion loss and pain postoperatively.

LEVEL OF EVIDENCE

Level IV, case series.

Off-track Hill-Sachs lesions predispose to recurrence after nonoperative management of first-time anterior shoulder dislocations

PURPOSE

The purpose of this study was to evaluate whether the presence of an off-track Hill-Sachs lesion has an impact on the recurrence rate after nonoperative management of first-time anterior shoulder dislocations.

METHODS

A retrospective cohort study was planned with a follow-up via questionnaire after a minimum of 24 months. Fifty four patients were included in the study (mean age: 29.5 years; 16 female, 38 male). All of these patients opted for primary nonoperative management after first-time traumatic anterior shoulder dislocation, in some cases even against the clinician's advice. The glenoid track and the Hill-Sachs interval were evaluated in the MRI scans. The clinical outcome was evaluated via a shoulder-specific questionnaire, ASES-Score and Constant Score. Further, patients were asked to report on recurrent dislocation (yes/no), time to recurrent dislocation, pain, feeling of instability and satisfaction with nonoperative management.

RESULTS

In 7 (13%) patients, an off-track Hill-Sachs lesion was present, while in 36 (67%) the lesion was on-track and 11 (20%) did not have a structural Hill-Sachs lesion at all. In total, 31 (57%) patients suffered recurrent dislocations. In the off-track group, all shoulders dislocated again (100%), while 21 (58%) in the on-track group and 3 (27%) in the no structural Hill--Sachs lesion group had a recurrent dislocation, p = 0.008. The mean age in the group with a recurrence was 23.7 ± 10.1 years, while those patients without recurrent dislocation were 37.4 ± 13.1 years old, p < 0.01. The risk for recurrence in patients under 30 years of age was higher than in those older than 30 years (OR = 12.66, p < 0.001). There were no significant differences between patients with on- and off-track lesions regarding patients' sex, height, weight and time to reduction and glenoid diameter. Off-track patients were younger than on-track patients (24.9 ± 7.3 years vs. 29.6 ± 13.6 years). However, this difference was not statistically significant.

CONCLUSION

The presence of an off-track Hill-Sachs lesion leads to significantly higher recurrence rates compared to on-track or no structural Hill--Sachs lesions in patients with nonoperative management and should be considered when choosing the right treatment option. Therefore, surgical intervention should be considered in patients with off-track Hill-Sachs lesions.

LEVEL OF EVIDENCE

IV.

Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long-term results

INTRODUCTION

Arthroscopic stabilisation is a well-recognised surgical technique with a variable rate of failure reported between 0-35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate.

MATERIAL AND METHODS

41 patients that underwent arthroscopic shoulder stabilisation for glenohumeral instability between 2001-2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognised in order to assess possible risk factors.

RESULTS

The overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent/good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery.

CONCLUSION

The arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favourable outcome, with a redislocation rate of 9% and low complication rate.

Factors related to large bone defects of bipolar lesions and a high number of instability episodes with anterior glenohumeral instability

Background

Significant bone defects are associated with poor clinical results after surgical stabilization in cases of glenohumeral instability. Although multiple factors are thought to adversely affect enlargement of bipolar bone loss and increased shoulder instability, these factors have not been sufficiently evaluated. The purpose of this study was to identify the factors related to greater bone defects and a higher number of instability episodes in patients with glenohumeral instability.

Methods

A total of 120 consecutive patients with symptomatic unilateral instability of the glenohumeral joint were retrospectively reviewed. Three-dimensional surface-rendered/registered models of bilateral glenoids and proximal humeri from computed tomography data were matched by software, and the volumes of bone defects identified in the glenoid and humeral head were assessed. After relationships between objective variables and explanatory variables were evaluated using bivariate analyses, factors related to large bone defects in the glenoid and humeral head and a high number of total instability episodes and self-irreducible dislocations greater than the respective 75th percentiles were evaluated using logistic regression analyses with significant variables on bivariate analyses.

Results

Larger humeral head defects (P < .001) and a higher number of total instability episodes (P = .032) were found to be factors related to large glenoid defects. On the other hand, male sex (P = .014), larger glenoid defects (P = .015), and larger number of self-irreducible dislocations (P = .027) were related to large humeral head bone defects. An increased number of total instability episodes was related to longer symptom duration (P = .001) and larger glenoid defects (P = .002), and an increased number of self-irreducible dislocations was related to larger humeral head defects (P = .007).

Conclusions

Whereas this study showed that bipolar lesions affect the amount of bone defects reciprocally, factors related to greater bone defects differed between the glenoid and the humeral head. Glenoid defects were related to the number of total instability episodes, whereas humeral head defects were related to the number of self-irreducible dislocations.

Long-term results of arthroscopic Bankart repairs for anterior instability of the shoulder in patients aged thirty years or older

INTRODUCTION

Bankart repair is a popular treatment for anterior shoulder instability. However, long-term failure rates of arthroscopic Bankart repair remain higher than Latarjet procedures. The purpose of this study was to report long-term results of arthroscopic Bankart repair in patients greater than 30 years old and analyze risk factors of failure following arthroscopic Bankart repair that are independent of younger age.

MATERIALS AND METHODS

Between January 1999 and December 2003, 41 patients aged 30 years or older treated with arthroscopic Bankart repair for anterior shoulder instability were evaluated. Outcome measures included pain (VAS), range of motion, post-operative Walch-Duplay, WOSII scores, complications, failure rate, and risk factors of failure. Failure was defined as recurrent dislocation or subluxation.

RESULTS

At a mean 12-year follow-up (range; 10-15 years), the failure rate of arthroscopic Bankart repair in patients aged 30 years and older was 37%. The mean post-operative Walch-Duplay score was significantly higher in patients who had no recurrence compared to those who had had recurrence of instability (100 versus 90, p=0.02). An ISIS score≥3 (p=0.02), a glenoid bone lesion (p=0.06), and a Hill-Sachs lesion>15% defect (p=0.001) were risk factors for recurrent instability. When considering a modified ISIS score that accounted for bony defects on the glenoid and humeral side, patients with an ISIS score <3 + no glenoid lesion + Hill-Sachs ≤ 15% had a recurrence rate of 0%.

CONCLUSION

The failure rate of arthroscopic Bankart repairs in patients over 30 was higher than previously reported. Specifically, patients with an ISIS >3 and bony glenoid defects and/or Hill-Sachs lesions > 15% may be at higher risk for recurrent instability following an isolated arthroscopic Bankart repair. Alternative stabilization techniques may need to be considered for this subset of patients.

Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long- term results

INTRODUCTION

Arthroscopic stabilization is a well-recognized surgical technique with a variable rate of failure reported between 0-35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate.

MATERIAL AND METHODS

41 patients that underwent arthroscopic shoulder stabilization for glenohumeral instability between 2001-2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognized in order to assess possible risk factors.

RESULTS

The overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent / good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery.

CONCLUSION

The arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favorable outcome, with a redislocation rate of 9% and low complication rate.

Anterior glenohumeral instability: Current review with technical pearls and pitfalls of arthroscopic soft-tissue stabilization

The glenohumeral joint (GHJ) allows for a wide range of motion, but is also particularly vulnerable to episodes of instability. Anterior GHJ instability is especially frequent among young, athletic populations during contact sporting events. Many first time dislocators can be managed non-operatively with a period of immobilization and rehabilitation, however certain patient populations are at higher risk for recurrent instability and may require surgical intervention for adequate stabilization. Determination of the optimal treatment strategy should be made on a case-by-case basis while weighing both patient specific factors and injury patterns (i.e., bone loss). The purpose of this review is to describe the relevant anatomical stabilizers of the GHJ, risk factors for recurrent instability including bony lesions, indications for arthroscopic vs open surgical management, clinical history and physical examination techniques, imaging modalities, and pearls/pitfalls of arthroscopic soft-tissue stabilization for anterior glenohumeral instability.

Treatment type may influence degree of post-dislocation shoulder osteoarthritis: a systematic review and meta-analysis

PURPOSE

Age at primary dislocation, recurrence, and glenoid bone loss are associated with development of osteoarthritis (OA). However, an overview of OA following traumatic anterior shoulder instability is lacking and it is unclear to what degree type of surgery is associated with development of OA in comparison to non-operative treatment. The aim of this study was to determine the degree of OA at long-term follow-up after non-operative and operative treatments for patients with anterior shoulder instability. Surgery is indicated when patients experience recurrence and this is associated with OA; therefore, it was hypothesized that shoulders show a higher proportion or degree of OA following operative treatment compared to non-operative treatment.

METHODS

A literature search was performed in the PubMed/Medline, EMBASE, and Cochrane databases. Articles reporting the degree of OA that was assessed with the Samilson-Prieto or Buscayret OA classification method after non-operative and operative treatment for anterior shoulder instability with a minimum of 5 years follow-up were included.

RESULTS

Thirty-six articles met the eligibility criteria of which 1 reported the degree of OA for non-operative treatment and 35 reported the degree of OA for 9 different operative procedures. A total of 1832 patients (1854 shoulders) were included. OA proportions of non-operative and operative treatments are similar at any point of follow-up. The Latarjet procedure showed a lower degree of OA compared to non-operative treatment and the other operative procedures, except for the Bristow procedure and Rockwood capsular shift. The meta-analyses showed comparable development of OA over time among the treatment options. An increase in OA proportion was observed when comparing the injured to the contralateral shoulder. However, a difference between the operative subgroups was observed in neither analysis.

CONCLUSION

Non-operative and operative treatments show similar OA proportions at any point of follow-up. The hypothesis that shoulders showed a higher proportion or degree of OA following operative treatment compared to non-operative treatment is not supported by the data. Operative treatment according to the Latarjet procedure results in a lower degree of OA compared to other treatments, including non-operative treatment.

LEVEL OF EVIDENCE

IV.

Incidence of and Risk Factors for Glenohumeral Osteoarthritis After Anterior Shoulder Instability: A US Population-Based Study With Average 15-Year Follow-up

Background:

The rate of osteoarthritis (OA) in patients with a history of previous anterior shoulder instability (ASI) varies within the literature, with the majority of studies investigating rates after surgical stabilization. ASI appears to lead to increased rates of OA, although risk factors for developing OA in cohorts treated nonoperatively and operatively are not well-defined.

Purpose:

To determine the incidence of clinically symptomatic OA and identify potential risk factors for the development of OA in patients younger than 40 years with a known history of ASI.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

An established, geographically based database was used to identify patients in the United States who were younger than 40 years and were diagnosed with ASI between 1994 and 2014. Patient information, including demographic, imaging, and surgical details, was collected. Comparative analysis was performed between groups with and without OA at final follow-up as well as between patients who underwent surgical and nonsurgical management.

Results:

The study population consisted of 154 patients with a mean follow-up of 15.2 years (range, 5.1-29.8 years). The mean age at initial instability event was 20.9 years (95% CI, 19.9-22.0 years). Overall, 22.7% of patients developed clinically symptomatic glenohumeral OA. Multivariate analysis revealed that current or former smokers (odds ratio [OR], 4.3; 95% CI, 1.1-16.5; P = .030), hyperlaxity (OR, 10.1; 95% CI, 1.4-72.4; P = .020), laborer occupation (OR, 6.1; 95% CI, 1.02-36.1; P = .043), body mass index (BMI) (OR, 1.2; 95% CI, 1.03-1.3; P = .012), and age at initial instability (OR, 1.1; 95% CI, 1.02-1.2; P = .013) as potential independent risk factors when accounting for other demographic and clinical variables.

Conclusion:

In a US geographic population of patients younger than 40 years with ASI, approximately one-fourth of patients developed symptomatic OA at a mean follow-up of 15 years from their first instability event. When accounting for differences in patient demographic and clinical data, we noted a potentially increased risk for the development of OA in patients who are current or former smokers, have hyperlaxity, are laborers, have higher BMI, and have increased age at initial instability event. Smoking status, occupation, and BMI are modifiable factors that could potentially decrease risk for the development of symptomatic OA in these patients.

Relationship Between Age at Initial Shoulder Instability and Overall Outcomes After Arthroscopic Bankart Repair: Mean 6-Year Follow-up

Background:

Age at surgery plays a crucial role in the frequency of recurrent shoulder instability. However, there are few studies that evaluate the relationship between age at initial shoulder instability and overall outcomes after stabilization surgery.

Purpose:

To compare clinical outcomes and structural changes after arthroscopic Bankart repair in patients who experienced initial shoulder instability during adolescence versus those with later onset instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study included patients who underwent arthroscopic Bankart repair at a single institution between 2007 and 2017. Comparisons were made between patients who experienced initial shoulder instability during adolescence (age 13-19 years; group A) and those with later onset instability (age 20-35 years; group B). Clinical outcomes (recurrence rate, postoperative pain, functional scores, active range of motion, and return to sports) and structural changes demonstrated by magnetic resonance imaging (MRI) were evaluated at minimum 2-year follow-up. In addition, functional outcomes within each group were compared between the patients with and without postoperative recurrence.

Results:

A total of 58 patients were included (24 patients in group A and 34 patients in group B). The mean follow-up was 72.1 months. Group A demonstrated a significantly higher recurrence rate than group B (41.7% vs 11.8%, respectively; P = .009; risk ratio, 5.36 [95% CI, 1.43-20.09]) as well as significantly lower Rowe (76.9 ± 20.1 vs 88.7 ± 13.2, respectively; P = .01) and Constant-Murley scores (92.2 ± 7.6 vs 96.3 ± 4.2, respectively; P = .01). Postoperative MRI revealed no significant structural differences between the groups regarding the glenoid labrum, glenohumeral cartilage, or osseous reaction around the implanted anchors. In group A, patients with recurrence had less satisfaction regarding postoperative sports level than those without recurrence, whereas in group B, patients with recurrence had more postoperative pain and functional impairment compared with those without recurrence.

Conclusion:

Initial shoulder instability during adolescence was associated with a higher recurrence rate and lower functional scores after arthroscopic Bankart repair compared with later onset instability, although no significant structural differences were found between the groups on MRI at a mean 6-year follow-up.

Elastic fibers in orthopedics: Form and function in tendons and ligaments, clinical implications, and future directions

Elastic fibers are an essential component of the extracellular matrix of connective tissues. The focus of both clinical management and scientific investigation of elastic fiber disorders has centered on the cardiovascular manifestations due to their significant impact on morbidity and mortality. As such, the current understanding of the orthopedic conditions experienced by these patients is limited. The musculoskeletal implications of more subtle elastic fiber abnormalities, whether due to allelic variants or age-related tissue degeneration, are also not well understood. Recent advances have begun to uncover the effects of elastic fiber deficiency on tendon and ligament biomechanics; future research must further elucidate mechanisms governing the role of elastic fibers in these tissues. The identification of population-based genetic variations in elastic fibers will also be essential. Minoxidil administration, modulation of protein expression with micro-RNA molecules, and direct injection of recombinant elastic fiber precursors have demonstrated promise for therapeutic intervention, but further work is required prior to consideration for orthopedic clinical application. This review provides an overview of the role of elastic fibers in musculoskeletal tissue, summarizes current knowledge of the orthopedic manifestations of elastic fiber abnormalities, and identifies opportunities for future investigation and clinical application.

Glenohumeral Osteoarthritis: An Overview of Etiology and Diagnostics

BACKGROUND AND AIMS

Osteoarthritis (OA) is the world's most common joint disease and there is currently no cure. Glenohumeral osteoarthritis (GHOA) accounts for an estimated 5% -17% of patients with shoulder complaints. The etiology of GHOA is multifactorial, and we review the various non-specific and specific risk factors and further sub-classify them into local and systemic factors.

MATERIALS AND METHODS

Data for this review article were identified by searches of MEDLINE, PubMed, and references from relevant articles using search terms such as "glenohumeral," "osteoarthritis," "epidemiology," "etiology," "imaging," and "pathophysiology." Only articles published in English, German, and Finnish between 1957 and 2017 were included.

RESULTS

The prevalence of radiological shoulder OA has been estimated to be as high as 16% -20% in the middle-aged and elderly population, but the concordance between structural findings and symptoms seems to be weak, as many of these individuals are asymptomatic. The vast majority of GHOA is related to non-specific factors, namely advancing age, while specific risk factors are commonly found in young patients. Diagnosis of GHOA is made when typical clinical features and defined radiological findings overlap in an individual.

CONCLUSION

Ultimately the determinants of shoulder pain in GHOA remain incompletely understood. Improved understanding of the etiology and diagnosis of GHOA will enable clinicians to better determine which patients will benefit from different treatment modalities, as well as provide new avenues to potential treatments.

Outcomes of total shoulder arthroplasty for instability arthropathy with a prior coracoid transfer procedure: a retrospective review and matched cohort

BACKGROUND

Many surgeons are concerned about reports of increased complications, worse outcomes, and early failures in patients undergoing anatomic total shoulder arthroplasty after coracoid transfer. The purpose of this study was to evaluate minimum 2-year outcomes following anatomic total shoulder arthroplasty for instability arthropathy with a prior coracoid transfer procedure and compare them with a matched cohort of patients undergoing total shoulder arthroplasty for primary osteoarthritis.

METHODS

We identified 11 primary anatomic total shoulder arthroplasties performed by a single surgeon for instability arthropathy with a prior coracoid transfer procedure with a minimum of 2 years' follow-up (mean, 58 ± 35 months). A matched cohort of 33 patients with a total shoulder arthroplasty for primary osteoarthritis served as the control group. The American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, patient satisfaction, complications, and revisions were evaluated in both cohorts.

RESULTS

The coracoid transfer cohort showed no difference in the final ASES score (88 vs. 82, P = .166) or SANE score (85 vs. 67, P = .120) vs. the matched cohort. The postoperative ASES pain score (45 vs. 41, P = .004) was higher in the coracoid transfer cohort, but the mean improvement from preoperative to postoperative values for the ASES score (P = .954), ASES pain score (P = .183), and SANE score (P = .293) was no different between cohorts. Both cohorts had high patient satisfaction without a statistically significant difference (P = .784).

CONCLUSION

At early- to mid-term follow-up, total shoulder arthroplasty performed after a coracoid transfer demonstrated similar results to total shoulder arthroplasty performed for primary osteoarthritis. Longer follow-up and larger patient cohorts will provide further insights and highlight any potential differences in outcomes or revision rates.

Large Drill Holes Are Still Present in the Long Term After Arthroscopic Bankart Repair With Absorbable Tacks: An 18-Year Randomized Prospective Study

BACKGROUND

Studies have demonstrated the development of an osseous reaction at the drill sites of anchors after arthroscopic shoulder surgery.

PURPOSE

To investigate the drill-hole size at 18 years after arthroscopic Bankart repair using either fast polygluconate acid (PGA) or slow polylevolactic acid (PLLA) absorbable tacks and to compare the functional outcomes and development of osteoarthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

40 patients with unidirectional anterior shoulder instability, treated with arthroscopic Bankart repair, were randomized into the PGA group (n = 20) or the PLLA group (n = 20). Plain radiographs of both shoulders, as well as computed tomography (CT) images of the operated shoulder, were used to evaluate the drill-hole size, volume, and degenerative changes. Functional outcomes were assessed by use of the Rowe score, Constant score, and Western Ontario Shoulder Instability (WOSI) index.

RESULTS

Of the 40 patients, 32 patients returned for the follow-up (15 PGA and 17 PLLA). No significant differences were found in the population characteristics between the study groups. The mean follow-up time was 18 years for both groups. No significant differences were seen in range of motion, strength in abduction, or Constant, Rowe, and WOSI scores between the groups. Recurrence rate was 33% in the PGA group and 6% in the PLLA group during the follow-up period (P = .07). The drill-hole appearance on plain radiographs (invisible/hardly visible/visible/cystic) was 11/2/2/0 and 6/5/5/1 for the PGA and PLLA groups, respectively (P = .036). The mean ± SD drill-hole volume as estimated on CT images was 89 ± 94 and 184 ± 158 mm³ in the PGA and PLLA groups, respectively (P = .051). Degenerative changes (normal/minor/moderate/severe) on plain radiographs were 7/4/4/0 and 3/8/5/1 for the PGA and PLLA groups, respectively (P = .21), and on CT images were 5/7/3/0 and 2/6/6/3 for the PGA and PLLA groups, respectively (P = .030).

CONCLUSION

This long-term follow-up study demonstrated that the PLLA group had significantly more visible drill holes than the PGA group on plain radiographs. However, this difference was not evident on CT imaging, with both groups having several visible cystic drill holes and a substantial drill-hole volume defect. No significant differences were found between the study groups in terms of clinical outcomes.

Latarjet Procedure for Anterior Glenohumeral Instability: Early Postsurgical Complications for Primary Coracoid Transfer Versus Revision Coracoid Transfer After Failed Prior Stabilization

BACKGROUND

The Latarjet procedure (coracoid transfer) is often used to successfully treat failed instability procedures. However, given the reported increased complication rates in primary Latarjet surgery, there is a heightened concern for complications in performing the Latarjet procedure as revision surgery.

PURPOSE

To evaluate the early outcomes and complications of the Latarjet procedure as primary surgery compared with revision surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 157 patients were included and retrospectively reviewed: 103 patients in the revision group and 54 patients in the primary group. Patients were evaluated by physical examination findings as well as by documentation of complications and reoperations extracted from their electronic medical records.

RESULTS

The mean follow-up was 7.8 ± 11.0 months for the primary group and 7.0 ± 13.2 months for the revision group. There were no significant differences in overall complication rates between the primary and revision groups (16.7% vs 8.7%, respectively; P = .139). The complication rate was significantly higher in patients in the revision group who had undergone a prior open procedure compared with those who had undergone only arthroscopic procedures (30.0% vs 4.1%, respectively; P < .001). Of those patients who sustained a complication, 7 of the 9 underwent a reoperation in the primary group (13.0%), and 7 of the 9 did so in the revision group (6.8%); the risk of reoperations was not different between groups (P = .198). There were 4 patients in the primary group (7.4%) and 5 patients in the revision group (4.9%) who experienced recurrent dislocations during the follow-up period (P = .513). There was no difference in postoperative range of motion.

CONCLUSION

The Latarjet procedure is a reasonable option for the treatment of failed arthroscopic instability repair with an early complication rate similar to that found in primary Latarjet surgery.

Return to Sport Following Arthroscopic Repair of 270° Labral Tears

PURPOSE

To evaluate the rate of return to sport following arthroscopic repair of 270° labral tears.

METHODS

We performed a retrospective review of patients with 270° labral tears treated arthroscopically between 2013 and 2017 by a single surgeon. Patients were followed-up to assess whether they were able to return to sport, the level to which they returned and the timing of return. Complications, the Visual Analogue Scale for pain (VAS), the Rowe score, the Shoulder Instability-Return to Sport after Injury (SIRSI) score, and the Subjective Shoulder Value (SSV) were recorded.

RESULTS

The study included 25 patients, with a mean follow-up of 42.2 ± 16.5 months. Of the 25 patients, 19 (76.0%) returned to sport at a mean of 6.8 ± 2.6 months, while 15 (60%) returned at the same or a higher level. At final follow-up, the mean Rowe score was 80.6 ± 14.2; the mean SIRSI score was 61.8 ± 25.4; the mean SSV was 86.4 ± 15.2; and the mean VAS score was 2.2 ± 2.0. One patient reported recurrent subluxation, but no patients suffered a recurrent dislocation during the study period. No revision surgeries were performed within the study period.

CONCLUSION

Patients with 270° labral tears who were treated with arthroscopic repair showed an overall high rate of return to sport. Despite a low rate of recurring instability, not all patients were able to return to their previous levels of sports.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Evaluating the Uptake and Acceptability of Standardized Postoperative Rehabilitation Guidelines Using an Online Knowledge Translation Approach

BACKGROUND

Providing physical therapists with evidence-based and consensus-derived guidelines to manage postoperative shoulder patients is essential; these guidelines should be readily available and provide clinically applicable information. Knowledge translation (KT) initiatives that encourage interaction between clinicians and researchers, that have multifaceted components and use a variety of strategies, can significantly change practice.

OBJECTIVE

The objective of this study was to determine the uptake and acceptability of standardized postoperative shoulder guidelines with an accompanying online KT resource through evaluation of website analytics and a quantitative survey.

DESIGN

A multi-pronged approach was used to assess uptake and acceptability of the guidelines and online KT resource.

METHODS

Website analytics of usage and geographical location of users was measured as were physical therapist survey responses.

RESULTS

Website analytics revealed that 5406 individuals used the online resource between October 2012 and September 2013 with the average visit lasting 8 minutes; only 47% of users were within the guideline developers' surgical referral region. Physical therapists who used the new shoulder guidelines were very satisfied or satisfied (96%) with the guidelines, reporting they promoted patient-specific clinical decision-making extremely or very well (68%). They viewed the online KT resource positively, with 79% rating it as "very useful" or "quite useful." Physical therapists from regions beyond those expected to use the new shoulder guidelines were also aware of the website and also rated it as very useful.

LIMITATIONS

The survey sample was relatively small and did not directly assess patient outcomes.

CONCLUSIONS

An online KT web resource developed in conjunction with standardized postoperative shoulder guidelines was perceived as useful based on website analytics and survey responses. Active KT strategies such as this can improve uptake and dissemination of best practice in physical therapy.

An Algorithmic Approach to the Management of Shoulder Instability

The recurrence of anterior shoulder instability can be as high as 86.7% in high-risk patients who are treated nonoperatively after their first incident of instability. CT and MR arthrography are necessary for preoperative imaging and assessment of glenoid bone loss. Patient expectations in conjunction with appropriate preoperative imaging are critical for surgical planning. Arthroscopic shoulder stabilization is often sufficient in most cases where glenoid bone loss is minimal, with recurrent dislocation rates close to 4% in the literature. Open stabilization procedures are generally indicated in patients with greater than 20% glenoid bone loss.

Ten percent re-dislocation rate 13 years after the arthroscopic Bankart procedure

PURPOSE

The aim of the present study was to determine the long-term outcome after the arthroscopic Bankart procedure, in terms of recurrent instability, shoulder function, glenohumeral arthropathy and patient satisfaction.

METHODS

Patients who underwent the arthroscopic Bankart procedure between January 1999 and the end of December 2005 were invited to complete a set of Patient Reported Outcome Measures (PROMs) and visit the hospital for clinical and radiological assessment. PROMs included the Western Ontario Shoulder Instability Index (WOSI), the Oxford Shoulder Instability Score (OSIS) and additional questions on shoulder instability and patient satisfaction. Clinical assessment included the apprehension test and the Constant-Murley score. The Samilson-Prieto classification was used to assess arthropathy on standard radiographs. The primary outcome was a re-dislocation that needed reduction. Secondary outcomes in terms of recurrent instability included patient-reported subluxation and a positive apprehension test.

RESULTS

Of 104 consecutive patients, 71 patients with a mean follow-up of 13.1 years completed the PROMs, of which 53 patients (55 shoulders) were also available for clinical and radiological assessment. Re-dislocations had occurred in 7 shoulders (9.6%). Subluxations occurred in 23 patients (31.5%) and the apprehension test was positive in 30 (54.5%) of the 55 shoulders examined. Median functional outcomes were 236 for WOSI, 45 for OSIS, and 103 for the normalized Constant-Murley score. Of all 71 patients (73 shoulders), 29 (39.7%) reported being completely satisfied, 33 (45.2%) reported being mostly satisfied and 8 (11%) reported being somewhat satisfied. Glenohumeral arthropathy was observed in 33 (60%) of the shoulders.

CONCLUSION

Despite 10% re-dislocations and frequent other signs of recurrent instability, shoulder function and patient satisfaction at 13 years after arthroscopic Bankart repair were good.

LEVEL OF EVIDENCE

Level IV.

It's Not All About Redislocation: A Systematic Review of Complications After Anterior Shoulder Stabilization Surgery

BACKGROUND

The surgical treatment of recurrent shoulder instability has evolved in recent years to include a variety of soft tissue and bone block procedures, undertaken with either an open or arthroscopic approach. Although the utilization of such techniques has rapidly expanded, the associated risk of complications remains poorly defined. This information is vital for clinical decision making and patient counseling.

PURPOSE

To quantify the complication rate associated with all types of surgery for anterior glenohumeral joint dislocation.

STUDY DESIGN

Systematic review.

METHODS

A systematic search was undertaken of studies reporting complications from anterior shoulder stabilization surgery. Inclusion criteria were studies published in English between 2000 and 2017 with a minimum 2-year follow-up. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies criteria. Complication rates for all undesirable events contributing to the patient outcome were extracted and cumulative rates calculated.

RESULTS

Out of 1942 references, 56 studies were included, totaling 4362 procedures among 4336 patients. Arthroscopic soft tissue repair had a complication rate of 1.6% (n = 2805). When repair was combined with arthroscopic remplissage, the rate was 0.5% (n = 219). Open soft tissue repair had a complication rate of 6.2% (n = 219) and open labral repair with remplissage, a rate of 2.3% (n = 79). An open bone block procedure had a complication rate of 7.2% (n = 573) and an arthroscopic bone block procedure, a rate of 13.6% (n = 163).

CONCLUSION

This large systematic review demonstrates the overall complication rates (not purely recurrence rates) in modern shoulder stabilization surgery. With the growing interest in bone block stabilization procedures, including those performed arthroscopically, surgeons should be aware of the 10-fold increase in complications for these procedures over soft tissue arthroscopic surgery and counsel their patients accordingly.

Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up

BACKGROUND

The purpose of this study was to systematically review the evidence in the literature to ascertain the functional outcomes and recurrences rates, as well as subsequent revision rates, following arthroscopic Bankart repair at a minimum of 10 years' follow-up.

METHODS

Two independent reviewers performed a literature search based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, using the Embase, MEDLINE, and Cochrane Library databases. Studies were included if they were clinical studies on arthroscopic Bankart repair with a minimum of 10 years' follow-up. Statistical analysis was performed using SPSS software.

RESULTS

Our review found 9 studies including 822 shoulders meeting our inclusion criteria. The majority of patients were male patients (75.5%), the average age was 28.0 years (range, 15-73 years), and the mean follow-up period was 149.4 months. The most commonly used functional outcome score was the Rowe score, with a weighted mean of 87.0. Overall, 77.6% of athletes were able to return to sports postoperatively. The overall rate of recurrent instability was 31.2%, with 16.0% of patients having recurrent dislocations, and the overall revision rate was 17.0%. Evidence of instability arthropathy was found in 59.4% of patients, with 10.5% of patients having moderate to severe arthropathy.

DISCUSSION AND CONCLUSION

Arthroscopic Bankart repair for anterior shoulder instability has been shown to result in excellent long-term functional outcomes despite a relatively high rate of recurrent instability necessitating revision surgery. In addition, the high rate of instability arthropathy is a concern following arthroscopic Bankart repair in the long term.

[Osteoarthritis of the shoulder: pathogenesis, diagnostics and conservative treatment options]

PATHOGENESIS

Osteoarthritis of the shoulder is characterized by a progressive degenerative process, which is based on chronic inflammation with intra-articular release of different cytokines and proteolytic enzymes. The main predisposing factors are a history of trauma or surgery, as well as chronic overuse or instability of the glenohumeral joint. Affected patients especially suffer from impaired joint function and pain, which are often associated with cognitive and psychosocial restrictions.

DIAGNOSTICS

Possible co-pathologies have to be evaluated carefully both clinically and radiologically as they must be taken into account in the therapeutic procedure. If arthroplasty of the shoulder is planned, a pre-operative CT scan is mandatory in order to evaluate the bone stock of the glenoid, which has a decisive influence on the choice of implant.

TREATMENT

Conservative treatment options are oral pain medication, physical therapy, and intra-articular injections, whereby, in comparison to corticosteroids, hyaluronic acid seems to be advantageous especially with respect to the duration of a positive clinical effect.

Curved-guide system is useful in achieving optimized trajectory for the most inferior suture anchor during arthroscopic Bankart repair

BACKGROUND

A curved-drill guide system was recently introduced to achieve a better trajectory for a low anteroinferior anchor during arthroscopic Bankart repair. However, the clinical performance of such a device remains unclear. The purpose of this study was to evaluate the trajectory and position of the low anteroinferior suture anchor with use of the curved-guide system in clinical cases.

METHODS

We enrolled 41 cases of arthroscopic Bankart repair in this study. Of these cases, 9 were repaired using the curved drill guide whereas 32 were repaired using a conventional straight guide. Postoperative computed tomography scans were obtained, and 3-dimensional models of the scapula were reconstructed. Notable perforations of the opposite cortex by the most inferior anchors were recorded. The clock-face angle, insertion angle, and insertion distance were measured.

RESULTS

The anchor perforation rate in the curved-guide group (11%) was significantly lower than that in the straight-guide group (56%) (P = .02). The insertion distance in the curved-guide group was significantly shorter than that in the straight-guide group (4.0 ± 1.6 mm vs. 7.0 ± 2.4 mm, P < .01). The clock-face angle and insertion angle were significantly greater in the perforated straight-guide group than in the nonperforated groups. The percentage of anchors in the absolute safe zone (clock-face angle > 135° and < 165° and insertion angle < 100°), where no anchors perforated, was greater in the curved-guide group than the straight-guide group.

CONCLUSION

Compared with the conventional straight guide, the curved-guide system provides better placement of the most inferior suture anchor during arthroscopic Bankart repair.

Long-term outcomes following isolated arthroscopic Bankart repair: a 9- to 12-year follow-up

Background

The long-term outcomes following arthroscopic Bankart repair have been rarely reported. Because of its relative novelty, little is known about recurrent instability, postoperative arthritis, and patient satisfaction, particularly for well-established modern procedures. The purpose of the study was to evaluate the long-term outcomes following arthroscopic Bankart repair.

Methods

Patients who underwent isolated arthroscopic Bankart repair from 2003 to 2006 were retrospectively reviewed. Recurrent instability, radiographic, and clinical scores (American Shoulder and Elbow Surgeons [ASES], Simple Shoulder Test [SST], and Rowe scores) were evaluated. Patient factors (ie, age, gender, side, number of instability episodes, contact sports, and bone loss) were analyzed to determine the correlation with outcome measures.

Results

Among the 98 patients (102 shoulders), we were able to contact 50 patients (51 shoulders, mean age 27.0 years, mean follow-up 121.2 months). Significant bone loss in glenoid and humerus was arthroscopically observed in 16 (31.4%) and 28 (54.9%) shoulders, respectively. Sixteen shoulders (31.4%) experienced recurrent instability. Recent radiographs were obtained for 38 shoulders, 14 (36.8%) of which showed moderate to severe arthritis. Clinical outcomes at follow-up were 89.3, 10.8, and 76.0 for ASES, SST, and Rowe scores, respectively. Neither recurrent instability nor arthritis was correlated with any patient factors.

Conclusion

When isolated arthroscopic Bankart repair was used in all patients with shoulder instability regardless of bony defect, postoperative recurrent instability and arthritis rates were unacceptably high. Additional procedures should be chosen after careful consideration of multiple patient factors.