Utility of the Instability Severity Index Score in Predicting Failure After Arthroscopic Anterior Stabilization of the Shoulder

Instability Severity Index Score predicts recurrent shoulder instability after arthroscopic Bankart repair

PURPOSE

The Instability Severity Index (ISI) Score was developed to preoperatively assess the risk of recurrent shoulder instability after an arthroscopic Bankart repair. This study aims to validate the use of ISI Score for predicting the risk of recurrence after an arthroscopic Bankart repair in a heterogeneous population and proposes an appropriate cut-off point for treating patients with an arthroscopic Bankart repair or otherwise.

METHODS

This study analysed 99 shoulders after a traumatic dislocation that underwent arthroscopic Bankart repair with at least 3 years follow-up. Patients were divided into subcategories based on their respective ISI Score. Recurrence includes either a postoperative dislocation or perceived instability.

RESULTS

The overall recurrence rate was found to be 26.3%. A significant correlation was identified between ISI Score and the recurrence rate (odds ratio [OR]: 1.545, 95% confidence interval [CI]: 1.231-1.939, p < 0.001). Furthermore, ISI Score 4-6 (OR: 4.498, 95% CI: 1.866-10.842, p < 0.001) and ISI Score > 6 (OR: 7.076, 95% CI: 2.393-20.924, p < 0.001) both had a significantly higher risk of recurrence compared to ISI Score 0-3. In ISI Score subcategories 0-3, 4-6 and >6, the recurrence rate was, respectively, 15.4%, 40.7% and 71.4%.

CONCLUSION

ISI Score has predictive value in determining the recurrence risk of shoulder instability following an arthroscopic Bankart repair in a heterogeneous population. Based on the findings of this study, we recommend using arthroscopic Bankart repair in patients with ISI Score 0-3. Clinical and shared decision-making are essential in the group with ISI Score 4-6, since the recurrence rate is significantly higher than in patients with ISI Score 0-3. Arthroscopic Bankart repair is not suitable for patients with ISI Score > 6.

LEVEL OF EVIDENCE

Level III.

Effect of Glenoid Bone Loss and Shoulder Position on Axillary Nerve Anatomy During the Latarjet Procedure

BACKGROUND

The Latarjet procedure is increasingly being utilized for the treatment of glenoid bone loss and has a relatively high neurological complication rate. Understanding the position-dependent anatomy of the axillary nerve (AN) is crucial to preventing injuries.

PURPOSE

To quantify the effects of changes in the shoulder position and degree of glenoid bone loss during the Latarjet procedure on the position of the AN.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 10 cadaveric shoulders were dissected, leaving the tendons of the rotator cuff and deltoid for muscle loading. The 3-dimensional position of the AN was quantified relative to the inferior glenoid under 3 conditions: (1) intact shoulder, (2) Latarjet procedure with 15% bone loss, and (3) Latarjet procedure with 30% bone loss. Measurements were obtained at 0°, 30°, and 60° of glenohumeral abduction (equivalent to 0°, 45°, and 90° of shoulder abduction) and at 0°, 45°, and 90° of humeral external rotation (ER).

RESULTS

Abduction of the shoulder to 60° resulted in a posterior (9.5 ± 1.1 mm; P < .001), superior (3.0 ± 1.2 mm; P = .013), and lateral (19.1 ± 2.3 mm; P < .001) shift of the AN, and ER to 90° resulted in anterior translation (10.0 ± 1.2 mm; P < .001). Overall, ER increased the minimum AN-glenoid distance at 30° of abduction (14.9 ± 1.3 mm [0° of ER] vs 17.3 ± 1.5 mm [90° of ER]; P = .045). The Latarjet procedure with both 15 and 30% glenoid bone loss resulted in a superior and medial shift of the AN relative to the intact state. A decreased minimum AN-glenoid distance was seen after the Latarjet procedure with 30% bone loss at 60° abduction and 90° ER (17.7 ± 1.6 mm [intact] vs 13.9 ± 1.6 mm [30% bone loss]; P = .007), but no significant differences were seen after the Latarjet procedure with 15% bone loss.

CONCLUSION

Abduction of the shoulder induced a superior, lateral, and posterior shift of the AN, and ER caused anterior translation. Interestingly, the Latarjet procedure, when performed on shoulders with extensive glenoid bone loss, significantly reduced the minimum AN-glenoid distance during shoulder abduction and ER. These novel findings imply that patients with substantial glenoid bone loss may be at a higher risk of AN injuries during critical portions of the procedure. Consequently, it is imperative that surgeons account for alterations in nerve anatomy during revision procedures.

CLINICAL RELEVANCE

This study attempts to improve understanding of the position-dependent effect of shoulder position and glenoid bone loss after the Latarjet procedure on AN anatomy. Improved knowledge of AN anatomy is crucial to preventing potentially devastating AN injuries during the Latarjet procedure.

Glenoid track revisited

The risk of Hill-Sachs lesion (HSL) to cause instability depends not only on the HSL but also on the glenoid size. Clinically, the only method to assess the risk of instability considering the dynamic interaction of both, the HSL together with the glenoid bone loss, is the glenoid track concept. Since it was introduced in a cadaveric study, its clinical efficacy and validity have been reported in the literature. Sometimes, the medial margin of the footprint (lateral margin of the glenoid track) is difficult to identify when a HSL is overriding the footprint. In such cases, we propose a method to draw an imaginary line connecting 2 landmarks. Although 3-dimensional computed tomography is the most accurate and widely used method to assess on/off-track lesions, our interest gradually is shifting toward magnetic resonance imaging (MRI), which has no radiation concern. The current magnetic resonance method is still under way. There are various risk factors influencing the recurrent instability after surgery. The glenoid track concept deals with only 1 of these factors, that is, instability caused by bony lesions. Therefore, the following 2 issues are important: 1) how to assess the glenoid track precisely and 2) how to incorporate other risk factors into consideration. The former can be achieved by obtaining the custom-made glenoid track width using not the fixed value of 83%, but more individualized value obtained by measuring the active horizontal extension angle of the opposite shoulder in the sitting position. At the same time, the gray zone (peripheral-track lesion) needs to be clearly defined. The latter can be achieved by incorporating the risk factors other than the bony lesions. One example is the Glenoid Track Instability Management Score (GTIMS), a combination of the glenoid track concept and the instability severity index score. This new scoring system is expected to increase the predictive potential of the scoring system, and accordingly to enhance clinical decision-making.

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.

Two-year minimum survivorship and radiographic analysis of a pressfit short humeral stem for total shoulder arthroplasty

Background

Newer generation humeral stem designs in total shoulder arthroplasty (TSA) are trending towards shorter lengths and uncemented fixation. The goal of this study is to report a 2-yr minimum clinical and radiographic outcomes of an uncemented short-stem press-fit humeral stem in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA).

Methods

A retrospective multicenter database review was performed of all patients who received an uncemented short-length press-fit humeral stem (Equinoxe Preserve humeral stem, Exactech, Inc., Gainesville, FL, USA) in ATSA and RTSA with a minimum two-year follow-up. The primary outcome was the prevalence of humeral stems at risk of radiographic loosening. Secondary outcomes included evaluation of functional outcome scores and prevalence of revision TSA for humeral stem loosening. Two blinded observers performed radiographic analyses, which included humeral stem alignment, canal filling ratio, radiolucent lines, stress shielding (calcar and greater tuberosity), and changes in component position (subsidence and stem shift). At risk stems were defined by the presence of one or more of the following: humeral stem with shifting or subsidence, scalloping of the humeral cortex, or radiolucent lines measuring 2 mm or greater in 3 or more zones.

Results

287 patients (97 ATSA and 190 RTSA) were included in this study. The mean follow-up was 35.9 (±6.1) months. There were significant improvements for all functional outcome scores (P < .05), range of motion (P < .05), and visual analogue pain scale pain (P < .05). The prevalence of humeral stem at risk of radiographic loosening was 1% in the ATSA group (1/97) and 18.4% in the RTSA group (35/190). Calcar resorption was seen in 34% of ATSA and 19% of RTSA, with severe resorption in 12.4% of ATSA and only 3.2% of RTSA. Greater tuberosity resorption was present in 3.1% of ATSA and 7.9% of RTSA. The mean canal filling ratio was 50.2% (standard deviation 11.2%). Using logistic regression, a significant positive correlation between canal filling ratio and stress shielding (P < .01) was seen for both calcar and tuberosity stress shielding. The revision surgery rate was 0% in ATSA compared to 1.6% in RTSA.

Conclusion

This retrospective study demonstrates a low revision rate and low prevalence of humeral stems at risk of radiographic loosening at two years with a press-fit short-stem humeral design in ATSA. Physiologic subsidence of humeral stems can account for higher prevalence of humeral stems at radiographic risk of loosening in RTSA compared to ATSA.

Characterizing the Practices of Canadian Orthopedic Surgeons in the Management of patients With Anterior Glenohumeral Instability

OBJECTIVE

To determine the practice patterns of Canadian orthopedic surgeons in the management of patients with anterior glenohumeral instability (AGHI).

DESIGN

Cross-sectional survey.

SETTING

Canada.

PATIENTS OR OTHER PARTICIPANTS

Canadian orthopedic surgeons with membership in the Canadian Orthopedic Association or Canadian Shoulder and Elbow Surgeon group who had managed at least 1 patient with AGHI in the previous year.

INTERVENTIONS

A survey including demographics and questions on the management of patients with AGHI was completed. Statistical comparisons (χ 2 ) were completed with responses stratified using the instability severity index score (ISIS) in practice, years of practice, and surgical volumes.

MAIN OUTCOME MEASURES

Summary statistics were compiled, and response frequencies were considered for consensus (75%). Case series responses were stratified on use of the ISIS in practice, years of experience, and annual procedure volumes (χ 2 , P < 0.05).

RESULTS

Eighty orthopedic surgeons responded, with consensus on areas of diagnostic workup of AGHI, nonoperative management, and operative techniques. There was no consensus on indications for soft tissue and bony augmentation or postoperative management. There was no difference in practices based on the use of ISIS, years in practice, or surgical volumes.

CONCLUSIONS

Canadian orthopedic surgeons manage AGHI consistently with consensus achieved in preoperative diagnostics and operative techniques, although debate remains as to the indications for soft tissue and bony augmentation procedures.

Inconsistencies in Controlling for Risk Factors for Recurrent Shoulder Instability After Primary Arthroscopic Bankart Repair: A Systematic Review

BACKGROUND

Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging.

PURPOSE

The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score.

RESULTS

After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis.

CONCLUSION

Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.

Morphometric and Biomechanical Comparison of the Scapular Spine and Coracoid Graft in Anterior Shoulder Instability

BACKGROUND

The scapular spine has been described as a relatively new bone graft alternative used in glenoid augmentation. The classic Latarjet procedure, which transfers the coracoid as a graft, is regarded as the gold standard. The comparison of these 2 techniques has not been fully reported.

PURPOSE

To compare the anatomic and biomechanical properties of glenoid augmentation using scapular spine graft or coracoid graft.

STUDY DESIGN

Controlled laboratory study.

METHODS

The study used 20 fresh-frozen human cadaveric shoulders. A 25% anterior glenoid defect was created, and the specimens were divided randomly to receive glenoid augmentation by scapular spine or coracoid grafts. For both procedures, the grafts were secured to the glenoid defect with 2 screws. Morphometric data, including the glenoid articular area, amount of restoration, and graft dimensions, were obtained. A biomechanical test was conducted in a direct-loading scenario. The construct stiffness, cyclic displacement, and ultimate failure of each specimen were collected.

RESULTS

No significant difference was found in glenoid articular restoration between the scapular spine group and the coracoid group (31% vs 33%, respectively; P = .311). Morphometric analysis indicated that coracoid grafts exhibited significantly greater thickness and height than scapular spine grafts. In biomechanical results, the scapular spine group exhibited significantly greater construct stiffness than the coracoid group (206.3 ± 58.8 vs 148.3 ± 76.0 N/mm, respectively; P = .023). The average failure load in the scapular spine group was not significantly higher than that in the coracoid group. No significant differences in cyclic displacement were found between the 2 techniques.

CONCLUSION

In a simulated 25% anterior glenoid bony defect, a scapular spine graft was comparable with the classic Latarjet procedure in restoring the glenoid articular dimension and exhibited superior construct stiffness in a cadaveric model.

CLINICAL RELEVANCE

The scapular spine may serve as an alternative graft choice in glenoid augmentation surgery considering the amount of articular restoration and initial fixation stability.

Remplissage for Anterior Shoulder Instability: History, Indications, and Outcomes

Remplissage is a nonanatomic capsulotenodesis of the infraspinatus tendon used to fill engaging or "off-track" Hill-Sachs lesions in patients at high risk of recurrent instability with isolated Bankart repair. Indications for remplissage are expanding, as the importance of subcritical bone loss and the glenoid track on patient outcomes and recurrence rates continues to be investigated. Remplissage is also suggested in patients at high risk of recurrent instability following isolated anterior labral repair, such as collision and contact athletes with Hill-Sachs lesions that have not reached the threshold of "off track." Multiple arthroscopic remplissage techniques exist including, more recently, knotless techniques.

Glenoid Bone Loss Directly Affects Hill-Sachs Morphology: An Advanced 3-Dimensional Analysis

BACKGROUND

While the glenoid track concept presents a useful prediction for recurrent glenohumeral instability, little is known about the humeral head bony architecture as it relates to glenoid erosion in the setting of bipolar bone loss.

PURPOSE

To (1) qualitatively and quantitatively analyze the interplay between glenoid bone loss (GBL) and Hill-Sachs lesions (HSLs) in a cohort of patients with anterior instability using 3-dimensional imaging software and (2) assess the relationships between GBL and HSL characteristics.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients were identified who had anterior shoulder instability with a minimum 5% GBL and evidence of HSL confirmed on computed tomography. Unilateral 3-dimensional models of the ipsilateral proximal humeral head and en face sagittal oblique view of the glenoid were reconstructed using MIMICS software (Materialise NV). GBL surface area, width, defect length, and glenoid track width were quantified. The volume, surface area, width, and depth of identified HSLs were quantified with their location (medial, superior, and inferior extent) on the humeral head. Severity of GBL was defined as percentage glenoid bone surface area loss and categorized as low grade (5%-10%), moderate grade (>10% to 20%), high grade (>20% to 30%), and extensive (>30%). Analysis of variance was then computed to determine significance (P < .05) between severity of GBL and associated HSL parameters.

RESULTS

In total, 100 patients met inclusion criteria (mean age, 27.9 years; range, 18-43 years), which included 58 right shoulders and 42 left shoulders (84 male, 16 female). Among groups, there were 32 patients with low-grade GBL (mean GBL = 6.1%), 38 with moderate grade (mean GBL = 16.2%), 17 with high grade (mean GBL = 23.7%), and 13 with extensive (mean GBL = 34.0%), with an overall mean GBL of 18.1% (range, 5%-39%). Patients with 5%-10% GBL had significantly narrower HSLs (average and maximum width; P < .03) and deeper HSLs (average depth; P = .002) as compared with all other GBL groups, while greater GBL was associated with wider and shallower HSLs. GBL width, percentage width loss, defect length, and glenoid track width all significantly differed across the 4 GBL groups (P < .05).

CONCLUSION

HSLs had significantly different morphological characteristics depending on the severity of GBL, indicating that GBL was directly related to the characteristics of HSLs. Patients presenting with smaller glenoid defects had significantly narrower and deeper HSLs with less humeral head surface area loss, while greater GBL was associated with wider and shallower HSLs.

Postoperative recovery comparisons of arthroscopic Bankart to open Latarjet for the treatment of anterior glenohumeral instability

BACKGROUND

Recurrent anterior glenohumeral instability is a disabling pathology that can be successfully treated by arthroscopic Bankart repair or open Latarjet. However, there is a paucity of studies comparing the postoperative recovery. The purpose of this study is to evaluate the postoperative pain and functional recovery following arthroscopic Bankart versus open Latarjet.

METHODS

This is a retrospective analysis of a multicenter prospective outcomes registry database. Postoperative recovery outcomes of either a primary or revision arthroscopic Bankart and open Latarjet procedures were compared. A minimum of 1-year follow-up was required. Outcomes measures included pain visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) function score, ASES index score, and single assessment numeric evaluation (SANE) score. Overall, 787 patients underwent primary arthroscopic Bankart, 36 underwent revision arthroscopic Bankart and 75 underwent an open Latarjet procedure.

RESULTS

When compared to primary arthroscopic Bankart, open Latarjet demonstrated significantly lower VAS scores at 6 weeks (p = 0.03), 3 months (p = 0.01), and 2 years (p < 0.05). Medium-term outcomes for ASES scores and SANE score, at 1 and 2 years showed no difference. Latarjet demonstrated significantly lower (p < 0.05) preoperative early postoperative VAS pain scores with no difference at 1 year or 2 years when compared to primary Bankart. There was no difference in ASES function or index between Bankart and Latarjet. Revision Bankart provided inferior outcomes for VAS, ASES function, and ASES index when compared to primary Bankart and Latarjet at 1 year and 2 years.

CONCLUSIONS

Primary arthroscopic Bankart repair and open Latarjet provided nearly equivalent improvements in pain (VAS) and functional outcomes (ASES, SANE, VR-12) during the early recovery phase (2 years). This study supports the use of either procedure in the primary treatment of anterior glenohumeral instability. Revision arthroscopic Bankart repair demonstrated deteriorating outcomes at 1 and 2 years postoperatively.

Long-term outcomes of arthroscopic Bankart repair and Hill-Sachs remplissage for bipolar bone defects

PURPOSE

To evaluate long-term results after arthroscopic Bankart repair and Hill-Sachs remplissage (BHSR) in bipolar bone defects with less than 20% of glenoid bone loss (GBL) and to analyse risk factors for recurrent dislocation.

METHODS

From 2009-2012, 43 patients with recurrent anterior shoulder instability were treated with BHSR. Inclusion criteria were GBL < 20% and minimum of 4-yearfollow-up. There were 35 males and 8 females with a mean age of 29 years (range 16-53). The mean ISIS score was 3.6 (range 2-6). Patients were evaluated for recurrence, range of motion and functional outcomes (Walch-Duplay and Rowe score). Post-operative MRI was performed at least 6 months after surgery to evaluate infraspinatus capsulotenodesis healing. Glenoid track was assessed retrospectively from pre-operative computed tomography. Mean follow-up was 7.3 years (range 4-11).

RESULTS

At the last follow-up, good to excellent outcomes were reported in 86% of patients. Average post-operative Walch-Duplay was 87.9 (range 75-100) and ROWE 93.7 (range 70-100). Infraspinatus capsulotenodesis healing was achieved in 86%. The rate of recurrence and revision surgery was 9.3% and 13.9%, respectively. Recurrence was associated with higher ISIS score (p = 0.0191) and lower age at surgery (p = 0.0227). Four (9.3%) Hill-Sachs lesions were considered off-track. The presence of off-track Hill-Sachs was associated with higher risk of recurrence (p < 0.00001).

CONCLUSION

Arthroscopic BHSR improves shoulder instability in the setting of bipolar bone defects with less than 20% of GBL. Patient-related factors and pre-operative glenoid track should be taken into consideration to reduce the risk of recurrence.

Validação clínica do conceito de glenoid track na instabilidade glenoumeral anterior

Objective  To evaluate the correlation of the glenoid track and glenoidal bone loss with the recurrence dislocation rate and the Rowe score.

Methods  Retrospective study that assessed the glenoid track and glenoidal bone loss through preoperative magnetic resonance imaging. Patients undergoing primary arthroscopic repair of anterior Bankart were included. Patients with glenoidal bone loss greater than 21%, rotator cuff tear, scapular waist fracture, and posterior or multidirectional instability were not included. Rowe score were the primary outcome, and the recurrence rate was the secondary outcome.

Results  One hundred and two patients were included. Postoperative recurrent instability was reported by 8 patients (7.8%). Four patients (50%) in the group with recurrence presented glenoidal bone loss greater than 13.5% against 24 (25.5%) in the group without recurrence ( p  = 0.210), with a negative predictive value of 94.6%. Three patients (37.5%) in the recurrence group were considered off-track, against 13 (13.8%) in the group without recurrence ( p  = 0.109), with a negative predictive value of 94.2%. Patients with absolute glenoid track value ≤ 1.5 mm had worse results in relation to the recurrence group, with 6 patients (75%) presenting recurrence ( p  = 0.003).

Conclusion  Off-track injury and glenoidal bone loss greater than the subcritical are not related to the recurrence rate and Rowe score, despite the high negative predictive value. The cut of the absolute value of the glenoid track at 1.5 mm had a significant relationship with the recurrence rate.

Editorial Commentary: A Consensus of Experts Complements the Clinical Evidence on Diagnosis and Treatment of Anterior Glenohumeral Instability

The current diagnostic and treatment strategies for anterior glenohumeral instability have been refined by high-quality clinical and basic science studies, but many controversies remain. These include the bone loss threshold for arthroscopic Bankart repair and the influence of other clinical factors on this decision, the optimal bracing position following anterior glenohumeral dislocation, and the optimal coracoid graft orientation during the Latarjet procedure. Randomized clinical trials often present conflicting results, and many of these are small-sample and fragile studies. Obtaining an expert consensus on the topic, by means of the Delphi method, is an attractive alternative to such clinical trials. Several studies employing variations of the Delphi method have addressed the diagnosis and treatment of anterior glenohumeral instability. These have stressed the importance of a meticulous technique during arthroscopic Bankart repair and of recognition of glenoid and humeral bone loss and treating this appropriately. These studies have also helped identify areas where consensus is modest or lacking to motivate additional clinical research study.

Instability Severity Index Score Does Not Predict the Risk of Shoulder Dislocation after a First Episode Treated Conservatively

The first purpose of this study was to verify the association between Instability Severity Index Score (ISIS) and Recurrent Shoulder Dislocation (RSD) after a first episode treated conservatively. The second aim is to identify the risk factors associated with RSD after a primary acute shoulder anterior dislocation treated conservatively. A total of 111 patients with first traumatic anterior shoulder dislocation treated at a single trauma centre between January 2014 and March 2016 were enrolled. The main predictive variables of risk factors and the ISIS score were calculated. Among the 85 patients included, 26 cases of RSD were observed (30.6%). Considering the whole population, no significant association between ISIS and RSD were reported. Regarding other risk factors, high-risk working activities and rotator cuff injury had a significantly higher RSD risk. Sex, dominant limb, familiar history, hyperlaxity, contact or overhead sports, competitive sport, post-reduction physiokinesitherapy, return to sports activity time, Hill-Sachs lesion, bony Bankart lesion and great tuberosity fracture did not seem to influence the risk of RSD. No correlation between ISIS score and RSD in patients treated conservatively after a first episode of shoulder dislocation were reported. The only risk factors with a significant association to RSD were high-risk working activities and rotator cuff injury.

Return to sport following Latarjet glenoid reconstruction for anterior shoulder instability

BACKGROUND

Latarjet coracoid transfer reconstruction is the gold standard for the treatment of recurrent shoulder instability with anterior-inferior glenoid bone loss, and return to sport is often a primary outcome of interest in this patient population. The purpose of this study was to determine the rate of return to sport in patients undergoing the Latarjet procedure and variables that are associated with a higher likelihood of a successful return to sport.

METHODS

A prospectively maintained institutional registry was retrospectively queried between August 2012 and August 2016 for all patients who underwent the Latarjet procedure. Patients were contacted electronically and via telephone to administer a previously validated and standardized return-to-sport survey. Patients self-reported return to sport, varying sports participation, recurrence of instability, and time to return to sport. Multivariate analysis was performed to determine variables associated with each outcome.

RESULTS

Of 83 patients, 66 (75.3%) were available for final follow-up, of whom 60 participated in sports prior to surgery and were eligible for inclusion. The average follow-up period was 53.8 ± 11.8 months. The average age at surgery was 26.7 ± 11.3 years, and the average body mass index was 26.2 ± 4.0 kg/m². There were 54 patients (90%) who were able to return to sport at an average of 8.6 ± 4.1 months following surgery. In total, 36 patients (60%) were able to return to sport at the same level or a better level of intensity, 19 of 28 patients (67.9%) were able to return to throwing sports without difficulty, and 31 of 60 patients (51.7%) reported that their shoulder was a hindrance to some activity. An increased likelihood of returning to sport was associated with increased body mass index (P = .016), male sex (P = .028), and decreased humeral bone loss volume (P = .034). An increased likelihood of returning to sport at the same level or a better level of intensity was associated with reduced humeral bone loss volume (P = .026). Recurrent instability was associated with humeral bone loss (P = .038).

CONCLUSION

Although a large majority of patients were able to return to sport following the Latarjet procedure, some patients experienced limitation with throwing and return to sport at the preinjury level. Greater humeral bone loss was associated with inferior outcomes. These findings should be discussed with patients in the preoperative setting to manage expectations appropriately.

Advanced 3-Dimensional Characterization of Hill-Sachs Lesions in 100 Anterior Shoulder Instability Patients

PURPOSE

We sought to qualitatively and quantitatively describe characteristics of Hill-Sachs lesions (HSL) in a cohort of anterior shoulder instability patients using advanced 3-dimensional (3-D) modeling software and assess the impact of various HSL parameters on the HSL volume, location, and orientation in patients with anterior shoulder instability.

METHODS

A total of 100 recurrent anterior instability patients with evidence of HSL with a mean age of 27.2 years (range = 18 to 43 years) were evaluated. Three-dimensional models of unilateral proximal humeri were reconstructed from CT scans, and the volume, surface area (SA), width, and depth of identified HSLs were quantified along with their location (medial, superior, and inferior extent). Multiple angular orientation measures of HSLs were recorded, including Hill-Sachs rim (HSLr) angle in order to classify the level and location of potential humeral head engagement. Mann-Whitney U test assessed the relationship between measured parameters.

RESULTS

By volume, larger HSL had greater humeral head surface area (HH SA) loss (P = .001), HSL width (P = .001), were more medial (P = .015), and more inferior (P = .001). Additionally, more medial lesions had greater HSLr angles (P = 0.001). The mean depth, width, and volume of HSLs were 3.3 mm (range = 1.2-7.1 mm), 16.0 mm (range = 6.2-30.4 mm) and 449.2 mm³ (range = 62.0-1365.6 mm³), respectively. The medial border of the HSL extended to 17.2 ± 4.4 (range = 9.3-28.3 mm) off the most medial edge of the HH cartilage margin (medialization). The mean HSLr was 29.3 ± 10.5°.

CONCLUSION

There was a statistically significant association between HSL medialization and HSL volume, position, and orientation. More medialized HSL have larger volume, greater width, more SA loss and higher lesion angles and are more inferior in the humeral head. As it has been established that more medialized lesions have poorer clinical outcomes, this study highlights that HS lesions have varying angles and medialization, which may portend eventual treatment and outcomes.

LEVEL OF EVIDENCE

IV, case series.

Editorial Commentary: Should We Condemn the Shoulder Instability Severity Index Scoring System? Not at All!... Can We Improve Its Radiographic Component? Yes, We Can!

Is patient selection necessary in shoulder instability surgery? Absolutely. The risk-benefit discussion that the surgeon must have with the patient before proposing an arthroscopic Bankart repair remains crucial to provide informed consent. The most important preoperative risk factors are incorporated in the instability severity index (ISI) score to assist surgeons in the decision-making process. This 10-point score is based on factors derived from a preoperative questionnaire, physical examination, and simple plain radiographs. Using this score at the first visit, the surgeon can explain to the patient and family why a Bankart repair may be contraindicated and why other surgical options may be more suitable. A recent study found that the ISI score has no limited predictive value when applied in a preselected population of military patients without severe bone loss or hyperlaxity. This is not surprising because the authors analyzed a preselected patient population with lower risk than the general population. The value of the ISI scoring system relies on the fact that this tool has been developed after evaluation of arthroscopic Bankart repair in an unselected patient population and that there is no need for sophisticated imaging studies to make the decision. This scoring system should not be condemned but complemented with preoperative advanced imaging studies (computed tomography [CT] scanning or magnetic resonance imaging) to assess the severity of the bone lesions more accurately. Today, the choice of the surgical procedure depends not only on the clinical risk factors included in the ISI score (age, type of sports, level of practice, hyperlaxity) but also on the presence, location and size of bony lesions, as identified and measured on advanced CT scanning images.

Limited Predictive Value of the Instability Severity Index Score: Evaluation of 217 Consecutive Cases of Recurrent Anterior Shoulder Instability

PURPOSE

To review the existing variables and their ability to predict recurrence of shoulder instability as it relates to the Instability Severity Index Score (ISIS), as well as evaluate any other pertinent imaging and patient history variables that may impact risk of recurrent anterior instability after arthroscopic Bankart repair.

METHODS

All consecutive patients with recurrent anterior shoulder instability and who had arthroscopic instability repair were identified. Exclusion criteria were prior surgery on the shoulder, posterior or multidirectional instability, instability caused by seizure disorder, or a rotator cuff tear. All ISIS variables were recorded (age <20 years, sport type and level, hyperlaxity, Hill-Sachs on anteroposterior external rotation radiograph, loss of glenoid contour on anteroposterior radiograph), as well as additional variables: (1) number of instability events; (2) total time of instability; (3) glenoid bone loss (GBL) percent; and (4) Hill-Sachs measures (H/L/W/D/Volume). Postoperative outcomes were assessed based on the Western Ontario Shoulder Instability Index (WOSI), Single Assessment Numeric Evaluation (SANE) scores, and American Shoulder and Elbow Surgeons (ASES) scores, and recurrent anterior instability. Regression analysis was used to determine preoperative variables that predicted outcomes and failures.

RESULTS

There were 217 consecutive patients (209 male patients [96.5%], 8 female patients [3.5%]) who met the inclusion criteria and were all treated with a primary arthroscopic shoulder stabilization during a 3.5-year period (2007-2011), with a mean follow-up time of 42 months (range, 26-58). The mean age at first instability event was 23.9 years (range, 16-48 years) and the mean cumulative ISIS score for the overall group was 3.6 (range, 1-6). Outcomes were improved from mean preoperative (WOSI = 1,050/2,100; ASES = 61.0; SANE = 52.5) to postoperative (WOSI = 305/2,100; ASES = 93.5; SANE = 95.5). A total of 11.5% (25/217) of patients had evidence of recurrent instability (subluxation or dislocation). Additionally, all 25 patients who failed postoperatively also had consistently inferior ASES, SANE, and WOSI outcome scores when compared with successfully treated patients. Factors associated with failure were GBL greater than 14.5% (P < .001), total time of instability symptoms greater than 3 months (P = .03), Hill-Sachs volume greater than 1.3 cm³ (P = .02), contact sports participation (P = .05), and age 20 years or younger (P < .01). There was no correlation in outcomes with Hill-Sachs on presence of glenoid contour loss on radiograph (P = .07), participation sports, or ISIS (mean = 3.4 success vs 3.9 failure, P > .05).

CONCLUSIONS

At a mean follow-up of 42 months was an 11.5% failure rate after arthroscopic Bankart stabilization surgery. This study shows no correlation between treatment outcome and the ISIS measure, given a mean score of 3.4 for the overall cohort with little difference identified in those who failed. However, several important parameters previously unidentified were detected including, GBL greater than 14.5%, Hill-Sachs volume greater than 1.3 cm³, and duration of instability symptoms (>3 months). The ISIS may need to be redesigned to incorporate variables that more accurately portray the actual risk of failure after arthroscopic stabilization, including quantification of both glenoid and humeral head bone loss.

LEVEL OF EVIDENCE

III (Retrospective Case Series).

Editorial Commentary: Recurrence After Arthroscopic Bankart Repair: What the Instability Severity Index Score Will and Will Not Predict

The recurrence of shoulder instability is a challenging complication after anterior open or arthroscopic stabilization in patients with glenohumeral instability. Use of the arthroscopic Bankart procedure has increased over the last decade, because of its less invasiveness and low complication rates compared with the Latarjet procedure. However, arthroscopic repair has the possibility of a greater recurrent instability rate. The Instability Shoulder Index Score (ISIS) has been developed to predict the success of isolated arthroscopic Bankart repair for the management of recurrent anterior shoulder instability. The risk factors associated with the recurrence of instability are age, level and type of sports participation, shoulder hyperlaxity, and humeral and glenoid bony lesions. The ISIS is a validated tool to predict the recurrence of dislocation after arthroscopic surgery in patients with shoulder instability. The arthroscopic Bankart procedure can be performed in patients with ISIS ≤3 with a low risk of recurrence of glenohumeral instability. The Latarjet procedure should be recommended in patients with ISIS >6. The management of patients with ISIS between 4 and 6 is still controversial and ranges from arthroscopic Bankart procedure with the addition of remplissage to the Latarjet procedure. Because advanced imaging techniques, such as computed tomography scans, allow us to assess appropriately the glenoid and humeral bone defect, their use is recommended in addition to ISIS.

High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review

Purpose

To determine the definitions for recurrence used in the literature, assess the consensus in using these definitions, and determine the impact of these definitions on recurrence rates.

Methods

A literature search was performed in PubMed and EMBASE including studies from 2000 to 2020 reporting on recurrence rates after anterior arthroscopic shoulder instability surgery. Dislocation, apprehension, subluxation and recurrence rates were compared.

Results

Ninety-one studies were included. In 68% of the eligible studies, recurrence rates are not well defined. Thirty (33%) studies did not report on dislocations, 45 (49%) did not report on subluxations, and 58 (64%) did not report on apprehension. Seventeen different definitions for recurrence of instability, 4 definitions of dislocations, and 8 definitions of subluxation were used.

Conclusion

Recurrence rates are poorly specified and likely underreported in the literature, hampering comparison with results of other studies. This highlights the need for a consensus on definition of recurrence across shoulder instability studies. We recommend not using the definition recurrence of instability anymore. We endorse defining dislocations as a radiographically confirmed dislocation or a dislocation that is manually reduced, subluxations as the feeling of a dislocation that can be (spontaneously) reduced without the need for a radiographically confirmed dislocation, and a positive apprehension sign as fear of imminent dislocation when placing the arm in abduction and external rotation during physical examination. Reporting on the events resulting in a dislocation or subluxation aids in making an estimation of the severity of instability.

Level of Evidence

Level IV, systematic review.

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.

Anterior Glenohumeral Instability in the Adolescent Athlete

Glenohumeral instability is multifactorial and has both static and dynamic elements. The initial management of first-time dislocations has become increasingly controversial, although recent evidence supports operative treatment for adolescents who participate in contact sports. Risk factors for recurrent glenohumeral instability include adolescent age, hyperlaxity, glenoid bone loss, off-track Hill-Sachs lesions, and fixation with <=3 anchors. High rates of return to sport can be expected when the surgical plan is tailored to individual pathology.

Arthroscopic Latarjet Procedure: Indications, Techniques, and Outcomes

»

The proposed advantages of the arthroscopic approach in the Latarjet procedure for shoulder dislocation include improved visualization for accurate positioning of the coracoid graft, the ability to address any associated intra-articular pathologies, and the diminished potential for the formation of postoperative scar tissue and stiffness associated with an open procedure.

»

Young age, the presence of glenoid and/or humeral bone loss, a history of dislocation, a history of failed arthroscopic stabilization surgery, and an active lifestyle are all associated with recurrent dislocation and are relative indications for an osseous augmentation procedure.

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Both the open and arthroscopic Latarjet procedures result in substantial improvements in patient function, with comparable rates of recurrent instability and complication profiles.

A lower Instability Severity Index score threshold may better predict recurrent anterior shoulder instability after arthroscopic Bankart repair: a systematic review

Importance

The Instability Severity Index (ISI) score was developed to evaluate a patient’s risk of recurrent shoulder instability following arthroscopic Bankart repair. While patients with an ISI score of >6 were originally recommended to undergo an open procedure (ie, Latarjet) to minimise the risk of recurrence, recent literature has called into question the utility of the ISI score.

Objective

The purpose of this systematic review was to evaluate the efficacy of the ISI score as a tool to predict postoperative recurrence among patients undergoing arthroscopic Bankart procedures.

Evidence review

Articles were included if study participants underwent arthroscopic Bankart repair for anterior shoulder instability and reported postoperative recurrence by ISI score at a minimum of 2 years of follow-up. Methodological study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Pearson’s χ2 test was used to compare recurrence rates among patients above and below an ISI score of 4. Sensitivity, specificity, mean ISI scores and predictive value of individual factors of the ISI score were qualitatively reviewed.

Findings

Four studies concluded the ISI score was effective in predicting postoperative recurrence following arthroscopic Bankart repair; however, these studies found threshold values lower than the previously proposed score of >6 may be more predictive of recurrent instability. A pooled analysis of these studies found patients with an ISI score <4 to experience significantly lower recurrence rates when compared with patients with a score ≥4 (6.3% vs 26.0%, p<0.0001). The mean ISI score among patients who experienced recurrent instability was also significantly higher than those who did not.

Conclusions and relevance

The ISI score as constructed by Balg and Boileau may have clinical utility to help predict recurrent anterior shoulder instability following arthroscopic Bankart repair. However, this review found the threshold values published in their seminal article to be insufficient predictors of recurrent instability. Instead, a lower score threshold may provide as a better predictor of failure. The paucity of level I and II investigations limits the strength of these conclusions, suggesting a need for further large, prospective studies evaluating the predictive ability of the ISI score.

Level of evidence

IV.

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.

Age, participation in competitive sports, bony lesions, ALPSA lesions, > 1 preoperative dislocations, surgical delay and ISIS score > 3 are risk factors for recurrence following arthroscopic Bankart repair: a systematic review and meta-analysis of 4584 shoulders

PURPOSE

Determining the risk of recurrent instability following an arthroscopic Bankart repair can be challenging, as numerous risk factors have been identified that might predispose recurrent instability. However, an overview with quantitative analysis of all available risk factors is lacking. Therefore, the aim of this systematic review is to identify risk factors that are associated with recurrence following an arthroscopic Bankart repair.

METHODS

Relevant studies were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, CINAHL/Ebsco, and Web of Science/Clarivate Analytics from inception up to November 12th 2020. Studies evaluating risk factors for recurrence following an arthroscopic Bankart repair with a minimal follow-up of 2 years were included.

RESULTS

Twenty-nine studies met the inclusion criteria and comprised a total of 4582 shoulders (4578 patients). Meta-analyses were feasible for 22 risk factors and demonstrated that age ≤ 20 years (RR = 2.02; P < 0.00001), age ≤ 30 years (RR = 2.62; P = 0.005), participation in competitive sports (RR = 2.40; P = 0.02), Hill-Sachs lesion (RR = 1.77; P = 0.0005), off-track Hill-Sachs lesion (RR = 3.24; P = 0.002), glenoid bone loss (RR = 2.38; P = 0.0001), ALPSA lesion (RR = 1.90; P = 0.03), > 1 preoperative dislocations (RR = 2.02; P = 0.03), > 6 months surgical delay (RR = 2.86; P < 0.0001), ISIS > 3 (RR = 3.28; P = 0.0007) and ISIS > 6 (RR = 4.88; P < 0.00001) were risk factors for recurrence. Male gender, an affected dominant arm, hyperlaxity, participation in contact and/or overhead sports, glenoid fracture, SLAP lesion with/without repair, rotator cuff tear, > 5 preoperative dislocations and using ≤ 2 anchors could not be confirmed as risk factors. In addition, no difference was observed between the age groups ≤ 20 and 21-30 years.

CONCLUSION

Meta-analyses demonstrated that age ≤ 20 years, age ≤ 30 years, participation in competitive sports, Hill-Sachs lesion, off-track Hill-Sachs lesion, glenoid bone loss, ALPSA lesion, > 1 preoperative dislocations, > 6 months surgical delay from first-time dislocation to surgery, ISIS > 3 and ISIS > 6 were risk factors for recurrence following an arthroscopic Bankart repair. These factors can assist clinicians in giving a proper advice regarding treatment.

LEVEL OF EVIDENCE

Level IV.

The Hill-Sachs interval to glenoid track width ratio is comparable to the instability severity index score for predicting risk of recurrent instability after arthroscopic Bankart repair

PURPOSE

The purpose of this study was to clinically validate the Hill-Sachs interval to glenoid track width ratio (H/G ratio) compared with the instability severity index (ISI) score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair.

METHODS

A retrospective evaluation was performed using data from patients with anteroinferior shoulder instability who underwent arthroscopic Bankart repair with a follow-up period of at least 24 months. A receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values for the H/G ratio and the ISI score to predict an increased risk of recurrent instability. The area under the ROC curve (AUC) of the two methods and the sensitivity and specificity of their optimal cut-off values were compared.

RESULTS

A total of 222 patients were included, among whom 31 (14.0%) experienced recurrent instability during the follow-up period. The optimal cut-off values for predicting an increased risk of recurrent instability were an H/G ratio of ≥ 0.7 and ISI score of ≥ 4. There were no significant differences between the AUC of the two methods (H/G ratio AUC = 0.821, standard error = 0.035 and ISI score AUC = 0.792, standard error = 0.04; n.s.) nor between the sensitivity and specificity of the optimal cut-off values (n.s. and n.s., respectively).

CONCLUSIONS

The H/G ratio is comparable to the ISI score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair. Surgeons are recommended to consider other strategies to treat anterior shoulder instability if H/G ratio is ≥ 0.7.

LEVEL OF EVIDENCE

III.

Immobilisation in external rotation after first-time traumatic anterior shoulder instability reduces recurrent instability: a meta-analysis

IMPORTANCE

Cadaveric and MRI findings have demonstrated significantly less labral separation and displacement when the shoulder is placed in external rotation as compared with internal rotation.

OBJECTIVE

The purpose of the current study is to meta-analyse the randomised controlled trials in the literature to compare immobilisation in external versus internal rotation after first-time anterior shoulder dislocation.

EVIDENCE REVIEW

A literature search of MEDLINE, EMBASE and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomised controlled trials comparing immobilisation in external rotation versus internal rotation for first-time anterior shoulder dislocation were included.

FINDINGS

Nine randomised controlled trials with 795 patients were included. The mean age of included patients was 29 years, 82.4% were male and the mean follow-up was 25.5 months. As compared with immobilisation in internal rotation, compliance was significantly higher (74.5% vs 67.4%, p=0.01), and the rate of recurrent dislocations was significantly lower (22.2% vs 33.4%, p=0.02) with immobilisation in external rotation. Additionally, in patients 20-40 years old the rate of recurrent dislocations was significantly lower in those treated with immobilisation in external rotation than internal rotation (12.1% vs 31.4%, p=0.006). Immobilisation in external rotation also resulted in a higher rate of return to preinjury level of play (60.1% vs 42.6%, p=0.0001).

CONCLUSIONS AND RELEVANCE

Immobilisation of the shoulder in external rotation after a traumatic first-time anterior shoulder dislocation results in a higher compliance rate, a lower recurrent dislocation rate and a higher rate of return to play as compared with immobilisation in internal rotation.

LEVEL OF EVIDENCE

Level I.

First-time Glenohumeral Dislocations: Current Evidence and Considerations in Clinical Decision Making

The decision to manage first-time shoulder dislocations conservatively or operatively has become increasingly complex because of conflicting literature. Although shoulder dislocations have traditionally been managed with reduction and immobilization, recent evidence has suggested high rates of subsequent recurrence. Surgical intervention is thought to better restore stability and decrease recurrence rates; however, it also has the potential for additional morbidity and financial cost. As such, recent literature has sought to better define patient risk profiles to identify optimal candidates for both conservative and operative management. The purpose of the current review is to provide a comprehensive and evidence-based assessment of the most recent literature to better delineate an appropriate treatment algorithm for this challenging clinical scenario.

The Arthroscopic Bankart Repair: State of the Art in 2020: Decision-making and Operative Technique

Traumatic anterior shoulder instability is prevalent among young athletes, and recurrent dislocations can result in compromised upper extremity function, increasing glenohumeral bone loss, and ultimately, posttraumatic arthritis. Although management algorithms have evolved in response to contemporary data and technical innovation, the arthroscopic Bankart repair continues to be a mainstay for the primary surgical management of first-time or recurrent anterior shoulder instability with marginal attritional glenoid bone loss (ie, <10% to 15%) and/or "on track" Hill-Sachs defects. The advantages of arthroscopic stabilization include its minimally invasive technique, high cost effectiveness, and relatively low recurrence rates and propensity for perioperative complications. The current article reviews contemporary indications/contraindications, management of the first-time dislocator, critical glenoid bone loss, surgical technique, and reported clinical outcomes of the arthroscopic Bankart repair.

Anterior Shoulder Instability Management: Indications, Techniques, and Outcomes

Anterior shoulder instability is common in young athletes. Male individuals younger than 20 years who are involved in contact sports are at particular risk of injury and recurrence. Essential imaging includes radiography and magnetic resonance imaging in all patients, with 3-dimensional computed tomography being helpful to evaluate glenoid bone loss and Hill-Sachs lesions. Evaluation of the glenoid track is essential to help determine appropriate treatment because off-track scenarios in which the Hill-Sachs width is greater than the glenoid width impart a risk of failure with isolated arthroscopic treatment. Associated injuries also must be evaluated, including bone loss, Hill-Sachs lesions, humeral avulsion of the glenohumeral ligament (HAGL), glenolabral articular disruption (GLAD), anterior labroligamentous periosteal sleeve avulsion (ALPSA), rotator cuff injury, other fractures, and axillary nerve injury. Optimal treatment continues to be debated. Conservative management with physical therapy for rotator cuff and periscapular strengthening can be attempted, with the addition of bracing if continued play is desired until the season's conclusion. Surgical intervention is considered in patients with recurrent dislocations, glenoid bone loss, or large Hill-Sachs lesions or in young athletes involved in contact or high-risk sports. Treatment options include arthroscopic capsulolabral repair with at least 4 anchors if good tissue quality and no bone loss exist. Remplissage has been recommended by some surgeons if a large Hill-Sachs exists. Open repair is suggested in patients with a high number of recurrent dislocations without bone loss or in those who participate in high-risk sports. Coracoid transfer or the Latarjet procedure is suggested in patients with bone loss greater than 20%. Bone grafting for glenoid bone loss using autograft or allograft, such as distal tibial allograft, is recommended in patients with a failed Latarjet procedure or those with significant bone loss. Hill-Sachs lesion grafting may also be beneficial in those with large lesions that engage.

Mathematical modeling of glenoid bone loss demonstrate differences in calculations that May affect surgical decision making

Objective

Two glenoid bone loss calculations are compared across a range of anatomic glenoid sizes.

Methods

20 cadaveric paired glenoid diameters were measured to create glenoid models with bone loss calculated in 1 mm linear increments up to 50% bone loss comparing the linear measurement percentage (LMP) to the circle line method (CLM) gold standard.

Results

The LMP overestimates glenoid bone loss at every potential 1 mm increment across each glenoid model until bone loss reaches 50%.

Conclusion

The widely-used LMP method overestimates bone loss compared to a gold standard potentially misguiding surgeons towards bony reconstruction in shoulder instability during preoperative planning.

A Multicenter Retrospective Study With a Minimum 5-Year Follow-up Comparing Arthroscopic Bankart Repair and the Latarjet Procedure

Background:

Arthroscopic Bankart repair (ABR) and the Latarjet procedure are surgical techniques commonly used to treat anterior shoulder instability. There is no consensus among shoulder surgeons regarding the indications for choosing one over the other.

Purpose:

To compare the results of the Latarjet procedure with those of ABR for the treatment of anterior shoulder instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data on all patients who were treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected at 4 medical centers. The minimum follow-up was 5 years. Data were retrieved from medical charts, and patients were interviewed to assess their level of satisfaction (range, 0-100), functional outcomes (using the American Shoulder and Elbow Surgeons shoulder score; the Subjective Shoulder Value; and the Disabilities of the Arm, Shoulder and Hand score), and quality of life (using the 12-Item Short Form Health Survey [SF-12]). Information on return to sports activities and postoperative level of activity compared with that of the preinjury state, complications, reoperations, and recurrent instability were recorded and evaluated.

Results:

A total of 242 patients were included. The Latarjet procedure was performed in 27 shoulders, and ABR was performed in 215 shoulders. Patients in the ABR group had significantly higher rates of redislocation (18.5%; P = .05) and subluxation (21.4%; P = .43) but a lower rate of self-reported apprehension (43.0%; P = .05) compared with patients in the Latarjet group (3.7%, 14.8%, and 63.0%, respectively). There were 5 patients in the ABR group who underwent reoperation with the Latarjet procedure because of recurrent instability. The functional scores in the Latarjet group were better than those in the ABR group. The SF-12 physical score was significantly better in the Latarjet group than in the ABR group (98.1 vs 93.9, respectively; P = .01). Patient satisfaction and subjective scores were similar in both groups.

Conclusion:

These results support recently published data on the Latarjet procedure that showed its superiority over ABR in midterm stability (dislocations or subluxations). The contribution of self-reported apprehension to the broad definition of stability is not clear, and apprehension rates were not correlated with satisfaction scores or the recurrence of dislocation or subluxation.

Arthroscopic stabilisation for shoulder instability

Since its first description over 30 years ago arthroscopic stabilisation has evolved. With improvements in knowledge, surgical techniques and materials technology, arthroscopic bankart repair has become the most widely used method for treating patients with symptomatic anterior shoulder instability. These procedures are typically performed in a younger, high demand patient population after a primary dislocation or to treat recurrent instability. A thorough clinical evaluation is required in the clinic setting not only to fully understand the injury pattern but also consider patient expectations prior to embarking on surgery. Diagnostic imaging will aid the clinician in determining the soft tissue pathology as well as assessing bone loss, which facilitates surgical decision-making. Selected patients may benefit from adjunctive procedures such as a remplissage for an "engaging" Hill-sachs lesion. This review will focus on the indications, pre-operative considerations, surgical techniques and outcomes of arthroscopic stabilisation.

Labral Morphology and Number of Preoperative Dislocations Are Associated With Recurrent Instability After Arthroscopic Bankart Repair

PURPOSE

To develop a method to measure capsule and labral volume on preoperative magnetic resonance imaging to predict surgical failure after primary Bankart repair.

METHODS

A retrospective case-control study was conducted on patients undergoing primary anterior arthroscopic shoulder stabilization. Surgical failure was defined as a recurrent dislocation event. Cases were matched to controls based on age and sex in a 1:2 ratio. Preoperative magnetic resonance (MR) arthrograms were analyzed by 2 trained reviewers using Vitrea software to measure labral and capsular volume with a 3-dimensional model. Labral size was also qualitatively measured on axial images. A "diffusely small" labrum was defined as labral height less than the width of the glenoid tidemark cartilage.

RESULTS

Of the 289 patients who had an arthroscopic Bankart repair from 2006 to 2015, 33 who had a postoperative dislocation met the inclusion criteria and were matched to 62 control patients who did not. There was no difference between groups with regard to age (P = .88), sex (P = .82), contact sport participation (P = .79), proportion of overhead athletes (P = .33), proportion of throwers (P = 1), surgical positioning in lateral decubitus (P = .18), or number of repair anchors used (P = .91). The average number of preoperative dislocations was significantly higher in the failure group (3.2 vs. 2.0, P < .0001). In patients with normal labrum morphology, the odds of having surgical failure increased by 26% for a 1-unit increase in the number of prior dislocations (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.02 to 1.55). The case and control groups had similar labral and capsular volume as measured in Vitrea. The failure group had a significantly higher proportion of patients with a diffusely small labral morphology (47% vs. 17%, P = .03). Controlling for number of preoperative dislocations, the odds of having a diffusely small labral morphology was 3.2 times more likely in the case group than the control group (95% CI 1.259 to 8.188). Interrater reliability between 2 independent reviewers was excellent for measurement of capsule volume (r = 0.91) and good for measurement of labral volume (r = 0.74).

CONCLUSIONS

This study presents a novel method of measuring labral and capsule volume with high interrater reliability. An increased number of recurrent dislocations prior to primary Bankart repair was associated with increased odds of recurrent instability after surgery. The OR for failure also increased with increasing number of preoperative dislocations. Diffusely small labral morphology was associated with having a postoperative redislocation.

LEVEL OF EVIDENCE

III (case-control study).

Outcomes After Latarjet Procedure: Patients With First-Time Versus Recurrent Dislocations

BACKGROUND

The preoperative number of dislocations has been previously proved to be a major factor influencing the results after Bankart repair with more preoperative dislocations correlated with higher recurrence rates and more reoperations. This could possibly be because of the lower quality of the tissue repaired during the procedure after multiple dislocations. On the other hand, the Latarjet procedure does not "repair" but rather reconstructs and augments the anterior glenoid.

PURPOSE/HYPOTHESIS

The main objective was to report the clinical outcomes of patients undergoing a Latarjet procedure after 1 dislocation versus multiple (≥2) dislocations. The hypothesis was that the preoperative number of dislocations would not influence clinical results.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients older than 18 years who had undergone a primary Latarjet procedure for shoulder instability with at least 2 years of follow-up were included. Three different techniques were used: a mini-open technique using 2 screws, an arthroscopic technique using 2 screws, and an arthroscopic technique using 2 cortical buttons. Patients were evaluated and answered a questionnaire to assess the number of episodes of dislocation before surgery, the time between the first dislocation and surgery, recurrence of the dislocation, revision surgery, the Walch-Duplay score, the Simple Shoulder Test score, and the visual analog scale (VAS) score for pain.

RESULTS

A total of 308 patients were included for analysis with a mean follow-up of 3.4 ± 0.8 years. Of that, 83 patients were included in the first-time dislocation group and 225 in the recurrent dislocation group. At last follow-up, the rates of recurrence and reoperation were not significantly different between groups: 4.8% in the first-time dislocation group versus 3.65% in the recurrent dislocation group and 6.1% versus 4.0%, respectively. The overall Walch-Duplay scores at last follow-up were also comparable between the 2 groups, 67.3 ± 24.85 and 71.8 ± 25.1, even though the first-time dislocation group showed a lower pain subscore (15.0 ± 8.6 vs 18.0 ± 7.5; P = .003). The VAS for pain was also significantly higher in the first-time dislocation group compared with the recurrent dislocation group (1.8 ± 2.3 vs 1.2 ± 1.7; P = .03).

CONCLUSION

The number of episodes of dislocation before surgery does not affect postoperative instability rates and reoperation rates after the Latarjet procedure. However, patients with first-time dislocations had more postoperative pain compared with patients with recurrent dislocations before surgery.

Outcomes of the Latarjet Procedure for the Treatment of Chronic Anterior Shoulder Instability: Patients With Prior Arthroscopic Bankart Repair Versus Primary Cases

BACKGROUND

It remains unclear whether results differ between a Latarjet procedure performed after a failed arthroscopic Bankart repair and one performed as the primary operation.

PURPOSE

To compare the postoperative outcomes of the Latarjet procedure when performed as primary surgery and as revision for a failed arthroscopic Bankart repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicenter retrospective comparative case-cohort analysis was performed for all patients undergoing a Latarjet procedure for recurrent anterior shoulder instability. Patients were separated into 2 groups depending on if the Latarjet procedure was performed after a failed arthroscopic Bankart repair (group 1) or as the first operation (group 2). Outcome measures included recurrent instability, reoperation rates, complications, pain, Walch-Duplay scores, and Simple Shoulder Test.

RESULTS

A total of 308 patients were eligible for participation in the study; 72 (23.4%) did not answer and were considered lost to follow-up, leaving 236 patients available for analysis. Mean follow-up was 3.4 ± 0.8 years. There were 20 patients in group 1 and 216 in group 2. Despite similar rates of recurrent instability (5.0% in group 1 vs 2.3% in group 2; P = .5) and revision surgery (0% in group 1 vs 6.5% in group 2; P = .3), group 1 demonstrated significantly worse pain scores (2.56 ± 2.7 vs 1.2 ± 1.7; P = .01) and patient-reported outcomes (Walch-Duplay: 52 ± 25.1 vs 72.2 ± 25.0; P = .0007; Simple Shoulder Test: 9.3 ± 2.4 vs 10.7 ± 1.9; P = .001) when compared with those patients undergoing primary Latarjet procedures.

CONCLUSION

Functional outcome scores and postoperative pain are significantly worse in patients undergoing a Latarjet procedure after a failed arthroscopic Bankart repair when compared with patients undergoing primary Latarjet. The assumption that a failed a Bankart repair can be revised by a Latarjet with a similar result to a primary Latarjet appears to be incorrect. Surgeons should consider these findings when deciding on the optimal surgical procedure for recurrent shoulder instability.

Glenoid Track Instability Management Score: Radiographic Modification of the Instability Severity Index Score

PURPOSE

The purpose of this study is (1) to test the proposed treatment algorithm, the Glenoid Track Instability Management Score (GTIMS), which incorporates the glenoid track concept into the instability severity index score (ISIS), and (2) to compare treatment decision-making using either GTIMS versus ISIS in 2 cohorts of patients with operatively treated anterior instability.

METHODS

A multicenter, retrospective review of two consecutive groups consisting of 72 and 189 patients treated according to ISIS and GTIMS, respectively, was conducted. Inclusion criteria for all patients were ≥2 confirmed traumatic anterior shoulder instability events and a physical examination demonstrating a positive anterior apprehension and relocation test. The GTIMS was graded for all 189 patients in the cohort, which uses 3-dimensional computed tomography as the sole radiographic parameter to assess on-track (0 points) versus off-track (4 points) Hill-Sachs lesions. This method differs from ISIS, which uses multiple plain radiographs for the 4-point imaging portion of the score. Outcomes scores were compared within the GTIMS and ISIS groups, as well as between them for overall comparisons based on the Western Ontario Shoulder Instability Index (WOSI), the Single Assessment Numerical Evaluation (SANE) score, and the mean rates of recurrent instability.

RESULTS

A total of 261 consecutive patients from 2009 to 2014 who presented with recurrent anterior shoulder instability were treated according to either ISIS (n = 72/261, 27.6%) or GTIMS (n = 189/261, 72.4%). At a mean follow-up time of 33.2 months (range 24-49 months), the overall cohort mean ISIS of 2.9 ± 2.2 (range 0-9) was significantly higher than the mean GTIMS of 1.9 ± 1.9 (range = 0-9, P < .001). Of the 72 ISIS treated patients, 50 (69.4%) had an ISIS score of ≥ 4 and underwent a Latarjet, and the 22 patients (30.6%) with an ISIS score of < 4 underwent an arthroscopic Bankart repair. Based on GTIMS in the 189-patient cohort, using the same cutoff of 4 to indicate the need for a Latarjet, 162 patients were treated with arthroscopic Bankart repair (85.7%) and 27 with Latarjet (14.3%). The overall outcomes improved for patients treated with a Latarjet in both groups (GTIMS WOSI from 1099 [47.7% normal] to 395 [81.3% normal]; GTIMS SANE from 48 to 81; ISIS WOSI from 1050 [50% normal] to 345 [83.4% normal]; ISIS SANE from 50 to 84; P < .01). Similar positive outcomes were seen in patients treated with arthroscopic Bankart repair (GTIMS WOSI from 1062 [49.2% normal] to 402 [80.6% normal]; GTIMS SANE from 49 to 82; ISIS WOSI from 1080 [51.8% normal] to 490 [76.7% normal]; ISIS SANE from 48 to 77; P < .01). Of note, the patients with arthroscopically indicated ISIS had significantly worse outcomes scores than those treated arthroscopically according to GTIMS (P < .01). Of the 189 patients graded with GTIMS, there would have been 33 more Latarjet procedures recommended based on ISIS score. Thus the distribution of procedures based on ISIS versus GTIMS was significantly different (χ² = 45.950; P < .001), indicating a higher rate of recommending Latarjets when using ISIS versus GTIMS.

CONCLUSIONS

When ISIS scoring and plain radiograph parameters only are used, this predicted a 2-fold increase in recommending a Latarjet versus GTIMS scoring criteria, which uses advanced imaging and the on- and off-track principle to more conservatively delineate anterior instability treatment with promising postoperative patient outcomes. Overall, there were minimal differences in outcomes between GTIMS and ISIS Latarjet patients; however, better outcomes were seen in patients indicated for arthroscopic Bankart repair according to GTIMS and on-off track computed tomography scanning indications.

LEVEL OF EVIDENCE

II, Prospective Cohort Study.

Instability severity index score values below 7 do not predict recurrence after arthroscopic Bankart repair

PURPOSE

To evaluate the efficacy of the Instability Severity Index Score (ISIS) in predicting an increased recurrence risk after an arthroscopic Bankart repair.

METHODS

Retrospective review of a cohort of patients operated in three different centres. The inclusion criteria (recurrent anterior instability [dislocation or subluxation] with or without hyperlaxity, arthroscopic Bankart repair) and the exclusion criteria (concomitant rotator cuff lesion, acute first-time dislocation, surgery after a previous anterior stabilization, surgery for an unstable shoulder without true dislocation or subluxation; multidirectional instability) were those used in the study that defined the ISIS score. The medical records and a telephone interview were used to identify the six variables that define the ISIS and identify recurrences.

RESULTS

One hundred and sixty-three shoulders met the inclusion and exclusion criteria. Of these, 140 subjects (22 females/118 males; mean age 35.5 ± 7.9) with 142 (89.0%) shoulders were available for follow-up after 5.3 (1.1) (range 3.1-7.4) years. There were 20 recurrences (14.1%). The mean (SD) preoperative ISIS was 1.8 (1.6) in the patients without recurrence and 1.8 (1.9) in the patients with recurrence (n.s.). In the 117 subjects with ISIS between 0 and 3 the recurrence rate was 12.8%; in the 25 with ISIS 4 to 6 the rate was 20% (n.s.).

CONCLUSION

For subjects with anterior shoulder instability in which an arthroscopic Bankart repair is being considered, the use of the ISIS, when the values obtained are ≤ 6 was not useful to predict an increased recurrence risk in the midterm in this retrospectively evaluated case series. The efficacy of the ISIS score in defining a group of subjects with a preoperative increased risk of recurrence after an arthroscopic Bankart instability repair is limited in lower risk populations (with ISIS scores ≤ 6).

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

A Cost-Minimization Analysis of Intraoperative Costs in Arthroscopic Bankart Repair, Open Latarjet, and Distal Tibial Allograft

Background:

The optimal surgical treatment of anterior shoulder instability remains controversial.

Hypothesis:

(1) Implants and facility-related costs are the primary drivers of variation in direct costs between arthroscopic Bankart and Latarjet procedures, and (2) distal tibial allograft (DTA) is more costly than Latarjet as a function of the graft expense.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Intraoperative cost data were derived for all arthroscopic anterior stabilizations and Latarjet and DTA procedures performed at a single academic institution from January 2012 to September 2017. Cost comparisons were made between those undergoing arthroscopic stabilization and Latarjet and between Latarjet and DTA. Multivariate regressions were performed to determine the difference in direct costs accounting for various patient- and surgery-related factors.

Results:

A total of 87 arthroscopic stabilizations, 44 Latarjet procedures, and 5 DTA procedures were performed during the study period. Arthroscopic Bankart repair was found to be 17% more costly than Latarjet, with suture anchor implant cost being the primary driver of cost. DTA was 2.9-fold more costly than Latarjet, with greater costs across all domains. Multivariate analysis also found the number of prior arthroscopic procedures performed (P = .007) and whether the procedure was performed in an ambulatory or inpatient setting (P < .0001) to be significantly associated with higher direct costs.

Conclusion:

Latarjet is less costly than arthroscopic Bankart repair, largely because of implant cost. Value-driven strategies to narrow the cost differential could focus on performing these procedures in an outpatient setting in addition to reducing overall implant cost for arthroscopic procedures. Perceived potential benefits of DTA over Latarjet may be outweighed by higher costs.

Reliability of the Instability Severity Index Score as a Predictor of Recurrence after Arthroscopic Anterior Capsulolabral Reconstruction: A Multicenter Retrospective Study

Background

Although the instability severity index score (ISIS) is widely used to predict recurrence after arthroscopic anterior instability surgery, its reliability, especially on the weightings and cutoff values, is questionable. The goal of the current retrospective study was to investigate recurrence after arthroscopic capsulolabral reconstruction to evaluate whether each domain of the ISIS has the appropriate predictive power for recurrence by using logistic regression analyses with odds ratios (ORs).

Methods

This study included 120 consecutive patients who underwent arthroscopic capsulolabral reconstruction between 2004 and 2016. We retrospectively reviewed patients' preoperative history and radiographs, postoperative recurrence or sensation of instability, and risk factors related to the ISIS. The mean postoperative follow-up was 27.6 months (range, 12 to 96 months; median, 21 months). Twenty-six patients with recurrence or positive apprehension were classified as the recurrence group; 94 patients without any symptoms were classified as the non-recurrence group. Logistic regression analyses with ORs were used to verify the utility of each domain of the ISIS for predicting recurrence.

Results

The mean ISIS did not differ significantly between the recurrence and non-recurrence groups (4.3 ± 1.8 vs. 3.4 ± 2.1 points; p = 0.063). Among the domains of ISIS, factors related to bone defects, the presence of a Hill-Sachs lesion and glenoid bone loss had the lowest ORs (0.77 and 0.38, respectively).

Conclusions

Not all ISIS domains accurately predicted recurrence after arthroscopic capsulolabral reconstruction. The ISIS may not be a proper reference for determining Latarjet procedure in patients with anterior shoulder instability.

Analysis of complication after open coracoid transfer as a revision surgery for failed soft tissue stabilization in recurrent anterior shoulder instability

BACKGROUND

The coracoid transfer represents a treatment option for patients with recurrent shoulder instability. Only a few studies exist about the complication rate of the coracoid transfer as a revision surgery following failed soft tissue stabilization. The purpose of this study was to analyze the results and complication rate after coracoid transfer as a revision surgery.

METHODS

In this study 38 patients (4 females, 34 males, mean age 27 years) were included of whom 29 patients were available for follow-up after a mean of 27 months. Previous shoulder stabilization procedures were predominantly arthroscopic (n = 25). Complications were divided according to their timely appearance into early (< 3 months) and late (> 3 months) postoperatively as well as need for revision. Clinical scores [Constant Score (CS), Rowe Score (RS), Walch-Duplay-Score (WDS), WOSI and Subjective-Shoulder-Value (SSV)] were evaluated preoperatively and at final follow-up.

RESULTS

In this patient cohort, the overall complication rate was 27.6%, all of them occurred > 3 months postoperatively. In seven of eight cases (24.1%) a repeat surgical procedure was conducted. Recurrent instability occurred in three patients (10.3%) of which two received a revision surgery (n = 1 iliac-crest bone graft, n = 1 labral repair). Due to persistent pain five patients underwent an arthroscopic implant removal. The complication rate was with 40% higher in patients with two or more previous surgeries (n = 4 out of 10 patients) compared to patients with one previous surgery (21%, n = 4 out of 19 patients). The scores increased significantly comparing pre- to postoperative [CS 74-90 points, RS 27-91 points, WDS 16-89 points, WOSI 40-76% and SSV 41-82% (p < 0.05)].

CONCLUSION

The open coracoid transfer as a revision surgery after failed soft tissue stabilization leads to satisfying clinical results. However, the complication rate is high though comparable to data in the literature when used as a primary surgery. The indication for a coracoid transfer should be judged carefully and possible alternatives should be considered.

Management of Recurrent Anterior Shoulder Instability With Bipolar Bone Loss: A Systematic Review to Assess Critical Bone Loss Amounts

BACKGROUND

There is increasing evidence to suggest that the amount of glenoid bone loss to indicate bone block procedures may be lower than previously thought, particularly in the presence of a Hill-Sachs defect.

PURPOSE

To better establish treatment recommendations for anterior shoulder instability among patients with bipolar bone lesions.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic review of the literature was performed with PubMed, EMBASE, Cochrane Library, and Scopus databases according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Studies evaluating outcomes of operative management in anterior shoulder instability that also reported glenoid bone loss in the presence of Hill-Sachs defects were included. Recurrence rates, glenoid bone loss, and humeral bone loss were pooled and analyzed with forest plots stratified by surgical procedure. Methods of quantification were analyzed for each article qualitatively.

RESULTS

Thirteen articles were included in the final analysis, with a total of 778 patients. The mean ± SD age was 24.9 ± 8.6 years. The mean follow-up was 30.1 months (range, 11-240 months). Only 13 of 408 (3.2%) reviewed bipolar bone loss articles quantified humeral and/or glenoid bone loss. Latarjet procedures had the greatest glenoid bone loss (21.7%; 95% CI, 14.8%-28.6%), followed by Bankart repairs (13.1%; 95% CI, 9.0%-17.2%), and remplissage (11.7%; 95% CI, 5.5%-18.0%). Humeral bone loss was primarily reported as percentage bone loss (22.2%; 95% CI, 13.1%-31.3% in Bankart repairs and 31.7%; 95% CI, 21.6%-41.1% in Latarjet) or as volumetric defects (439.1 mm³; 95% CI, 336.3-541.9 mm³ in Bankart repairs and 366.0 mm³; 95% CI, 258.4-475.4 mm³ in remplissage). Recurrence rates were as follows: Bankart repairs, 19.5% (95% CI, 14.5%-25.8%); remplissage, 4.4% (95% CI, 1.3%-14.0%); and Latarjet, 8.7% (95% CI, 5.0%-14.7%). Bankart repairs were associated with significantly greater recurrence of instability in included articles (P = .013).

CONCLUSION

There exists a need for universal and consistent preoperative measurement of humeral-sided bone loss. The presence of concomitant Hill-Sachs defects with glenoid pathology should warrant more aggressive operative management through use of bone block procedures. Previously established values of critical glenoid bone loss are not equally relevant in the presence of bipolar bone loss.

Scapular Spine Dimensions and Suitability as a Glenoid Bone Graft Donor Site

BACKGROUND

Current structural bone graft options used for glenoid augmentation in glenohumeral instability have known drawbacks. The scapular spine may be a possible alternative graft choice, but its dimensions and anatomy are not fully reported.

HYPOTHESIS

The scapular spine's harvestable graft dimensions will be similar to harvestable dimensions of the coracoid and iliac crest.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The scapular spine, coracoid, and iliac crest dimensions were recorded and compared bilaterally in 50 patients with 3-dimensional computed tomography imaging. The portion of the scapular spine with the largest harvestable dimensions was quantified and its location defined. Measurements were independently taken by 2 investigators and averaged for the final result.

RESULTS

The scapular spine has 81.5 mm of harvestable length and a "flare" located approximately 49.6 mm lateral to the medial scapular border, where the widest harvestable cross section is located (mean harvestable dimensions: 10.9-mm height, 11.5-mm width). Mean coracoid dimensions were 24-mm length, 14.2-mm height, and 10.6-mm width. Mean iliac crest width was 14.7 mm. In sum, 96% of scapular spines, 85% of coracoids, and 100% of iliac crests exceeded minimum dimensions of 8 mm × 8 mm × 20 mm. The coronal radius of curvature of the glenoid was significantly different from the corresponding plane of all measured structures.

CONCLUSION/CLINICAL RELEVANCE

The scapular spine has dimensions similar to the coracoid and iliac crest in the majority of patients and is therefore appropriate for further investigation as a potential graft choice in glenohumeral instability. A harvest location 49.6 mm lateral to the medial scapular border will provide the largest cross-sectional graft while avoiding the acromial base.