Influence of Glenoid Labral Bumper Height and Capsular Volume on Clinical Outcomes After Arthroscopic Bankart Repair as Assessed With Serial CT Arthrogram: Can Anterior-Inferior Volume Fraction Be a Prognostic Factor?

There is high variability in quantitative measurement techniques in glenohumeral capsular measurements for shoulder instability: A systematic review

PURPOSE

Instability of the glenohumeral joint remains a complex clinical issue with high rates of surgical failure and significant morbidity. Advances in specific radiologic measurements involving the glenoid and the humerus have provided insight into glenohumeral pathology, which can be corrected surgically towards improving patient outcomes. The contributions of capsular pathology to ongoing instability remain unclear. The purpose of this study is to provide a systematic review of existing glenohumeral capsular measurement techniques published in the last 15 years.

METHODS

A systematic review of multiple databases was performed following PRISMA guidelines for all primary research articles between 2008 and 2023 with quantitative measurements of the glenohumeral capsule in patients with instability, including anterior, posterior and multi-directional instability.

RESULTS

There were a total of 14 articles meeting the inclusion criteria. High variability in measurement methodology across studies was observed, including variable amounts of intra-articular contrast, heterogeneity among magnetic resonance sequence acquisitions, differences in measurements performed and the specific approach taken to compute each measurement.

CONCLUSION

There is a need for standardization of methods in the measurement of glenohumeral capsular pathology in the setting of glenohumeral instability to allow for cross-study analysis.

LEVEL OF EVIDENCE

Level III.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Case series, Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Management of Shoulder Instability in Patients with Underlying Hyperlaxity

PURPOSE OF REVIEW

Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD).

RECENT FINDINGS

Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.

Influence of joint volume on range of motion after arthroscopic rotator cuff repair

BACKGROUND

Capsular contracture is a well-known etiology in the primary stiff shoulder; thus capsular contracture and resultant decreased joint volume could lead to postoperative stiffness, which is a commonly reported morbidity after arthroscopic rotator cuff repair (ARCR). The purpose of this study was (1) to quantify the joint volume (total joint volume and each quadrant compartmental volume) using computed tomography arthrography (CTA) and (2) to demonstrate the relationship between joint volume and postoperative range of motion (ROM) after ARCR.

MATERIALS AND METHODS

Eighty-three patients (60 ± 5.11 years, men = 26, women = 57) who had undergone ARCR between January 2015 to December 2020 due to small to medium full-thickness tear and followed by CTA 6 months postoperatively were retrospectively reviewed. An image reconstruction program (3D Slicer, version 4.11.2 software) was used to calculate the joint volume (total joint volume and quadrant compartment joint volumes; anteroinferior, anterosuperior, posterosuperior and posteroinferior). For shoulder ROM, data including scaption (Sc), external rotation on side (ERs), external rotation at 90° (ER90), and internal rotation on back (IRb) were collected 6 months postoperatively. An evaluation of the correlation between joint volume and each shoulder motion was performed.

RESULTS

There were moderate correlations between the total joint volume and each motion (Sc: Pearson coefficient, 0.32, p = 0.0047; ERs: Pearson coefficient, 0.24, p = 0.0296; ER90: Pearson coefficient, 0.33, p = 0.0023; IRb: Pearson coefficient, 0.23, p = 0.0336). Among the quadrant compartments, the anteroinferior (Sc: Pearson coefficient, 0.26, p = 0.0199; ERs: Pearson coefficient, 0.23, p = 0.0336; ER90: Pearson coefficient, 0.25, p = 0.0246; IRb: Pearson coefficient, 0.26, p = 0.0168) and posterosuperior (Sc: Pearson coefficient, 0.24, p = 0.029; ER90: Pearson coefficient, 0.29, p = 0.008; IRb: Pearson coefficient, 0.22, p = 0.0491) and posteroinferior (Sc: Pearson coefficient, 0.30, p = 0.0064; ER90: Pearson coefficient, 0.29, p = 0.0072) showed moderate correlations with each shoulder motion.

CONCLUSION

Total joint volume, anteroinferior compartment joint volume, posterosuperior compartment joint volume and posteroinferior compartment joint volume were related to postoperative ROM after ARCR. Perioperative methods to increase the joint volume, especially the anteroinferior, posterosuperior and posteroinferior parts of the capsule may prevent postoperative stiffness after ARCR.

LEVEL OF EVIDENCE

Level III; Retrospective Case-Control Study.

Comparison of arthroscopic primary and revision Bankart repair for capsulolabral restoration: a matched-pair analysis

INTRODUCTION

There have been no previous studies comparing serial radiologic results between primary and revision Bankart repair despite the significance of capsulolabral height and slope restoration. The purpose of this study was (1) to compare serially the height and slope of the repaired labrum in the early postoperative period among primary and revision Bankart repair groups, and (2) to compare clinical outcomes between the two groups.

MATERIALS AND METHODS

This study included each 24 patients who underwent arthroscopic primary Bankart repair (Group A) and revision Bankart repair (Group B) matched by age, sex, and glenoid defect ratio. Postoperative serial radiologic assessment of the repaired labral height and slope was proceeded using magnetic resonance imaging (MRI) or computed tomographic arthrography (CTA) at 3 weeks and 6 months.

RESULTS

There were no significant differences in labral height and slope at 3 weeks and 6 months postoperatively in Group A. However, significant reductions in labral height and slope were evident between 3 weeks and 6 months postoperatively in Group B (P < 0.05). Group A yielded superior results to Group B with respect to labral height and slope at each time point (P < 0.05) in between-group analyses. The clinical outcomes were not significantly different between the two groups except for the patients' return to their premorbid sports activity level (P = 0.024).

CONCLUSIONS

The height and slope of the repaired capsulolabral structures in the early postoperative period after arthroscopic revision Bankart repair group were significantly lower than those of the primary Bankart repair group. Also the reduction of labral height and slope was significant in the revision Bankart repair group over time. Nonetheless, clinical outcomes did not differ significantly except return to premorbid sports activity level at final follow-up.

Disabled Throwing Shoulder: 2021 Update: Part 2-Pathomechanics and Treatment

The purpose of this paper is to provide updated information for sports healthcare specialists regarding the disabled throwing shoulder (DTS). A panel of experts, recognized for their experience and expertise in this field, was assembled to address and provide updated information on several topics that have been identified as key areas in creating the DTS spectrum. Each panel member submitted a concise presentation on one of the topics within these areas, each of which were then edited and sent back to the group for their comments and consensus agreement in each area. Part two presents the following consensus conclusions and summary findings regarding pathomechanics and treatment, including (1) internal impingement results from a combination of scapular protraction and humeral head translation; (2) the clinically significant labral injury that represents pathoanatomy can occur at any position around the glenoid, with posterior injuries most common; (3) meticulous history and physical examination, with a thorough kinetic chain assessment, is necessary to comprehensively identify all the factors in the DTS and clinically significant labral injury; (4) surgical treatment should be carefully performed, with specific indications and techniques incorporating low profile implants posterior to the biceps that avoid capsular constraint; (5) rehabilitation should correct all kinetic chain deficits while also developing high-functioning, throwing-specific motor patterns and proper distribution of loads and forces across all joints during throwing; and (6) injury risk modification must focus on individualized athlete workload to avoid overuse. LEVEL OF EVIDENCE: V, expert opinion.