Risk Factors for the Postoperative Recurrence of Instability After Arthroscopic Bankart Repair in Athletes

Risk factors for recurrence following arthroscopic Bankart repair: a systematic review

BACKGROUND

Recurrent instability remains a major source of morbidity following arthroscopic Bankart repair. Many risk factors and predictive tools have been described, but there remains a lack of consensus surrounding individual risk factors and their contribution to outcomes. The purpose of this study is to systematically review the literature to identify and quantify risk factors for recurrence following arthroscopic Bankart repair.

METHODS

A literature search was performed using the PubMed/MEDLINE databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were included if they evaluated risk factors for recurrent instability following arthroscopic Bankart repair.

RESULTS

Overall, 111 studies were included in the analysis, including a total of 19,307 patients and 2750 episodes of recurrent instability with 45 risk factors described. Age at operation was reported by 60 studies, with 35 finding increased risk at younger ages. Meta-analysis showed a 2-fold recurrence rate of 27.0% (171 of 634) for patients <20 years old compared with 13.3% (197 of 1485) for older patients (P < .001). Seventeen studies completed multivariable analysis, 13 of which were significant (odds ratio 1.3-14.0). Glenoid bone loss was evaluated by 39 studies, with 20 finding an increased risk. Multivariable analysis in 9 studies found odds ratios ranging from 0.7 to 35.1; 6 were significant. Off-track Hill-Sachs lesions were evaluated in 21 studies (13 significant), with 3 of 4 studies that conducted multivariable analysis finding a significant association with odds ratio of 2.9-8.9 of recurrence. The number of anchors used in repair was reported by 25 studies, with 4 finding increased risk with fewer anchors. Pooled analysis demonstrated a 25.0% (29 of 156) risk of recurrence with 2 anchors, compared with 18.1% (89 of 491) with 3 or more anchors (P = .06). Other frequently described risk factors included glenohumeral joint hyperlaxity (46% of studies reporting a significant association), number of preoperative dislocations (31%), contact sport participation (20%), competitive sport participation (46%), patient sex (7%), and concomitant superior labral anterior-posterior tear (0%).

CONCLUSION

Younger age, glenoid bone loss, and off-track Hill-Sachs lesions are established risk factors for recurrence following arthroscopic Bankart repair. Other commonly reported risk factors included contact and competitive sports participation, number of fixation devices, and patient sex.

The Latarjet Procedure for Recurrent Anterior Shoulder Instability in the Contact Athlete

In young athletes, anterior shoulder instability is a prevalent condition. Because of high-energy traumas, contact athletes often suffer recurrent instability, bone loss and postoperative recurrences. Patients younger than 20 years, symptomatic for more than 6 months, with ≥ 2 dislocations, with off-track Hill-Sachs lesion, glenoid bone loss, ALPSA lesion, Instability Severity Index Score > 3, and Glenoid Track Instability Management Score > 3 are at higher risk of failure. In cases of multiple dislocations with critical or subcritical glenoid bone loss, notably in collision and contact athletes, the Latarjet procedure is widely recognized as the treatment of choice.

Open Bankart Repair: Technique and Outcomes for the High-Level Athlete

Historically considered the gold standard technique for glenohumeral instability, the open Bankart repair is being performed at decreased rates because of the current trends favoring arthroscopic Bankart repair and the lack of consistent training of the open technique. However, open Bankart repairs may be more appropriate for certain high-risk populations (ie, high-level collision athletes) because of their reduced recurrent instability rates. Further investigations are needed to identify the indications for arthroscopic versus open Bankart repair and compare their outcomes in high-level athletes. This review highlights the indications, surgical technique, and clinical outcomes following open Bankart repairs in athletes.

Methodology and development of a machine learning probability calculator: Data heterogeneity limits ability to predict recurrence after arthroscopic Bankart repair

PURPOSE

The aim of this study was to develop and train a machine learning (ML) algorithm to create a clinical decision support tool (i.e., ML-driven probability calculator) to be used in clinical practice to estimate recurrence rates following an arthroscopic Bankart repair (ABR).

METHODS

Data from 14 previously published studies were collected. Inclusion criteria were (1) patients treated with ABR without remplissage for traumatic anterior shoulder instability and (2) a minimum of 2 years follow-up. Risk factors associated with recurrence were identified using bivariate logistic regression analysis. Subsequently, four ML algorithms were developed and internally validated. The predictive performance was assessed using discrimination, calibration and the Brier score.

RESULTS

In total, 5591 patients underwent ABR with a recurrence rate of 15.4% (n = 862). Age <35 years, participation in contact and collision sports, bony Bankart lesions and full-thickness rotator cuff tears increased the risk of recurrence (all p < 0.05). A single shoulder dislocation (compared to multiple dislocations) lowered the risk of recurrence (p < 0.05). Due to the unavailability of certain variables in some patients, a portion of the patient data had to be excluded before pooling the data set to create the algorithm. A total of 797 patients were included providing information on risk factors associated with recurrence. The discrimination (area under the receiver operating curve) ranged between 0.54 and 0.57 for prediction of recurrence.

CONCLUSION

ML was not able to predict the recurrence following ABR with the current available predictors. Despite a global coordinated effort, the heterogeneity of clinical data limited the predictive capabilities of the algorithm, emphasizing the need for standardized data collection methods in future studies.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Glenohumeral morphological predictors of recurrent shoulder instability following arthroscopic Bankart repair

PURPOSE

The purpose of this study was to evaluate glenohumeral morphological features on a magnetic resonance arthrogram (MRA) to determine risk factors for recurrence of anterior shoulder instability following arthroscopic Bankart repair (ABR).

METHODS

A retrospective review of patients who underwent ABR between 2012 and 2017 was performed to identify patients who had recurrence of instability following stabilisation (Group 1). These were pair-matched in a 2:1 ratio for age, gender and sport with a control (Group 2) who underwent ABR without recurrence. Preoperative MRAs were evaluated for risk factors for recurrence, with glenoid bone loss and Hill-Sachs lesions also measured. Multilinear and multilogistic regression models were used to evaluate factors affecting recurrence.

RESULTS

Overall, 72 patients were included in this study, including 48 patients without recurrence and 24 patients with recurrent instability. There was a significant difference between the two groups in mean glenoid bone loss (Group 1: 7.3% vs. Group 2: 5.7%, p < 0.0001) and the rate of off-track Hill-Sachs lesions (Group 1: 20.8% vs. Group 2: 0%, p = 0.0003). Of the variables analysed in logistic regression, increased glenoid anteversion (p = 0.02), acromioclavicular (AC) degeneration (p = 0.03) and increased Hill-Sachs width were associated with increased risk of failure. Increased chondral version (p = 0.01) and humeral head diameter in the anteriorposterior view were found to be protective and associated with a greater likelihood of success.

CONCLUSION

Glenoid anteversion was a risk factor for recurrent instability, whereas increased chondral version and humeral head diameter were associated with higher rates of success following ABR. Glenoid bone loss, presence of an off-track Hill-Sachs lesion, increased Hill-Sachs width and AC degeneration were also associated with failure. These findings should be used by surgeons to stratify risk for recurrence following ABR.

LEVEL OF EVIDENCE

Level III.

Efficacy and safety of the Latarjet procedure for the treatment of athletes with glenoid bone defects ≥ 20%: a single-arm meta-analysis

BACKGROUND

The shoulder joint is the most commonly dislocated joint in the human body, and the recurrence rate exceeds 50% after nonsurgical treatment. Although surgical treatment reduces the recurrence rate, there is controversy regarding the optimal surgical approach. Previous studies suggest that the Latarjet procedure yields favourable outcomes for specific populations at risk of recurrence, such as competitive athletes with significant glenoid defects. However, most of the existing related research consists of nonrandomized controlled trials with small sample sizes, and there is a lack of strong evidence regarding the efficacy and safety of the Latarjet procedure.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched. Athletes with ≥ 20% glenoid defects were selected for inclusion. The following data were extracted: general patient information, instability rates, return to sports (RTS) rates, imaging features (graft positioning rate and graft healing rate), functional assessments [Rowe score, Athletic Shoulder Outcome Scoring System(ASOSS), visual analogue scale (VAS), forward flexion function, and external rotation function], and complications.

RESULTS

After excluding suspected duplicate cases, a total of 5 studies were included in this meta-analysis. The studies involved a total of 255 patients, including 237 males (93%) and 18 females (7%). The average age at the time of surgery was 25.4 ± 8.5 years. All the studies had a minimum follow-up period of 2 years, with an average follow-up time of 48.7 ± 18.9 months. The pooled rate of return to sport (RTS) was 94.3% (95% CI: 87.3%, 98.8%), and 86.1% (95% CI: 78.2%, 92.5%) of patients returned to their preoperative level of activity. The pooled redislocation rate was 1.1% (95% CI: 0%, 3.8%). Regarding the imaging results, the combined graft retention rate was 92.1% (95% CI: 88.1%, 95.5%), and the graft healing rate was 92.1% (95% CI: 88%, 95.4%). Postoperative functional evaluation revealed that the combined Rowe score, ASOSS score, and VAS score were 93.7 ± 6.5 points, 88.5 ± 4.4 points, and 1.1 ± 10 points, respectively. The forward flexion and external rotation angles were 170.9 ± 6.9 degrees and 65.6 ± 4.5 degrees, respectively. After excluding one study with unclear complications, the combined complication rate was 9.4% (95% CI: 1.0%, 23.6%).

CONCLUSION

For athletes with shoulder instability and a total of ≥ 20% glenoid bone defects, the Latarjet procedure can achieve excellent functional outcomes, with the majority of patients returning to preoperative levels of sports activity. This procedure also leads to a low recurrence rate. Therefore, the Latarjet procedure has been proven to be a safe and effective treatment.

Arthroscopic Latarjet yields better union and prevention of instability compared to arthroscopic bony Bankart repair in shoulders with recurrent anterior instability: a systematic review

PURPOSE

To determine whether arthroscopic Latarjet procedure or arthroscopic bony Bankart repair provide better outcomes in terms of rates of recurrent instability, non-union and complications, as well as clinical scores and range of motion.

METHODS

An electronic literature search was performed using PubMed, Embase®, and Cochrane databases, applying the following keywords: "Arthroscopic bony Bankart" OR "Arthroscopic osseous Bankart" AND "Arthroscopic Latarjet" OR "Arthroscopic coracoid bone block".

RESULTS

The systematic search returned 1465 records, of which 29 were included (arthroscopic bony Bankart repair, n = 16; arthroscopic Latarjet, n = 13). 37 datasets were included for data extraction, on 1483 shoulders. Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair had significantly higher instability rates (0.14; CI 0.10-0.18; vs 0.04; CI 0.02-0.06), significantly lower union rates (0.63; CI 0.28-0.91 vs 0.98; CI 0.93-1.00), and significantly lower pain on VAS (0.42; CI 0.17-0.67 vs 1.17; CI 0.96-1.38). There were no significant differences in preoperative glenoid bone loss, follow-up, complication rate, ROWE score, ASES score, external rotation, and anterior forward elevation between arthroscopic Latarjet and arthroscopic bony Bankart repair.

CONCLUSION

Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair results in significantly (i) higher rates of recurrent instability (14% vs 4%), (ii) lower union rates (63% vs 98%), but (iii) slightly lower pain on VAS (0.45 vs 1.17). There were no differences in complication rates, clinical scores, or postoperative ranges of motion.

LEVEL OF EVIDENCE

IV.

Arthroscopic Bankart repair with peeling osteotomy of the anterior glenoid rim preserves glenoid morphology

BACKGROUND

A decrease in the glenoid size after arthroscopic Bankart repair (ABR) was common in shoulders without osseous fragments compared with those with osseous fragments. For cases of chronic recurrent traumatic anterior glenohumeral instability without osseous fragments, we have performed ABR with peeling osteotomy of the anterior glenoid rim (ABRPO) to make an intentional osseous Bankart lesion. The aim of this study was to compare the glenoid morphology after ABRPO with it after simple ABR.

METHODS

The medical records of patients who underwent arthroscopic stabilization for chronic recurrent traumatic anterior glenohumeral instability were retrospectively reviewed. Patients with an osseous fragment, with revision surgery and without complete data were excluded. Patients were assigned to 1 of 2 groups: Group A, ABR without peeling osteotomy procedure or Group B, with ABRPO procedure. Computed tomography was performed preoperatively and 1 year after surgery. The size of the glenoid bone loss was investigated by the assumed circle method. The following formula was used to calculate the decreased size of the glenoid: (Δ) = (postoperative size of the glenoid bone loss) - (preoperative size of the glenoid bone loss). The size of the glenoid 1 year after surgery was assessed to determine if it had decreased (Δ > 0%) or not decreased (Δ ≤ 0%) relative to the preoperative size.

RESULTS

This study evaluated 39 shoulders divided into 2 groups: 27 shoulders in Group A and 12 shoulders in Group B. In Group A, postoperative glenoid bone loss was significantly greater than preoperative glenoid bone loss (7.8 ± 6.2 vs. 5.5 ± 5.3, respectively, P = .02). In Group B, postoperative glenoid bone loss was significantly lower than preoperative glenoid bone loss (5.6 ± 5.4 vs. 8.7 ± 4.0, respectively, P = .02). The P value for the interaction of group (A or B) × time (preoperative or postoperative) was 0.001. The decreased size of the glenoid was significantly larger in Group A than in Group B (2.1 ± 4.2 vs. -3.1 ± 4.5, respectively, P = .001). The rate of shoulders in which the size of the glenoid decreased 1 year after surgery relative to the preoperative size was significantly higher in Group A than in Group B (63% [17/27] vs. 25% [3/2], respectively, P = .04).

CONCLUSIONS

The study showed that ABRPO preserved the glenoid size better than simple ABR without a peeling osteotomy procedure.

Arthroscopic Remplissage Combined With Bankart Repair Results in a Higher Rate of Return to Sport in Athletes Compared With Bankart Repair Alone or the Latarjet Procedure: A Systematic Review and Meta-analysis

BACKGROUND

Traumatic anterior shoulder instability affects athletes at a higher rate compared with the general population. In recent years, indications for arthroscopic remplissage, an adjunct procedure classically used to reduce the recurrence of anterior shoulder instability in patients with off-track Hill-Sachs lesions, have expanded.

PURPOSE

To investigate return-to-sport (RTS) rates, functional outcomes, and adverse events in athletes who underwent arthroscopic Bankart repair with remplissage compared with surgical alternatives such as Bankart repair alone or the Latarjet procedure.

STUDY DESIGN

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

METHODS

A literature review of the Embase, PubMed (MEDLINE), and Web of Science databases was conducted for articles published before May 22, 2022. For the systematic review, 16 of 457 studies that reported RTS rates at any time point after remplissage were deemed eligible for inclusion in quantitative analysis and 17 of 457 studies in qualitative analysis. For the meta-analysis, 8 of 457 studies reported RTS rates after remplissage compared with surgical alternatives including Bankart repair alone or the Latarjet procedure and were deemed eligible for inclusion.

RESULTS

In total, 538 athletes underwent remplissage and were included in the study. RTS at any level was achieved by 86% (395/457) of patients, and the odds of RTS at any level were significantly higher after remplissage compared with surgical alternatives (odds ratio [OR], 2.71 [95% CI, 1.14-6.43]; P = .02). The odds of RTS at a previous or higher level were also significantly higher after remplissage compared with surgical alternatives (OR, 2.07 [95% CI, 1.29-3.31]; P = .002). The mean Rowe score increased significantly from 43.9 ± 7.77 preoperatively (n = 173) to 92.2 ± 4.02 after remplissage (n = 397) (P < .001), but there was no significant difference in Rowe scores between remplissage and surgical alternatives (P = .54). After remplissage, the recurrence rate was 5.0% for athletes (n = 220) and 7.3% for all patients (n = 634), with a mean time to recurrence of 24.0 ± 12.5 months. Reoperations occurred in 3.6% of athletes (n = 110) and 4.1% of all patients (n = 445). Recurrence and reoperations were significantly less likely after remplissage compared with surgical alternatives (OR, 0.18 [95% CI, 0.08-0.39]; P < .001 and OR, 0.17 [95% CI, 0.06-0.50]; P = .001, respectively).

CONCLUSION

Arthroscopic Bankart repair with remplissage augmentation significantly improved RTS rates among athletes, both at any level and at previous levels of play. Additionally, remplissage appeared to significantly decrease recurrence and reoperation rates compared with surgical alternatives such as Bankart repair alone or the Latarjet procedure.

Functional and Sport-Specific Outcome Following Traumatic First-Time Shoulder Dislocation and Arthroscopic Surgical Repair in Rock Climbers

INTRODUCTION

Traumatic shoulder dislocations rank among the most common shoulder injuries in climbers, with rising numbers over the last years. The objective of this study was to analyze the outcome following traumatic first-time shoulder dislocation and subsequent surgical treatment in this population.

METHODS

In a retrospective study, climbers who experienced a traumatic shoulder dislocation were treated with an arthroscopic repair of the labrum-ligament complex (LLC). The functional outcome was assessed with a standardized questionnaire and clinical examination, including the Constant Murley and Single Assessment Numeric Evaluation scores. The sport-specific outcome was analyzed using the Union Internationale des Associations d'Alpinisme (UIAA) scale of difficulty and a sport-specific outcome score.

RESULTS

The functional and sport-specific outcome for 27 climbers (20 men; 7 women; 3 with bilateral injuries; age, 34±11 [17-61] y; data presented as mean±SD [range]) was assessed 53±29 (12-103) mo after surgery. The postoperative Constant Murley score was 95±8 (67-100) points. At follow-up, 93% (n=25) of patients had started climbing again. Twenty-one climbers (78%) reached a climbing level within the range of ±0.33 UIAA grades of their initial capability or even exceeded their preinjury grade. Only 7% (n=2) of the patients had a recurrent shoulder dislocation, leading to a secondary surgery, and, therefore, required ongoing postoperative treatment at the time of follow-up.

CONCLUSIONS

Arthroscopic repair of the LLC following first-time traumatic shoulder dislocation in climbers shows a good outcome and a low recurrence rate. After surgery, most patients are able to regain a high level of rock-climbing ability.

Anatomic risk factors for arthroscopic Bankart repair failure: A case-control study comparing failure and non-failure groups in an Asian population

Introduction

Post-arthroscopic Bankart repair failure/re-dislocation rates are influenced by several risk factors, including anatomic defects. There is limited evidence on the role of anatomic defects, especially for Hill-Sachs size in on-track lesions. This study aimed to assess glenoid bone loss, Hill-Sachs lesion and labral tear size and evaluate their contribution to post-operative instability after a primary repair.

Material and methods

Across 169 patients with on-track Bankart lesions who underwent primary arthroscopic Bankart repair from 2010 to 2015, this study matched 14 failure with 14 non-failure cases based on age/gender. Patient demographics, pre-operative radiological parameters (including size of glenoid bone loss and Hill-Sachs lesion) and labral tear size were compared between the failure and non-failure groups.

Result

All patients were male with a mean age of 21.01 ± 4.97. Significantly greater glenoid bone loss (p = 0.024) and labral tear size (p = 0.039) were found in the failure group. However, there was no significant difference in mean volume of Hill-Sachs lesion between the two groups (p = 0.739).

Conclusion

Extensive glenoid bone loss and labral tears are risk factors for post-arthroscopic Bankart failure. However, the size of Hill-Sachs lesion is not a risk factor for failure, in a specific group of on-track Hill-Sachs lesions.

Level of evidence

Retrospective Study, Level IV.

Glenoid index: a new risk factor for recurrence of glenohumeral instability after arthroscopic Bankart repair

Background

The glenoid index (GI) (glenoid height to width ratio) has been shown to be a risk factor for instability in young healthy athletes. Nevertheless, whether the altered GI is a risk factor for recurrence after a Bankart repair remains unknown.

Methods

Between 2014 and 2018, 148 patients ≥ 18 years old with anterior glenohumeral instability underwent a primary arthroscopic Bankart repair in our institution. We assessed return to sports, functional outcomes, and complications. We evaluate the association between the altered GI and the probabilities of recurrence in the postoperative period. Intraclass correlation coefficient was used to determine interobserver reliability.

Results

The mean age at the time of surgery was 25.6 years old (19 to 29), and the mean follow-up was 53.3 months (29 to 89). The 95 shoulders who met the inclusion criteria were divided into 2 cohorts, 47 shoulders had a GI ≤ 1.58 (group A) and 48 had a GI > 1.58 (group B). At the final follow-up, 5 shoulders in group A (10.6%) and 17 shoulders in group B (35.4%) suffered a recurrence of instability. Those patients with a GI > 1.58 had a hazard ratio of 3.86 (95% confidence interval: 1.42-10.48) (P = .004) compared with those with a GI ≤ 1.58 of suffering a recurrence. When correlating GI measurements between raters, we observed an intraclass correlation coefficient of 0.76 (95% confidence interval: 0.63-0.84), these results fall under the qualitative definition of good interobserver agreement.

Conclusion

In young active patients with an arthroscopic Bankart repair, an increased GI was associated with a significantly higher rate of postoperative recurrences. Specifically, those subjects with a GI > 1.58 had 3.86 times the risk of recurrence than those subjects with a GI ≤ 1.58.

Outcomes After Open Latarjet in Patients With or Without SLAP Lesions

Background

Up to 20% of shoulders with anterior instability are associated with superior labrum anterior-posterior (SLAP) lesions, and they remain untreated after an open Latarjet procedure. SLAP lesions can be responsible for pain and feelings of instability in high-demand patients.

Purpose/Hypothesis

The aim of this study was to compare the early functional outcomes and return to sport rates in athletes after the Latarjet procedure with versus without associated SLAP lesions. It was hypothesized that untreated SLAP lesions would not influence clinical results.

Study Design

Cohort study; Level of evidence, 3.

Methods

Inclusion criteria were athletes with anterior shoulder instability treated with Latarjet procedure, a minimum follow-up of 1 year, and an available preoperative computed tomography arthrogram. We recorded patient characteristics; type of sport; bone loss; Rowe, Single Assessment Numeric Evaluation (SANE), and 11-item Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; 5-point pain and satisfaction scores; reported apprehension; and return to sport. Patients with and without a preoperative type 5 SLAP lesion on imaging were compared.

Results

Fifty patients were included (mean age, 22 ± 5 years [range, 16-36 years]; mean follow-up, 27 ± 9 months [range, 12-42 months]). Thirty-four patients practiced contact sports, including 20 rugby players. Twelve patients (24%) had a preoperative SLAP lesion. Groups with (+) and without (-) a SLAP lesion were comparable in terms of age, sex, number of instability episodes, type of sport, and glenoid and humeral bone loss. The SLAP+ group had significantly worse outcomes with a lower Rowe score (79 ± 23 vs 91 ± 15; P = .018) and painless rate (50% vs 77%; P = .04). There were no significant differences between the groups in SANE score (SLAP+ vs SLAP-: 80% vs 87%), QuickDASH score (8% vs 8%), return to sport (83% vs 91%), apprehension (79% vs 50%), and reported satisfaction. There was 1 episode of postoperative subluxation in each group.

Conclusion

Patients who underwent an open Latarjet procedure with an associated SLAP tear more frequently reported postoperative pain than those without a SLAP lesion. Patients with untreated SLAP tears had significantly lower Rowe scores, although SANE score and return to sport were not significantly different between the groups.

The prevalence of shoulders with a large glenoid defect and small bone fragment increases after several instability events during conservative treatment for traumatic anterior instability

Background

Unstable shoulders with a large glenoid defect and small bone fragment are at higher risk for postoperative recurrence after arthroscopic Bankart repair. The purpose of the present study was to clarify the changes in the prevalence of such shoulders during conservative treatment for traumatic anterior instability.

Methods

We retrospectively investigated 114 shoulders that underwent conservative treatment and computed tomography (CT) examination at least twice after an instability event in the period from July 2004 to December 2021. We investigated the changes in glenoid rim morphology, glenoid defect size, and bone fragment size from the first to the final CT.

Results

At first CT, 51 shoulders showed no glenoid bone defect, 12 showed glenoid erosion, and 51 showed a glenoid bone fragment [33 small bone fragment (<7.5%) and 18 large bone fragment (≥7.5%); mean size: 4.9 ± 4.2% (0-17.9%)]. Among patients with glenoid defect (fragment and erosion), the mean glenoid defect was 5.4 ± 6.6% (0-26.6%); 49 were considered a small glenoid defect (<13.5%) and 14 were a large glenoid defect (≥13.5%). While all 14 shoulders with large glenoid defect had a bone fragment, small fragment was solely seen in 4 shoulders. At final CT, 23 of the 51 shoulders persisted without glenoid defect. The number of shoulders presenting glenoid erosion increased from 12 to 24, and the number of shoulders with bone fragment increased from 51 to 67 [36 small bone fragment and 31 large bone fragment; mean size: 5.1 ± 4.9% (0-21.1%)]. The prevalence of shoulders with no or a small bone fragment did not increase from first CT (71.4%) to final CT (65.9%; P = .488), and the bone fragment size did not decrease (P = .753). The number of shoulders with glenoid defect increased from 63 to 91 and the mean glenoid defect significantly increased to 9.9 ± 6.6% (0-28.4%) (P < .001). The number of shoulders with large glenoid defect increased from 14 to 42 (P < .001). Of these 42 shoulders, 19 had no or a small bone fragment. Accordingly, among a total of 114 shoulders, the increase from first to final CT in the prevalence of a large glenoid defect accompanied by no or a small bone fragment was significant [4 shoulders (3.5%) vs. 19 shoulders (16.7%); P = .002].

Conclusions

The prevalence of shoulders with a large glenoid defect and small bone fragment increases significantly after several instability events.

Association Between Preoperative Glenoid Bone Loss and Postoperative Outcomes After Coracoid Transfer Combined With Open Bankart Repair: Comparison of the Bristow and Latarjet Techniques

Background

Whether the extent of glenoid bone loss (GBL) affects clinical outcome after coracoid process transfer (CPT) is still unclear.

Purpose

To evaluate postoperative outcomes after CPT combined with open Bankart repair in young rugby players in terms of the extent of GBL and between the Bristow and Latarjet techniques.

Study Design

Cohort study; Level of evidence, 3.

Methods

The authors investigated 101 shoulders in 91 competitive rugby players who underwent CPT combined with open Bankart repair by the Bristow (group B; 66 shoulders) or Latarjet (group L; 35 shoulders) procedure between 2007 and 2017. The extent of GBL was calculated from the en face view of the glenoid on preoperative 3-dimensional computed tomography scans and was used to categorize shoulders into 4 grades (grade 0, 0%; grade 1, >0% and ≤10%; grade 2, >10% and ≤20%; grade 3, >20%). At the minimum 2-year follow-up, the authors analyzed the relationship between GBL or GBL grade and postoperative outcome scores (American Shoulder and Elbow Surgeons score, Rowe score, Western Ontario Shoulder Instability Index, and patient satisfaction), return-to-play (RTP) times, graft failure (insufficient union or translocation), and recurrence.

Results

The mean GBL in all shoulders was 10.9% ± 9.2% and was not significantly different between the 2 groups. There were no significant correlations between GBL and any outcome measure in either group. The mean RTP time was significantly shorter in group L versus group B (4.8 ± 1.1 vs 5.8 ± 1.8 months, respectively; P = .002), but it was not associated with GBL. In group B, the rate of graft failure was not significantly higher in shoulders with grade 0 or 1 GBL versus grade 2 or 3 GBL (8 [25.0%] vs 4 [11.8%], respectively; P = .21). In group B, graft failure was confirmed in 12 shoulders (18.2%), compared with 1 shoulder (2.9%) in group L. Postoperative recurrence occurred in significantly fewer shoulders in group B than in group L (2 [3.0%] vs 5 [14.3%], respectively; P = .047).

Conclusion

The extent of GBL did not affect outcome scores after CPT, regardless of operative procedure.

Arthroscopic Bankart Repair for Adolescent Anterior Shoulder Instability: Clinical and Imaging Predictors of Revision Surgery and Recurrent Subjective Instability

BACKGROUND

Multiple clinical and radiologic risk factors for recurrent instability after arthroscopic Bankart repair have been described. Humeral bone loss has gained more recent attention, particularly with respect to "off-track" lesions and increased rates of recurrent instability and revision surgery.

PURPOSE

To evaluate clinical and radiologic predictors of failure after arthroscopic Bankart repair in adolescents.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A single-institution retrospective study was performed in patients <19 years of age treated with arthroscopic Bankart repair from 2011 to 2017. Magnetic resonance imaging measurements of glenoid and humeral bone loss, the glenoid track, and the presence of off-track Hill-Sachs (HS) lesions were assessed. All patients had a minimum follow-up of 24 months and completed patient-reported outcome scores. Failure was defined as revision surgery or postoperative subjective instability.

RESULTS

A total of 59 patients (46 male, 13 female) with a median age of 16 years (range, 12-18 years) were included. Ten patients (17%) had revision surgery and 8 patients (14%) had subjective instability without revision surgery. No clinical or radiologic factors were significantly different between the failure cohort and the nonfailure cohort. Four patients (7%) measured off-track, and 2 of these patients experienced failure. A total of 38 patients (64%) were identified to have an HS defect. Subgroup analysis of these patients identified a greater HS interval (HSI) in patients who underwent revision surgery as compared with those patients who did not have revision surgery. Among patients with GT ratio ≥15 mm, there was a 50% rate of revision surgery. The Pediatric/Adolescent Shoulder Survey (PASS) and Single Assessment Numeric Evaluation (SANE) scores at the final follow-up were not significantly different among patients with or without revision surgery. However, those with subjective instability who had not undergone revision surgery had significantly lower PASS and SANE scores as compared with the remainder of the cohort.

CONCLUSION

Of the adolescents in this cohort, 31% either had revision surgery (17%) or reported subjective feelings of instability (14%) after arthroscopic Bankart repair. Off-track instability was identified in 7% of the cohort but was not predictive of failure. Among the subgroup of patients with an HS defect, those who underwent revision surgery had a significantly larger HSI.

A 2-Year Follow-up May Not be Enough to Accurately Evaluate Recurrences After Arthroscopic Bankart Repair: A Long-term Assessment of 272 Patients With a Mean Follow-up of 10.5 Years

BACKGROUND

There is a great discrepancy between the rates of recurrent instability reported after arthroscopic Bankart repair in relation to the follow-up time.

PURPOSE

To analyze the rate of recurrences after arthroscopic Bankart repair in the long term, emphasizing whether a minimum follow-up of 2 years is adequate to assess this outcome.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 2008 and April 2013, a total of 356 athletes underwent arthroscopic Bankart repair for anterior glenohumeral instability at our institution. Return to sports, the Rowe score, the Subjective Shoulder Value (SSV), and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. We analyzed the proportion of recurrences before and after 4 years of follow-up. Additionally, we performed a Kaplan-Meier analysis to evaluate recurrence-free time in patients with a recurrence.

RESULTS

The mean follow-up was 10.5 ± 1.6 years, and the mean age was 20.8 ± 3.9 years. In total, 90% of patients were able to return to sports; of these, 91% returned to their preinjury level of play. The Rowe, SSV, and ASOSS scores showed a statistical improvement after surgery (P < .01). The proportion of patients with a recurrence during the follow-up period was 25% (95% CI, 20%-31%; n = 70), and the mean time until a recurrence was 3.8 ± 2.6 years. Only 39% of the recurrences (95% CI, 30%-48%) occurred in the first 2 years after surgery, while 61% (95% CI, 50%-73%) occurred in the first 4 years after surgery.

CONCLUSION

In our study, the effectiveness of Bankart repair to stabilize the shoulder decreased significantly over time. Indeed, less than half of the recurrences occurred after 2 years of follow-up. Therefore, we propose that the recommended minimum follow-up should be 4 years; otherwise, it is very likely that the actual rate of recurrences will be significantly underestimated.

Is preoperative glenoid defect size a reliable indicator of postoperative recurrence after arthroscopic Bankart repair in teenage competitive athletes?

BACKGROUND

Being younger than 20 years of age at the time of arthroscopic Bankart repair (ABR) is known to be one of the most important risk factors for postoperative recurrence of instability. When deciding on the appropriate surgical approach, surgeons generally consider only the size of a critical glenoid defect, and most of them do not take into account factors such as the size of bone fragments and possible bone union after arthroscopic bony Bankart repair (ABBR). Therefore, this retrospective study aimed to clarify the risk factors for postoperative recurrence after ABR in teenage competitive athletes by focusing on glenoid rim morphologies and bone union.

METHODS

Participants were 115 teenage competitive athletes without a capsular injury who underwent primary ABR for chronic traumatic anterior instability and were followed up for a minimum of 2 years. Possible risk factors for postoperative recurrence were investigated by univariate and multivariate analysis. In shoulders with a glenoid defect and bone fragment, the influence of glenoid defect size and bone fragment size on bone union after ABBR was also investigated.

RESULTS

Postoperative recurrence was seen in 16 patients (13.9%). Regarding glenoid defect size, recurrence was seen in 1 (3.2%) of 31 shoulders with a glenoid defect smaller than 5% (including those with a normal glenoid), 15 (22.1%) of 68 shoulders with a glenoid defect of 5%-20%, and 0 (0%) of 16 shoulders with a glenoid defect of 20% or larger (P = .009). Regarding bone union, recurrence was seen in 4 (6.9%) of 58 shoulders with complete or partial bone union after ABBR and 8 (40%) of 20 shoulders with nonunion or disappearance of the bone fragment (P = .001). Regarding bone fragment size, recurrence was seen in 12 (20.7%) of 58 shoulders with a small or no bone fragment (<7.5%) and in 3 (8.6%) of 35 shoulders with a large bone fragment (≥7.5%; P = .154). Multivariate analysis identified non-union or disappearance of the bone fragment after ABBR as a significant risk factor for recurrence. Complete or partial bone union was seen in 25 (58.1%) of 43 shoulders with a small bone fragment (<7.5%) and 33 (94.3%) of 35 shoulders with a large bone fragment (≥7.5%; P < .001).

CONCLUSIONS

In teenage competitive athletes, bone union after ABBR affects postoperative recurrence after ABR, regardless of the preoperative glenoid defect size, and bone union rate after ABBR is significantly influenced by bone fragment size.

Arthroscopic Bankart Repair With Remplissage as an Alternative to Latarjet for Anterior Glenohumeral Instability With More Than 15% Glenoid Bone Loss

BACKGROUND

Surgical management of anterior shoulder instability continues to evolve. The clinical effectiveness of arthroscopic Bankart repair with remplissage (REMP) in patients with increasing glenoid bone loss (GBL) has not been thoroughly compared with Latarjet.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare 2-year outcomes of REMP versus open Latarjet in patients with >15% GBL. We hypothesized that there would be no difference.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicenter, retrospective study was performed on a consecutive series of patients who underwent primary REMP or Latarjet by 4 shoulder specialists between August 2013 and December 2019 for >15% GBL. Procedure performance was based on shared decision making between the surgeon and patient. Baseline and 2-year postoperative range of motion (ROM) and the following patient-reported outcomes (PROs) were collected: Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation, and visual analog scale for pain. Return to sport, satisfaction, complications, recurrence, and revisions were reviewed.

RESULTS

A total of 47 patients were available for study, including 22 who underwent REMP and 25 who underwent Latarjet. Baseline demographic characteristics, ROM, and PROs were similar between the groups. Mean preoperative GBL (REMP 25.8% ± 7.8% vs Latarjet 25.1% ± 9.0%; P = .800) and off-track lesions (REMP 59.1% vs Latarjet 44.0%; P = .302) were similar. Postoperative change in external rotation favored Latarjet (10° ± 22° vs -4° ± 13°; P = .017). Postoperative PROs, return to the sports (86.4% vs 87.5%; P = .99), and satisfaction (95.5% vs 95.8%; P = .99) were similar between groups. There were no recurrent dislocations in either group. One infected hematoma was encountered in the Latarjet cohort.

CONCLUSION

At short-term follow-up, the hypothesis was upheld. REMP and Latarjet provided similar outcomes for patients with >15% GBL, although REMP patients experienced slightly decreased external rotation. Although larger series and longer-term follow-ups are required, remplissage may be considered in patients with >15% glenoid bone loss.

Anterior glenoid rim erosion in the early stage after arthroscopic Bankart repair affects postoperative recurrence

Background

Recent studies reported that anterior glenoid rim erosion can occur in the early period after arthroscopic Bankart repair (ABR) for traumatic anterior shoulder instability. However, it is unknown whether such erosion is a risk factor for postoperative recurrence. This study evaluated risk factors for postoperative recurrence after ABR, specifically aiming to elucidate whether reduction of postoperative glenoid width due to anterior glenoid rim erosion is one of such factors.

Methods

A total of 220 shoulders that underwent ABR alone between 2013 and 2020 were retrospectively investigated. Patient age at surgery, whether the patient was a collision/contact athlete, anchor placement, preoperative glenoid bone defect (%), localization of the Hill-Sachs lesion, and change of glenoid width (%) in the 6 months after surgery were investigated for their statistical relation to recurrence by univariate and multiple logistic regression analysis.

Results

Postoperative recurrence occurred in 32 of 220 shoulders (14.5%). In univariate analysis, being a collision/contact athlete was the only variable with a significant effect on recurrence (odds ratio [OR], 2.555; 95% confidence interval [CI], 1.123-5.814; P = .03). Change of glenoid width reduction was larger in those with recurrence than without recurrence, but the difference was not statistically significant (-7.0 ± 6.6% vs. -5.0 ± 9.3%; P = .14). However, in multivariate logistic analysis, preoperative glenoid bone defect (%) (adjusted unit OR, 1.076; 95% CI, 1.018-1.137; P = .010) and postoperative change of glenoid width (%) (adjusted unit OR, 0.946; 95% CI, 0.900-0.994; P = .028) had a significant influence on postoperative recurrence.

Conclusion

Glenoid width reduction due to anterior glenoid rim erosion after ABR is a risk factor for recurrence.

Remplissage Yields Similar 2-Year Outcomes, Fewer Complications, and Low Recurrence Compared to Latarjet Across a Wide Range of Preoperative Glenoid Bone Loss

PURPOSE

The purpose of this study was to compare functional outcome, return to sport, satisfaction, postoperative recurrence, and complications in patients undergoing primary arthroscopic Bankart repair with remplissage (ABR) to primary Latarjet.

METHODS

A multicenter retrospective study was performed on patients undergoing primary ABR or open Latarjet between 2013 and 2019 who had a minimum 2-year follow-up. Baseline and two-year range of motion (ROM), patient-reported outcomes (PROs: Western Ontario Shoulder Instability Index [WOSI], Single Assessment Numeric Evaluation [SANE], and visual analog scale [VAS] for pain) recurrence, return to sport, satisfaction, and complications were reviewed.

RESULTS

This study included 258 patients, including 70 ABRs and 188 Latarjet procedures. Baseline demographics, ROM, and PROs were similar. Mean preop glenoid bone loss (GBL) (12.3% ± 10.9% vs 7.6% ± 9%; P < .001) and off-track lesions (23% vs 13%; P = .046) were higher in the ABR group, while preoperative GBL range was similar (0-42% vs 0-47%). Changes in the VAS (1.9 vs 0.9; P = .019) and WOSI (1096 vs 805; P < .001) were improved in ABR. The percentage of patients who achieved a minimal clinically important difference was improved in WOSI for ABR and PASS for ABR in SANE, VAS, and WOSI scores. The ABR cohort reported worse changes in external rotation (ER) (-4° vs +19°; P < .001). Return to sport among overhead and contact athletes favored ABR (91.5% vs 72.7%; P = .007). Satisfaction and recurrent dislocation were similar. Surgical complications were observed in 0% of ABR cases, compared to 5.9% in the Latarjet group.

CONCLUSION

Primary ABR resulted in 2-year functional outcomes that were as good or superior to primary Latarjet, with higher return to sport for overhead and contact activities, fewer complications, and comparably low recurrence rates, even despite greater bipolar bone loss in the ABR cohort. However, this comes at the expense of decreased external rotation, which may be considered in individual patients.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Suspension fixation of iliac bone grafts under arthroscopy is an effective method for the treatment of unstable bony Bankart disease of the shoulder joint in patients with joint relaxation

PURPOSE

To evaluate the results of arthroscopic autologous iliac bone graft suspension fixation combined with the Remplissage procedure in the treatment of recurrent shoulder dislocation with bony Bankart lesions and joint hyperlaxity.

METHODS

From 2018 to 2020, 22 patients with joint laxity underwent arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure due to recurrent shoulder dislocation. Clinical assessment included range of motion (forward flexion, abduction, 90° external rotation, conventional external rotation, adduction, and internal rotation), visual analog scale (VAS) score, Rowe score, University of California Los Angeles (UCLA) score, and Western Ontario Shoulder Instability Index (WOSI) score. Post-operatively, the healing of the bone graft was evaluated with computed tomography (CT) scanning.

RESULTS

All 22 patients were followed up for a mean of 19.3 ± 4.1 months. CT imaging showed that the healing time of the bone graft was 6-8 weeks. The patient satisfaction rate was 100%, there were no cases of redislocation, all patients returned to their preinjury training state, and the fear test was negative. At the final follow-up, the UCLA, VAS, Rowe, and WOSI scores were 29.8 ± 2.1, 2.2 ± 0.8, 89.4 ± 4.2, and 482.3 ± 46.2, respectively (p < 0.001).

CONCLUSION

Arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure are effective in preventing recurrent instability with joint hyperlaxity. Furthermore, no patient had redislocation.

LEVEL OF EVIDENCE

IV.

Consideration May Be Given to Lowering the Threshold for the Addition of Remplissage in Patients With Subcritical Glenoid Bone Loss Undergoing Arthroscopic Bankart Repair

Purpose

Treatment for patients with anterior glenohumeral instability with subcritical bone loss is evolving. The purpose of this study was to compare 2-year outcomes of arthroscopic Bankart repair with and without Hill–Sachs remplissage in patients with <15% glenoid bone loss.

Methods

A multicenter retrospective study was performed on a consecutive series of patients who underwent primary isolated arthroscopic Bankart repair (IBR) or arthroscopic Bankart repair with remplissage (REMP) by 4 shoulder specialists between 2013 and 2019. Range of motion (ROM) and patient-reported outcomes (PROs) were collected at baseline and 2 years postoperative: Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation, and visual analog scale for pain. Recurrence, return to sport, satisfaction, complications, and revisions also were reviewed.

Results

A total of 123 patients were available, including 75 IBR and 48 REMP. Baseline demographics, activity, ROM, and PROs were similar. Mean glenoid bone loss (2.5% vs 6.1%: P < .001) was greater in REMP, although the number of on-track lesions was similar (98.7% vs 93.8%: P = .298). WOSI scores were improved for REMP (196.5 vs 42.7: P = .004), but otherwise no difference in postoperative PROs or ROM. Differences between cohorts did not reach significance in return to sport (73% vs 83%: P = .203), recurrence (9.3% vs 2.1%: P = .148), or revisions (6.8% vs 2.1%: P = .403). For on-track lesions there were 6 recurrences in IBR (6 of 74; 8.1%) and 1 recurrence in REMP (1 of 45; 2.2%).

Conclusions

Despite slightly worse pathology, patients with subcritical bone loss who undergo REMP experience similar short-term postoperative function to isolated IBR. Recurrence, revision, and return to sport favored REMP but this study was underpowered to show statistical significance. Recurrence was common following IBR, despite subcritical glenoid bone loss and primarily on-track lesions, suggesting that REMP can be considered in on-track lesions.

Level of Evidence

III, retrospective comparative study.

The playing position significantly influences return to sports and recurrences after an arthroscopic Bankart repair in competitive rugby players

BACKGROUND

The purpose of our study was to investigate the influence of the different rugby playing positions on return to sports, functional outcomes, and recurrences after an arthroscopic Bankart repair.

METHODS

A total of 88 rugby players were treated for anterior shoulder instability in our institution between 2010 and 2018. Functional outcomes, return to sports, recurrences, complications, and revisions rates were evaluated according to the playing position.

RESULTS

Overall, 73.8% of the patients returned to rugby and 60% returned at the same level as before the injury. The tight forwards and outside backs experienced a significant decrease in their competitive level after surgery, and showed the lowest functional outcomes. The tight forwards and outside backs showed a statistically significant increase in recurrence and revision rates, and an OR for recurrence of 12.8 and 9.6, respectively.

DISCUSSION

The playing position significantly influenced return to sports and recurrences after an arthroscopic Bankart repair in competitive rugby players. Specifically, the tight forwards and outside backs have returned to a lower level than they had before surgery, showed the lowest functional outcomes, and a significant increase in recurrences and revisions rates than the other groups.

The Latarjet procedure in competitive athletes younger than 20 years old with a significant glenoid bone loss

PURPOSE

To analyze return to sports, functional outcomes, and complications following the Latarjet procedure in competitive athletes younger than 20 years old with a significant glenoid bone loss.

METHODS

Between 2010 and 2017, 60 competitive athletes younger than 20 years old with a significant glenoid bone loss were operated with the Latarjet procedure. Return to sports, range of motion, and the Rowe and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications and bone consolidation were also evaluated.

RESULTS

The mean follow-up was 58 months and the mean age was 16.3 years. Overall, 93% were able to return to sports and 84% returned at the same level. The Rowe and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P <  .001). The total complication rate was 22% and the revision rate was 1.6%. The recurrence rate was 3.3%. The bone block healed in 93% of the cases.

CONCLUSIONS

In competitive athletes younger than 20 years old with a significant glenoid bone loss, the Latarjet procedure resulted in excellent functional outcomes, with most of the patients returning to sports and at the same level they had before injury with a low rate of recurrences. However, this procedure is associated with a significant rate of complications and should preferably be performed by experienced surgeons.

Can We Identify Why Athletes Fail to Return to Sports After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis

BACKGROUND

No previous systematic reviews have reported on athletes who fail to return to sports after arthroscopic Bankart repair.

PURPOSE

To review the literature on athletes who fail to return to sports after arthroscopic Bankart repair to determine the rate of athletes who did not return to sports and to identify the specific reasons for failure to return to sports by nonreturning athletes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A meta-analysis was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Three electronic databases (PubMed, Scopus, Web of Science) were queried for articles meeting the inclusion criteria. Studies were considered eligible only if reporting the rate of failure for return to sports and providing the specific reasons why athletes were unable to return to sports. All records were screened by title, abstract, and full text by 2 authors independently, with any discrepancies resolved by a third senior author. For articles selected for inclusion, data were collected on the number of athletes, average age, average follow-up time, type of sport played, rate of failure to return to sports, and specific reasons for failure to return. A random-effects model was used to conduct the meta-analysis.

RESULTS

Seventeen studies were selected for inclusion reporting on a total of 813 athletes. The calculated weighted rate of failure to return to sports after arthroscopic Bankart repair was 15.6% (95% CI, 10.9%-21.1%). A significantly higher proportion of athletes cited shoulder-dependent versus shoulder-independent reasons for failure to return to sports (81.7% vs 18.3%; P < .0001). The most cited reasons for failure to return included recurrent or persistent instability (33.3%), fear of reinjury (17.7%), apprehension (9.9%), changes in priorities or personal interest (8.5%), lack of time (7.1%), and discomfort or pain with sports (6.4%).

CONCLUSION

Our study estimated the rate of failure to return to sports after arthroscopic Bankart repair to be 15.6%, with most athletes citing shoulder-related reasons as the primary factor precluding return. Identifying the potential reasons preventing successful return to sports can guide surgeons in counseling athletes regarding postoperative expectations and addressing hesitations for returning to sports.

Impact, incidence and prevalence of musculoskeletal injuries in senior amateur male rugby: epidemiological study

OBJECTIVES

Exposure to different types of injuries in rugby union is common. It is important to know about the injury epidemiology for medical teams care in order to optimize players´ performance and the treatment of common injuries, but there is limited specific information related to amateur rugby union. The purpose of this study is to determine the incidence, prevalence, injury burden, severity, nature of injuries sustained by senior amateur male rugby players from three clubs in Argentina during a given season.

METHODS

An observational, analytical, prospective, multicenter study was developed. Data collection was conducted from 15 March 2019 to 2 November 2019, during a complete season under the applicable standards of the Rugby Injury Consensus Group according to the Orchard Sports Injury and Illness Classification System.Incidence (injuries/1000 player-match-hours), prevalence (%), severity (time loss), injury burden (days lost/1000 player-match-hours), injured location and type of injury (%) were estimated.

RESULTS

250 players and 180 injuries were assessed. Injury prevalence was 52.4%. Incidence rate per match and training was 30.9/1000 player-match-hours, and 0.77/1000 player-training-hours, respectively.The median injury severity score was 23 (IQR 12.7-52) days lost accounting for an injury burden of 97.3/1000 player-hours. Of the total, 113 (62.8%) injuries were contact injuries. The lower limbs were the most commonly affected (58.9%). Hamstring strain injury had the highest incidence and anterior cruciate ligament tear was the most severe injury.

CONCLUSION

The prevalence, incidence, and injury burden reported in this study are unprecedented and would add knowledge for the amateur rugby union community. Trainers, physicians, and physical therapists, should consider it to improve their clinical practice.

Open Bristow Versus Open Latarjet for Anterior Shoulder Instability in Rugby Players: Radiological and Clinical Outcomes

Background:

Coracoid transfer is a reliable method for managing anterior shoulder instability in athletes who play contact sports; however, differences between the Bristow and Latarjet procedures are unclear.

Purpose:

To compare clinical outcomes and rates of bone union and bone resorption of the coracoid process between the open Bristow and open Latarjet procedures in rugby players.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Rugby players who underwent an open Bristow or an open Latarjet procedure were retrospectively reviewed for anterior shoulder instability, and 66 shoulders in the Bristow group and 35 in the Latarjet group were included. Graft union and resorption were evaluated using computed tomography at 3 months to 1 year postoperatively. Patient-reported outcome measures (American Shoulder and Elbow Surgeons score, Rowe score, and satisfaction rate) were obtained at a mean follow-up of 74 months (range, 45-160 months) for Bristow and 64 months (range, 50-76 months) for Latarjet procedures. Recurrence and the rate of return to play (RTP), frequency of pain after RTP, and retirement rate after RTP were also assessed.

Results:

In 97.1% of the Latarjet procedure cases, bone union of the coracoid was achieved at 3 months postoperatively; however, bone union was achieved in only 72.7% of the Bristow procedure cases at 6 months postoperatively. Bone resorption of the coracoid process occurred in 6.1% of shoulders after the Bristow procedure, whereas 100% of shoulders showed bone resorption after the Latarjet procedure. No statistical differences were found in outcome scores between the 2 procedures. Subluxation and persistent pain after returning to sports were identified at a significantly higher rate in the Latarjet group (5 shoulders [14%] and 9 shoulders [26%], respectively) than in the Bristow group (2 shoulders [3%] and 2 shoulders [3%]) (P = .0471 and P = .001, respectively).

Conclusion:

The Latarjet procedure had an advantage in the early and high rate of bone union but was at a disadvantage in bone resorption compared with the Bristow procedure. Subluxation and pain after returning to sports were more frequent in patients who underwent the open Latarjet procedure than in those who underwent the open Bristow procedure.

Arthroscopic Subscapularis Augmentation Using the Long Head of the Biceps Tendon for Anterior Shoulder Instability

The limitations of transferring the coracoid process along with the conjoined tendon are coracoacromial arch damage, technical difficulty, and nerve injury. The long head of the biceps tendon (LHBT) proximal transposition technique has a weaker sling effect and a risk of nerve injury. The arthroscopic subscapularis augmentation technique may have risks of shoulder external rotation restriction and subscapularis transection. Herein, we introduce an arthroscopic technique for the transfer of the LHBT for subscapularis augmentation to address these risks. Indications of this technique were patients younger than 45 years of age who engage in competitive sports, require forceful external rotation and abduction, have a related capsule-ligament insufficiency, and have a glenoid bone loss <25%. The steps include detaching the LHBT at the upper edge of the pectoralis major, transecting and braiding the LHBT, establishing a scapular tunnel, placing a guide suture through the upper third of the subscapular and scapular tunnel, passing the LHBT through the established tunnels, and fixating the LHBT. This technique achieves stability of the anterior shoulder by transecting and transferring the distal end of the LHBT to press on the upper third of the subscapularis muscle.

On-the-Edge Anchor Placement May Be Protective Against Glenoid Rim Erosion After Arthroscopic Bankart Repair Compared to On-the-Face Anchor Placement

PURPOSE

This retrospective study aimed to compare the effects of 2 different anchoring placements on glenoid rim erosion after arthroscopic Bankart repair (ABR).

METHODS

Shoulders that underwent ABR from January 2013 to July 2020 were divided into 2 groups according to anchor placement (on-the-face, group F; on-the-edge, group E). We retrospectively calculated the percent change of glenoid width (Δ) on the first postoperative computed tomography scan (CT; performed within 6 months) and second postoperative CT (performed at 6 to 12 months) relative to the width on the preoperative CT and compared percent changes between the 2 groups. Also, we investigated the influence of preoperative glenoid structures (normal, erosion, bony Bankart) and the postoperative recurrence rate.

RESULTS

We examined 225 shoulders in 214 patients (group F, n = 151; group E, n = 74). At first CT, anchoring placement was significantly associated with postoperative decrease of glenoid width (group F, -7.6% ± 7.9%; group E, -0.1% ± 9.7%; P < .0001). The difference between groups F and E was significant in shoulders with a preoperative glenoid defect (bony Bankart, -6.6% ± 8.8% vs 2.5% ± 11.2%, respectively; P < .0001; erosion, -6.6% ± 6.2% vs -2.6% ± 5.3%, respectively; P = .03). In 112 shoulders, CT was performed twice; Δ was -6.9% ± 7.3% in group F (n = 64) and -1.7% ± 10.1% in group E (n = 48; P = .005) at the first CT and -3.2% ± 10.0% and 1.0% ± 10.6% (P = .10), respectively, at the second CT, indicating recovery of glenoid width in both groups. The postoperative recurrence rate in patients with at least 2 years' follow-up was 14.7% in group F and 14.6% in group E.

CONCLUSIONS

In the early stage after ABR, on-the-edge glenoid anchor placement was associated with less glenoid rim erosion than on-the-face anchor placement.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

A Glenoid Defect of 13.5% or Larger Is Not Always Critical in Male Competitive Rugby and American Football Players Undergoing Arthroscopic Bony Bankart Repair: Contribution of Resultant Large Bone Fragment

PURPOSE

To investigate bone union and postoperative recurrence after arthroscopic bony Bankart repair (ABBR) in male competitive rugby and American football players with a subcritical glenoid defect of ≥13.5% and to compare findings with those in players with a glenoid defect of <13.5%.

METHODS

Participants were male competitive rugby or American football players with a glenoid defect and bone fragment who underwent ABBR from July 2011 to December 2018 and were followed for a minimum of 2 years. We investigated the influence of glenoid defect and bone fragment size on bone union and postoperative recurrence after ABBR.

RESULTS

We included 45 rugby players and 35 American football players. A total of 38 shoulders were assigned to the small defect group (<13.5%) and 42 to the large defect group (≥13.5%). The complete bone union rate was 47.4% in the small defect group and 71.4% in the large defect group (P = .040), and postoperative recurrence was seen in 13 (34.2%) and 5 shoulders (11.9%), respectively (P = .030). In the small defect group, the bone fragment size was <7.5% in 30 shoulders and ≥7.5% in 8 shoulders; in comparison, the respective numbers were 12 and 30 shoulders in the large defect group, and large fragments (>7.5%) were significantly more common in this group (P < .001). The complete union rate was significantly higher in shoulders with a large fragment (≥7.5%) than in those with a small fragment (<7.5%; 78.9% versus 42.9%, respectively; P = .001). The recurrence rate was 33.3% in shoulders with a small fragment (<7.5%) and 10.5% in shoulders with a large fragment (≥7.5%; P = .017) and was significantly lower in shoulders with a complete union than in those without a complete union (6.3% versus 46.9%, respectively; P < .001).

CONCLUSION

The postoperative recurrence rate after ABBR was lower in male competitive rugby and American football players with a large glenoid defect (≥13.5%) than in those with a small glenoid defect (<13.5%) and might be associated with a higher rate of complete bone union of the resultant large bone fragment (≥7.5%).

LEVEL OF EVIDENCE

III, case-control study.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Management of common upper extremity injuries in throwing athletes: a critical review of current outcomes

Given the rising incidence and prevalence of shoulder injuries in throwing athletes, this review aims to evaluate management options and outcomes of common shoulder injuries in overhead throwers. Laxity of the glenohumeral joint is often adaptive for overhead athletes to achieve the velocity necessary to compete in the professional ranks. Surgical repair of the stabilizers of the humeral head-specifically the labrum and rotator cuff-often causes inflammation, scarring, and overtensioning of the glenohumeral joint which lead to poor postoperative performance. Thus, nonsurgical management should be exhausted in this population before considering surgical intervention.

Sex-specific differences in outcomes after anterior shoulder surgical stabilization: a meta-analysis and systematic review of literature

Background

Methods

Results

Conclusion

Does the immediate repair of Bankart lesion following first dislocation reduce the chances of recurrence after arthroscopic repair in soldiers?

PURPOSE

The study attempted to compare the effects of immediate and delayed arthroscopic Bankart repair on the shoulder dislocation recurrence.

METHODS

In total, 465 soldiers with first-time anterior shoulder dislocation were included in the study. Of the total, 285 soldiers underwent a quick arthroscopic Bankart repair procedure, whether 180 soldiers underwent a delayed repair procedure. The initial dislocation was traumatic in both groups and operated using the standard arthroscopic suture anchor repair technique. Patient's age, repair time since the first dislocation, number of dislocations before surgery, number of suture anchors used during the repair, duration of surgical procedure, duration from surgery to return to work, and recurrence of dislocation after surgery were recorded. Rowe score, Constant score, and American Shoulder and Elbow Surgeons score were used for clinical assessment.

RESULTS

The operating time and recurrence rate were higher in the group subjected to delayed repair procedure than in the group subjected to immediate repair procedure. Repair timing was found to be crucial for a successful outcome.

CONCLUSIONS

The findings suggest that Bankart repair must be performed immediately to minimize recurrence and other degenerative changes, which may require an additional surgical procedure for satisfactory repair. More studies are required to reach a definitive conclusion.

LEVELS OF EVIDENCE

Level III.

Short-term complications of the Latarjet procedure: a systematic review

PURPOSE

The purpose of this study is to evaluate the short-term complication rate following the open and arthroscopic Latarjet procedures and to meta-analyze the studies comparing the 2 approaches.

METHODS

PubMed was searched according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to find clinical and biomechanical studies comparing complication rates in open and arthroscopic Latarjet procedures. A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the PRISMA guidelines. Clinical studies reporting on the complications following the open or arthroscopic Latarjet were included. Meta-analysis was performed for comparative studies using Review Manager, version 5.3. A P value of <.05 was considered statistically significant.

RESULTS

Overall, 89 studies (Level of Evidence [LOE] I: 2, LOE II: 2, LOE III: 24, LOE IV: 61) met inclusion criteria, with 7175 shoulders. Following the open Latarjet procedure, the overall complication rate was 6.1%, with a 1.9% occurrence of graft-related complications, 1.1% hardware, 1.1% wound, 0.9% nerve, and 1.2% other complications. Following the arthroscopic Latarjet procedure, the overall complication rate was 6.8%, with a 3.2% occurrence of graft-related complications, 1.9% hardware, 0.5% wound, 0.7% nerve, and 0.5% other complications. Complications were reported in 7 studies comparing 379 patients treated with the open Latarjet and 531 treated with the arthroscopic Latarjet, with no statistically significant difference between the two (P = .81).

CONCLUSION

Our study established that the overall complication rate following the Latarjet procedure was 6%-7%, with the most common complication being graft-related. Furthermore, based on the current evidence, there is no significant difference in the complication rate between the open and arthroscopic Latarjet procedures.

Evaluation and Management of Glenohumeral Instability With Associated Bone Loss: An Expert Consensus Statement Using the Modified Delphi Technique

PURPOSE

To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss.

METHODS

A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus.

RESULTS

After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out.

CONCLUSIONS

The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed.

LEVEL OF EVIDENCE

Level V, consensus statement.

Arthroscopic Bankart Repair and Open Bristow Procedure in the Treatment of Anterior Shoulder Instability With Osseous Glenoid Lesions in Collision Athletes

Background:

Traumatic anterior shoulder instability in collision sports athletes often involves osseous glenoid lesions, which make surgical treatment challenging. High redislocation rates have been seen in collision sports athletes treated using arthroscopic Bankart repair.

Purpose:

To investigate the effectiveness of a combined arthroscopic Bankart repair and open Bristow procedure for the treatment of traumatic anterior shoulder instability in collision sports athletes, with a focus on osseous glenoid lesions.

Study Design:

Case series; Level of evidence, 4.

Methods:

We reviewed 149 shoulders in 141 competitive collision sports athletes (mean ± standard deviation age, 20.1 ± 4.1 years; 8 bilateral cases) who underwent a combined arthroscopic Bankart repair and open Bristow procedure with minimum 2 years of follow-up. Osseous Bankart lesions were arthroscopically reduced and fixed using a coracoid graft.

Results:

Clinical outcomes as indicated by mean Rowe score improved significantly from 50.0 preoperatively to 98.9 postoperatively (P < .001) at a median follow-up of 3.4 years (range, 2.5-7 years). There were 2 recurrent dislocations (1.3%), both of which had nonunion of the transferred coracoid. Osseous Bankart lesions were observed in 85 shoulders, and osseous glenoid lesions ≥10% of the diameter of the nonoperative side were found in 58 shoulders, including 24 off-track cases. Clinical outcomes were not significantly different between patients with a glenoid defect ≥10% and <10%. Nonunion of the transferred coracoid was observed in 16 shoulders (10.7%), which had inferior Rowe scores; however, we could not define any risk factors for nonunion, including patient characteristics or bone morphology. Postoperative computed tomography performed in 29 patients >1 year after surgery showed successful repair of the osseous glenoid lesions, with a restored glenoid articular surface in all cases. Significant pre- to postoperative increases were seen in glenoid diameter (mean, 13.1% [95% CI, 9.9%-16.3%]; P < .001) and area (mean, 10.6% [95% CI, 8.5%-12.7%]; P < .001).

Conclusion:

A combined arthroscopic Bankart repair and open Bristow procedure improved bone morphology and was a reliable surgical method for treating collision sports athletes with traumatic anterior shoulder instability involving osseous glenoid lesions.

Bipolar Bone Defects in Shoulders With Primary Instability: Dislocation Versus Subluxation

Background:

In shoulders with traumatic anterior instability, a bipolar bone defect has been recognized as an important indicator of the prognosis.

Purpose:

To investigate bipolar bone defects at primary instability and compare the difference between dislocation and subluxation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

There were 156 shoulders (156 patients) including 91 shoulders with dislocation and 65 shoulders with subluxation. Glenoid defects and Hill-Sachs lesions were classified into 5 size categories on 3-dimensional computed tomography (CT) scans and were allocated scores ranging from 0 (no defect) to 4 points (very large defect). To assess the combined size of the glenoid defect and Hill-Sachs lesion, the scores for both lesions were summed (range, 0-8 points). Patients in the dislocation and subluxation groups were compared regarding the prevalence of a glenoid defect, a bone fragment of bony Bankart lesion, a Hill-Sachs lesion, a bipolar bone defect, and an off-track Hill-Sachs lesion. Then, the combined size of the bipolar bone defects was compared between the dislocation and subluxation groups and among patients stratified by age at the time of CT scanning (<20, 20-29, and ≥30 years).

Results:

Hill-Sachs lesions were observed more frequently in the dislocation group (75.8%) compared with the subluxation group (27.7%; P < .001), whereas the prevalence of glenoid defects was not significantly different between groups (36.3% vs 29.2%, respectively; P = .393). The combined defect size was significantly larger in the dislocation versus subluxation group (mean ± SD combined defect score, 2.1 ± 1.6 vs 0.8 ± 0.9 points, respectively; P < .001) due to a larger Hill-Sachs lesion at dislocation than subluxation (glenoid defect score, 0.5 ± 0.9 vs 0.3 ± 0.6 points [P = .112]; Hill-Sachs lesion score, 1.6 ± 1.2 vs 0.4 ± 0.7 points [P < .001]). Combined defect size was larger in older patients than younger patients in the setting of dislocation (combined defect score, <20 years, 1.6 ± 1.2 points; 20-29 years, 1.9 ± 1.5 points; ≥30 years, 3.4 ± 1.6 points; P < .001) but was not different in the setting of subluxation (0.8 ± 1.0, 0.7 ± 0.9, and 0.8 ± 0.8 points, respectively; P = .885). An off-track Hill-Sachs lesion was observed in 2 older patients with dislocation but was not observed in shoulders with subluxation.

Conclusion:

The bipolar bone defect was significantly more frequent, and the combined size was greater in shoulders with primary dislocation and in older patients (≥30 years).

Glenoid Pathology, Skeletal Immaturity, and Multiple Preoperative Instability Events Are Risk Factors for Recurrent Anterior Shoulder Instability After Arthroscopic Stabilization in Adolescent Athletes

PURPOSE

To identify risk factors for recurrent shoulder instability after arthroscopic stabilization in adolescent athletes.

METHODS

A retrospective case-control study was undertaken of all patients younger than 18 years undergoing arthroscopic shoulder stabilization for anterior instability between 2009 and 2016. Two patient cohorts were identified: (1) patients with recurrent instability (frank dislocations or subluxations) after arthroscopic stabilization and (2) an age- and sex-matched cohort of patients with no recurrent instability at a minimum of 2 years' follow-up from index surgery. Patient demographic, injury, radiographic, and surgical variables were recorded. Variables with P < .10 on univariate analysis were entered into a binary logistic multivariate regression analysis.

RESULTS

We identified 35 patients (20.5%) in whom arthroscopic stabilization failed at a mean of 1.2 ± 1.0 years after their index surgical procedure. A separate age- and sex-matched cohort of 35 patients with no evidence of recurrent instability was identified (mean follow-up, 5.4 ± 2.0 years; minimum follow-up, 2 years). Univariate analysis identified increased glenoid bone loss (P = .039), decreased glenoid retroversion (P = .024), and more than 1 instability event prior to surgery (P = .017) as significant risk factors for recurrent instability. Multivariate regression analysis revealed that glenoid retroversion less than 6°, skeletal immaturity, and more than 1 prior instability event significantly and independently predicted future recurrence. The risk of recurrence after arthroscopic stabilization was increased by 3 times in patients with 2 risk factors and by 4 times in patients with all 3 risk factors.

CONCLUSIONS

Anterior glenoid bone loss, glenoid version, skeletal immaturity, and multiple preoperative instability events are risk factors for failed arthroscopic stabilization in adolescent athletes with anterior instability.

LEVEL OF EVIDENCE

Level III, case-control study.

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).

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.

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.

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.

Sex differences in outcomes after arthroscopic bankart repair

Objectives

Risk factors for anterior shoulder dislocation include young age, contact activities and male sex. The influence of sex on patient-reported outcomes of arthroscopic Bankart repair (ABR) is unclear, with few studies reporting potential differences. This study’s purpose was to compare patient-reported outcomes of males and females following ABR.

Methods

Prospectively collected data was analysed for 281 patients (males: 206, females: 75) after ABR with preoperative, 1-year and 2-year follow-up responses. The Wilcoxon signed-rank and χ² tests, preoperative, 1 year and 2 year follow-up results were examined to determine differences of scores in males versus females.

Results

No statistically significant sex differences were observed in Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), Visual Analogue Scale (VAS) or Single Assessment Numerical Evaluation (SANE) Scores at 1-year or 2-year follow-up. Females had lower Veterans RAND 12-item health survey (VR-12) mental health subscores at 2-year follow-up (females: 52.3±9.0, males: 55.8±7.6, p=0.0016). Females were more likely to report that treatment had ‘exceeded expectations’ at 2-year follow-up regarding motion, strength, function and normal sports activities.

Conclusion

Results of study demonstrate that ABR has similar outcomes for both males and females. There were no statistically significant sex-related differences in SST, ASES, VAS or SANE scores following ABR. VR-12 mental health subscores showed a minimal difference at 2-year follow-up, with lower scores in females.

Level of evidence

Retrospective cohort study; level II.

High Rate of Return to Sports and Low Recurrences With the Latarjet Procedure in High-Risk Competitive Athletes With Glenohumeral Instability and a Glenoid Bone Loss <20

Purpose

To analyze return to sports, functional outcomes, and complications following the Latarjet procedure in competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%.

Methods

All the included patients were operated between 2010 and 2016. The inclusion criteria were competitive athletes with anterior glenohumeral instability, a glenoid bone defect <20% who participated in contact sports, forced overhead sports, or had a previous failed Bankart repair and had a minimum 2 years’ follow-up. Return to sports, range of motion (ROM), the Rowe score, and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications and bone consolidation were also evaluated.

Results

A total of 65 athletes were included in the study. The mean follow-up was 53 months (±13), and the mean age was 23.9 years (range, 16-31 years). Overall, 94% were able to return to sports and 84% returned at the same level. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P < .001). No significant difference in shoulder ROM and functional scores was found between primary and revision cases. The total complication rate was 11% and the revision rate was 1.5% The recurrence rate was 4.6%. The bone block healed in 95% of the cases.

Conclusions

In high-risk competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%, the Latarjet procedure resulted in excellent functional outcomes, with most of the patients returning to sports and at the same level they had before injury with a low rate of recurrences

Level of Evidence

Therapeutic case series; Level of evidence, IV

High Variability in Functional Outcomes and Recurrences Between Contact Sports After Arthroscopic Bankart Repair: A Comparative Study of 351 Patients With a Minimum 3-Year Follow-Up

Purpose

To compare return to sports, functional outcomes, and complications of a consecutive series of contact athletes with anterior glenohumeral instability treated with isolated arthroscopic Bankart repair for isolated anterior instability.

Methods

Between January 2008 and December 2016, 351 competitive athletes who participated in contact or collision sports underwent isolated arthroscopic Bankart repair at our institution (rugby n = 105, soccer n = 90, martial arts n = 36 boxing n = 28, field hockey n = 30, handball n = 31, and basketball n = 31). Return to sports, the Rowe score, and the Athletic Shoulder Outcome Scoring System (ASOSS) score were used to assess functional outcomes. Complications also were evaluated.

Results

The mean follow-up period was 66.7 months (range, 36-148 months) and the mean age of the 351 patients was 21.3 years (range, 17-30 years).Overall, 309 patients (88%) were able to return to sports, and 284 (81%) returned at the same level as before the injury. The mean time to return to sports was 5.3 months. The rate of return to sports, the level achieved by the patients, and time to return to sports varied significantly between sports. The Rowe and ASOSS scores showed statistical improvement after operation (P < .001). The ASOSS score varied significantly between sports (P < .001). There were 40 recurrences (11.3%), 7 complications (2%) and 21 patients (6%) underwent revision surgery. There was a significant difference in the rate of recurrences and revisions between the different contact sports.

Conclusions

In athletes with glenohumeral instability who undergo isolated arthroscopic Bankart repair for isolated anterior instability, there is great variability in the rate of return to sport at the same level, in shoulder performance after returning to competition, and in the postoperative recurrence rates. Due to the high variability found in our study, results after arthroscopic Bankart repair in contact athletes should not be reported globally by including the different sports under the "collision or contact sports" label.

Level of Evidence

Retrospective Case Series; Level of evidence, 4.

Benefits of bone graft augmentation to arthroscopic Bankart repair for recurrent anterior shoulder instability with glenoid bone loss

PURPOSE

Glenoid bone loss contributes to recurrent instability after arthroscopic Bankart repair alone. With significant glenoid bone loss, better results have been reported after arthroscopic Bankart repair with glenoid arc reconstruction. However, no reports compare augmentation using bone graft with non-augmentation for glenoid bone loss. The purpose of this study was to assess clinical results of an arthroscopic Bankart repair with or without arthroscopic bone graft augmentation. It was hypothesized that such bone graft augmentation would restore shoulder stability, and lead to excellent outcomes.

METHODS

Of 552 patients treated for anterior glenohumeral instability with arthroscopic Bankart repair, 68 met this study's inclusion criteria of glenoid bone loss over 20% and follow-up of at least 2 years. Patients were divided into 2 groups based on whether with bone graft augmentation for glenoid bone loss [Group A: n = 35, median age; 21 years (range 13-72 years)], or not (Group B: n = 33, median age; 21 years (range 13-50 years)]. For grafting, either autologous iliac bone or artificial bone made of hydroxyapatite was used. Rowe score, recurrence rate, and return to sport were used to assess the results.

RESULTS

Mean Rowe score was 95.0 (SD 10.6) in Group A and 69.7 (SD 27.2) in Group B (p < 0.05). The recurrence rate was 2.9% (1/36) in Group A and 48.5% (16/33) in Group B (p < 0.05). Regarding contact/collision athletes, 24 were contained in Group A and 22 in Group B. Of the patients with recurrence in Group B, 13 (59.1%) were contact/collision athletes. Finally, 50% of the contact/collision sports athletes for both groups returned to their sports at the same as pre-injury level. Of the 11 patients who returned to the same level of contact/collision sports in Group B, seven returned with residual instability. Nine athletes in Group A and 3 in Group B quit their sports for personal or social reasons.

CONCLUSIONS

Bone graft augmentation was beneficial when used with Arthroscopic Bankart repair for recurrent anterior shoulder instability with glenoid bone loss. Especially, for recurrent anterior shoulder instability with glenoid bone loss in contact/collision sports athletes, bone graft augmentation should be strongly considered as beneficial.

LEVEL OF EVIDENCE

Level IV.