Trends in Shoulder Stabilization Techniques Used in the United States Based on a Large Private-Payer Database

Analysis of reasons for failure to return to sport after Latarjet surgery: a systematic review

BACKGROUND

The purpose of this study was to perform a systematic review of the literature to identify Shoulder Instability Return to Sport after Injury (SIRSI) scores in athletes who underwent open Latarjet surgery, determine the reasons why athletes failed to return to play (RTP) after Latarjet surgery, and compare SIRSI scores of those who did vs. did not RTP.

METHODS

According to PRISMA guidelines, the PubMed, SportDiscus, and Ovid MEDLINE databases were queried to identify studies evaluating return to sport after Latarjet surgery. Study quality was assessed using the MINORS criteria. Studies were included if RTP after Latarjet surgery and a psychological factor were evaluated, with potential psychological factors including readiness to RTP and reasons for failure to RTP.

RESULTS

Fourteen studies, 10 of level III evidence and 4 of level IV evidence, with 1034 patients were included. A total of 978 athletes were eligible to RTP. Of these, 792 (79%) successfully returned to play and 447 (56.4%) returned to play at their previous level of play. Mean RTP time was 6.2 months. Postoperative SIRSI scores averaged 71.2 ± 8.8 at a mean of 21 months' follow-up. Postoperative SIRSI scores for those able to RTP was 73.2, whereas athletes unable to RTP scored an average of 41.5. Mean postoperative SIRSI scores for those in contact sports was 71.4, whereas those in noncontact sports was 86.5. There were 31 athletes with a documented reason why they did not RTP, with postoperative shoulder injury being the most common reason (54.5%). Fear of reinjury and feeling "not psychologically confident" each represented 6.5% of the total.

CONCLUSION

Athletes who RTP have higher average SIRSI scores than those who are unable to RTP. Of the athletes who documented why they did not RTP, more than half cited a shoulder injury as their reason for not returning to play, whereas fear of reinjury and lack of psychological readiness were other common reasons.

Clinical outcomes of open Latarjet-Patte procedures performed for recurrent anterior shoulder instability with primary bone loss versus failed arthroscopic Bankart repair

BACKGROUND

This study compares the outcomes of Latarjet-Patte procedures (LPs) performed for primary glenohumeral instability in the setting of critical bone loss (LP-BL) versus salvage surgery performed after a failed arthroscopic Bankart repair (LP-FB).

METHODS

LP's performed by senior author from 2017 to 2021 were separated into cohorts by LP indication. Data abstracted from electronic medical records included demographic information, preoperative clinical scores, radiological imaging, and complications. Postoperative clinical outcome scores collected after a 2-year minimum follow-up included: patient-reported outcomes measurement information system (PROMIS) upper extremity (UE), PROMIS pain interference, PROMIS pain intensity, American Shoulder and Elbow Surgeons (ASES), and visual analog scale pain scores.

RESULTS

A total of 47 patients (LP-BL: n=29, LP-FB: n=18) with a mean age of 29 years (range, 15-58 years) were included in this study. Both cohorts achieved good upper extremity functionality without significant differences as indicated by mean PROMIS UE (LP-BL: 52.6±10.0 vs. LP-FB: 54.6±7.6, P=0.442) and ASES score (LP-BL: 89.9±15.7 vs. LP-FB: 91.5±14.4, P=0.712). However, the LP-FB cohort reported lower levels of pain (LP-FB: 0.5±1.1 vs. LP-BL: 1.9±2.7, P=0.020) at their latest follow-up. There were no significant differences in complication rates including re-dislocation between cohorts (LP-BL: 2/29 [6.9%] vs. LP-FB: 2/18 [11.1%], P=0.629).

CONCLUSIONS

When performed after failed Bankart repair, the LP results in similar postoperative functional outcomes and similar rates of complications and re-dislocations when compared to the primary indication of recurrent glenohumeral instability in the setting of critical bone loss. Level of evidence: III.

Biomechanical comparison of open Bankart repair vs. conjoint tendon transfer in a 10% anterior glenoid bone loss shoulder instability model

BACKGROUND

The treatment of shoulder instability in patients with subcritical glenoid bone loss poses a difficult problem for surgeons as new evidence supports a higher failure rate when a standard arthroscopic Bankart repair is used. The purpose of this study was to compare a conjoint tendon transfer (soft-tissue Bristow) to an open Bankart repair in a cadaveric instability model of 10% glenoid bone loss.

METHODS

Eight cadaveric shoulders were tested using a custom testing system that allows for a 6-degree-of-freedom positioning of the glenohumeral joint. The rotator cuff muscles were loaded to simulate physiologic muscle conditions. Four conditions were tested: (1) intact, (2) Bankart lesion with 10% bone loss, (3) conjoint tendon transfer, and (4) open Bankart repair. Range of motion, glenohumeral kinematics, and anterior-inferior translation at 60° of external rotation with 20 N, 30 N, and 40 N were measured in the scapular and coronal planes. Glenohumeral joint translational stiffness was calculated as the linear fit of the translational force-displacement curve. Force to anterior-inferior dislocation was also measured in the coronal plane. Repeated measures analysis of variance with a Bonferroni correction was used for statistical analysis.

RESULTS

A Bankart lesion with 10% bone loss increased the range of motion in both the scapular (P = .001) and coronal planes (P = .001). The conjoint tendon transfer had a minimal effect on the range of motion (vs. intact P = .019, .002), but the Bankart repair decreased the range of motion to intact (P = .9, .4). There was a significant decrease in glenohumeral joint translational stiffness for the Bankart lesion compared with intact in the coronal plane (P = .021). The conjoint tendon transfer significantly increased stiffness in the scapular plane (P = .034), and the Bankart repair increased stiffness in the coronal plane (P = .037) compared with the Bankart lesion. The conjoint tendon transfer shifted the humeral head posteriorly at 60° and 90° of external rotation in the scapular plane. The Bankart repair shifted the head posteriorly in maximum external rotation in the coronal plane. There was no significant difference in force to dislocation between the Bankart repair (75.8 ± 6.6 N) and the conjoint tendon transfer (66.5 ± 4.4 N) (P = .151).

CONCLUSION

In the setting of subcritical bone loss, both the open Bankart repair and conjoint tendon transfer are biomechanically viable options for the treatment of anterior shoulder instability; further studies are needed to extrapolate these data to the clinical setting.

Female Patients Undergoing Latarjet Surgery Show Similar 2-Year Secondary Surgery Rates but Greater Risk of Emergency Department Visits Compared With a Matched Cohort of Male Patients

PURPOSE

To evaluate sex-based differences in 30-day postoperative emergency department (ED) visits, 90-day complication rates, and 2-year secondary surgery rates after the Latarjet procedure for the treatment of recurrent shoulder instability.

METHODS

A national administrative claims database was used to identify patients with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for shoulder subluxation or dislocation on the day of first-time stabilization with the Latarjet technique between 2015 and 2021. Male patients were matched 4:1 to female patients based on age, Elixhauser Comorbidity Index (ECI) score, and body mass index class. Rates of 30-day ED visits and 90-day complications were compared between cohorts, and risk factors for ED visits were identified by multivariate regression. The incidence of secondary surgery within 2 years was compared by Kaplan-Meier analysis.

RESULTS

Prior to matching, 1,059 male and 360 female patients met the inclusion and exclusion criteria. Subsequent 4:1 (male-to-female) matching controlling for age, ECI score, and body mass index yielded 694 male and 185 female patients who underwent the Latarjet procedure. The overall incidence of 30-day ED visits was 9.3%, with an incidence of 8.2% for male patients and 13.5% for female patients. On the basis of multivariate logistic regression, these 30-day ED visits were associated with female sex (odds ratio, 1.79; P = .029) and incrementally higher ECI scores; relative to an ECI score of 0, ECI scores of 1 to 2, 3 to 4, and 5 or greater were associated with odds ratios of 5.31 (P = .006), 8.12 (P < .001), and 12.84 (P < .001), respectively. Ninety-day complications occurred in 1.5% of the total cohort, and the incidence was not statistically different between sexes. Overall, 2-year secondary surgery rates were similar between male and female patients (5.1% and 6.7%, respectively; P = .4).

CONCLUSIONS

Female patients undergoing the Latarjet procedure for recurrent shoulder instability showed similar 90-day complication and 2-year secondary surgery rates to a matched cohort of male patients. Female sex, along with ECI score, however, was associated with a greater rate of 30-day ED visits.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Significant Increase in Early Reoperation After Latarjet-Bristow Procedure Versus Arthroscopic Bankart Repair for Anterior Shoulder Instability: A Propensity-Score Matched Analysis

PURPOSE

To compare the 30-day outcomes, including length of stay, short-term complications, hospital readmission, all-cause reoperation, and death after arthroscopic Bankart (AB) and Latarjet.

METHODS

Patients in the National Surgical Quality Improvement Program database who had undergone either AB or Latarjet-Bristow (LB) procedures for anterior shoulder instability from 2012 to 2018 were identified using Current Procedural Terminology codes. Nearest neighbor propensity score matching was used to address any potential demographic differences. The 30-day incidence of postoperative complications were compared, and univariate and multivariate logistic regressions were used to identify risk factors associated with the incidence of post-operative complications.

RESULTS

A total of 7,519 patients were identified, with 6,990 (93.0%) undergoing AB and 529 (7.0%) LB. After propensity score matching, the baseline demographics were not significantly different (P > .05). There was no significant difference in rate of total adverse events between the AB and LB cohorts (P = .06). There was a significant difference in the rate of return to the operating room between LB (1.9%) when compared to AB (0%) (P < .001). Of reoperations, 40% were due to need for revision stabilization (0.8% of all LB cases) and 40% were for irrigation and debridement. There was also a significant difference in operative time (AB = 87 minutes, LB = 131 minutes; P < .0001).

CONCLUSIONS

Overall 30-day complication rates were low for both groups, with similar rates among AB and LB patients. However, there was a statistically significant increased rate of short-term reoperation or revision stabilization in the LB cohort.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

What keeps a shoulder stable - Is there an ideal method for anterior stabilisation?

The gleno-humeral joint is by far the most mobile in the human body but also afflicted by dislocations, predominantly anterior. Surgical stabilisation is often successful but failures not uncommon. The following review describes potential causes of failure and highlights the need of adapting surgical methods to pathomorphology.

The clinical utility of immediate post-operative PACU plain film radiographs following uncomplicated open Latarjet procedure - An institutional series of consecutive patients

Background

Immediate post-operative plain film radiograph x-rays in PACU following open Latarjet procedure are often ordered as routine. However, such radiographs utilize institutional cost and time, whilst potentially exposing patients to often-unnecessary additional radiation. This study sought to evaluate whether routine immediate post-operative radiographs following uncomplicated open Latarjet procedures impacted clinical decision-making in our institution.

Methods

From 2017 to 2020, patients who underwent open Latarjet procedure by one of four fellowship-trained upper limb surgeons at a single institution were included in this study. Post-operative radiographs taken immediately in PACU were reviewed to determine if any reported radiographic findings impacted on clinical decision-making in the immediate post-operative setting. SPSS was used for descriptive statistics.

Results

A total of 337 patients underwent an X-ray in PACU immediate after uncomplicated open Latarjet procedure. Overall, 98.5% were male (n = 332), the mean patient age of included patients was 22.9 ± 4.2 years. No patient had an abnormal finding on their post-operative x-ray. Two patients returned to the operating room in the immediate post-operative period, both requiring washout and debridement due to haemtoma or superficial wound infection.

Conclusion

The findings of this study suggest that the use of post-operative plain films in PACU following open Latarjet procedure remains a costly use of resources, with little ultimate impact on clinical decision making in the short-term post-operatively.

Level of Evidence

IV - Institutional Case Series of Consecutive Patients.

Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs

Background

Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability.

Methods

Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure.

Results

The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures.

Conclusion

Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.

Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes

The shoulder, being the most mobile joint in the human body, is often susceptible to dislocations and subluxations more so than other joints. As such, shoulder instability constitutes a common complaint among patients worldwide, especially those who are young, participate in contact sports, and have increased innate flexibility in their joints. Management options in the setting of instability vary between conservative and surgical options that aim to mitigate symptoms and allow return of function. Surgical options can be arthroscopic and open, with a general shift among surgeons towards utilizing arthroscopic surgery in the past several decades. Nevertheless, open procedures still play a role in managing shoulder instability patients, especially those with significant bone loss, recurrent instability, coexisting shoulder pathologies, and high risk of failure with arthroscopic surgery. In these clinical settings, open procedures, like the Latarjet procedure, open Bankart repair, glenoid bone augmentation using iliac crest autograft or distal tibial allograft, and salvage options like glenohumeral arthrodesis and arthroplasty may show good clinical outcomes and low recurrence rates. Each of these open procedures possesses its own set of advantages and disadvantages and entails a specific set of indications based on published literature. It is important to cater treatment options to the individual patient in order to optimize outcomes and reduce the risk of complications. Future research on open shoulder stabilization procedures should focus on the long-term outcomes of recently utilized procedures, investigate different graft options for procedures involving bone augmentation, and conduct additional comparative analyses in order to establish concrete surgical management guidelines.

Shoulder arthroplasty in the setting of previous stabilization surgery: a systematic review of matched case control studies at minimum 2 years follow-up

Background

Anterior shoulder instability causes considerable patient morbidity and the volume of shoulder stabilization surgery being performed annually is rising. Despite stabilization surgery, instability arthropathy in the long-term may arise requiring consideration of shoulder arthroplasty. This study evaluated the outcomes of shoulder arthroplasty following previous stabilization surgery with their associated changes in bony anatomy or soft tissue structure.

Methods

A systematic review was performed as per Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies reporting outcomes of shoulder arthroplasty in the setting of previous stabilization surgery. Studies of >10 patients with a minimum of 24 months follow-up were included.

Results

Overall, 377 shoulder arthroplasties composed of 247 anatomical total shoulder arthroplasties (aTSAs), 102 reverse total shoulder arthroplasties (RTSAs), and 28 hemiarthroplasties (HAs) were reported across 14 included studies at mean age 55.4 years, with 203 compared to 451 control shoulders in 7 matched case-control studies. The mean interval from arthroplasty to stabilization procedure was 19.7 years, with 27.2% of patients having undergone multiple procedures and 39.5% bone transfer procedures. Improvements in patient outcomes were observed both for patients who had underwent aTSA or RTSA, with the American Shoulder and Elbow Surgeons score the most commonly used scoring system. Across matched studies comparing to control, large improvements in American Shoulder and Elbow Surgeons were seen for both aTSA and RTSA implants, 38.1-80.5 and 34.9-82.3, which compared to control groups 38.0-85.5 and 35.5-82.3, respectively. There were differences observed in complication profiles between aTSA and RTSA procedures, with lower revision rates in the short-term to medium-term for RTSA implants in present literature. A significantly higher rate of aTSA revision was observed compared to matched control patients undergoing aTSA for primary osteoarthritis without previous stabilization surgery, 9.4% (13/139) vs. 4.1% (11/269) (P = .044). Aseptic loosening posed a particular challenge in the aTSA group, with significantly higher rates of 5.0% (7/139 f = 54.6 months) compared to control 0.74% (2/269 f = 49.1 months, P = .0088). No significant difference in infection rate was observed between matched study and control groups, 1.5% vs. 2.2% (P = .76).

Conclusion

Shoulder arthroplasty may improve functional outcomes for patients experiencing instability arthropathy with a history of stabilization surgery. Careful consideration of potential complications is warranted both in surgical planning and patient counselling given the altered anatomy and biomechanics, with significantly higher revision and loosening rates observed following aTSA compared to control.

Open Latarjet with Metal-Free Cerclage Fixation

Despite multiple modifications, the Latarjet is still the most popular procedure for recurrent anterior shoulder instability with glenoid bone loss. Partial or subtotal resorption of the graft is common, potentially leading to hardware prominence and risk of anterior soft-tissue impingement. To minimize the technical difficulties and morbidity associated with metallic implants, a coracoid and conjoint tendon transfer with a mini-open approach using Cerclage tape suture is described, as an alternative for the Latarjet procedure typically performed with metal screws and plates.

Is sling immobilization necessary after open Latarjet surgery for anterior shoulder instability? A randomized control trial

BACKGROUND

There is a current lack of knowledge regarding optimal rehabilitation and duration of sling immobilization after an open Latarjet procedure. A shift towards immediate self-rehabilitation protocols in shoulder surgery is observed to avoid postoperative stiffness and fasten return to sport. Avoiding sling immobilization could further simplify rehabilitation and provide an even faster return to activities of daily living and enhance patient satisfaction.

METHODS

This study is a single-center, randomized control trial. Sixty-eight patients will be instructed with the same standardized immediate postoperative self-rehabilitation protocol. Patients will be allocated 1:1 between a sling immobilization group for the first three postoperative weeks and no sling group without postoperative immobilization. The primary endpoint will be functional outcome at 6 months postoperative evaluated by the disease-specific Rowe score. Secondary endpoints will include baseline, 1.5-, 6-, and 12-month single assessment numeric evaluation (SANE) of instability score and visual analog pain scale (VAS). At the 6-month time point, graft bony union and position will be assessed by computed tomography. Motion capture technology will evaluate the baseline and 6-month postoperative range of motion. Finally, time to return to work and sport during the first postoperative year, along with patient satisfaction at one postoperative year, will also be recorded.

DISCUSSION

This study will allow further insights into the optimal rehabilitation protocol after open Latarjet surgery and enhance patient care by helping identify rehabilitation and coracoid graft-related factors influencing functional outcomes, bony union, range of motion, and patient satisfaction.

TRIAL REGISTRATION

The protocol was approved by the ethical committee board (CCER 2019-02,469) in April 2020 and by ClinicalTrials.gov (Identifier: NCT04479397 ) in July 2020.

On the Rise: The Increasing Frequency of Pediatric Shoulder Stabilization Surgery in Children and Adolescents

The management of shoulder instability in children and adolescents continues to evolve. The purpose of this study was to evaluate the epidemiology of shoulder stabilization procedures in a large, nationally representative pediatric population. The Pediatric Health Information System (PHIS) database was queried for patients 18 years and younger undergoing surgical shoulder stabilization between 2008 and 2017. Patients undergoing arthroscopic surgery were compared with patients undergoing complex (open or bony augment stabilization) procedures. Annual trends were calculated using linear regression. A total of 3925 procedures were performed, of which 92.9% were arthroscopic Bankart repairs. There was a significant increase in overall pediatric shoulder stabilizations and arthroscopic repairs between 2008 and 2017. Complex procedures were performed most often in the Northeast, but the annual frequency did not increase nationally. [Orthopedics. 202X;XX(X):xx-xx.].

Risk for recurrent instability and reoperation following arthroscopic and open shoulder stabilization in a large cross-sectional population

Background

Recurrent shoulder instability is an orthopedic problem with potentially long-term functional ramifications. Although arthroscopic stabilization has become increasingly utilized over open stabilization, optimal surgical intervention to minimize recurrent instability remains controversial.

Methods

The PearlDiver Mariner database was queried for all cases of open and arthroscopic shoulder stabilization from 2010 to 2019. Utilization trends were aggregated after identifying cohorts of 107,210 and 13,217 patients who respectively underwent arthroscopic or open stabilization using Current Procedural Terminology codes. Subsets from those cohorts with laterality-specific International Classification of Diseases, Tenth Revision codes for shoulder instability were used to evaluate 2-year rates of recurrent instability (presence of shoulder dislocation or revision open or arthroscopic stabilization). Linear regression and chi-squared analysis were used to analyze utilization trends and to compare recurrent instability.

Results

Arthroscopic stabilization comprised 90% of all stabilization procedures with annual utilization continuing to increase into 2019. Latarjet utilization increased from 15% to 42% of all open stabilization procedures while open Bankart repair utilization decreased from 56% to 35%. The rate of recurrent instability was 10.2% after arthroscopic stabilization and 12.3% after open stabilization (P = .01). Rates of redislocation (4.0% vs. 2.6%, P < .01), conversion to shoulder arthroplasty (1.2% vs. 0.4%, P < .01), and revision open stabilization (6.8% vs. 2.3%, P < .01) after index open stabilization were significantly higher than after index arthroscopic stabilization. There was no difference in revision stabilization or dislocation rates between open procedures.

Conclusion

Despite increasing utilization of coracoid transfer, arthroscopic stabilization is still the dominant modality used for surgical treatment of shoulder instability and in our analysis, showed lower 2-year rates of dislocation, revision open stabilization, and conversion to shoulder arthroplasty.

No Differences in 90-Day Complications and Admissions After Latarjet Procedure for Primary Bone Loss Versus Latarjet Procedure for Failed Arthroscopic Instability Repair

Purpose

To investigate the variance in 90-day complication, emergency department (ED) visit, revision, and readmission rates between the Latarjet procedure (LP) performed as a primary procedure for the treatment of recurrent shoulder instability associated with critical levels of glenohumeral bone loss and the LP performed as a salvage surgical procedure after failed arthroscopic instability repair (FAIR).

Methods

Patients who underwent a primary LP from 2016-2021 in a single surgeon’s practice were identified and divided into 2 cohorts based on the indication for surgery: primary LP for critical bone loss (unipolar or bipolar) (LP-PBL) or LP as salvage surgery for FAIR (LP-FAIR). Patients without a minimum follow-up period of 90 days were excluded. Chart review was conducted to analyze the prevalence of complications, ED visits and/or admissions, and secondary procedures in the 90-day postoperative period. Radiographic images were reviewed to evaluate for graft and/or hardware failure. An unpaired t test and the Fisher exact test were used to compare the 2 groups regarding continuous and categorical data, respectively, and the significance level was set at P < .05.

Results

The final sample sizes consisted of 54 patients in the LP-PBL group and 23 patients in the LP-FAIR group. In the postoperative period, 4 complications were observed in the first 90 days. These included complex regional pain syndrome (n = 1) and superficial wound dehiscence (n = 1) in the LP-PBL cohort. Superficial suture abscess (n = 1) and audible crepitation (n = 1) were observed in the LP-FAIR cohort. There was 1 secondary intervention (arthroscopic debridement) in the LP-FAIR cohort. No statistically significant difference in complication rates, ED visits or admissions, or secondary procedures was found between the LP-PBL and LP-FAIR groups.

Conclusions

The results of this study indicate that the 90-day complication, ED visit, revision, and readmission rates after open LP are low irrespective of the extent of glenoid or bipolar bone loss and history of arthroscopic instability repair.

Level of Evidence

Level III, retrospective cohort study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trends in utilization and patient demographics for shoulder instability procedures from 2010 to 2019

BACKGROUND

Improved techniques and increased surgeon experience have optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there are limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographic characteristics (age and sex) from 2010 to 2019 for 4 shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR).

METHODS

We identified >87,000 patients using an all-payer claims database. The utilization rate was defined as the number of cases of a procedure divided by the total number of surgical cases for shoulder instability for any given year. Age was divided into 3 groups: <25 years, 25-35 years, and >35 years. Trends were reported in terms of the compounded annual growth rate (CAGR).

RESULTS

Although ABR was the most common shoulder instability procedure overall (91% utilization rate), the LP had the greatest increase in utilization from 2010 to 2019 (2.0% to 4.5%; CAGR, +9.8%). In comparison, the utilization of ABB procedures increased by 4.3% annually whereas that of OBR declined by 6.9% annually. The utilization of ABR showed minimal change. Notably, the LP was performed more frequently in younger patients over time. The percentage of patients aged < 25 years who underwent the LP increased from 30% to 41% from 2010 to 2019 (CAGR, +3.4%). There was a trend toward the performance of more LPs in men than in women (+1.2% vs. -3.5%, P < .05), although most cases (68%) were still performed in men.

CONCLUSION

ABR continues to account for most shoulder instability procedures. The LP had the greatest increase in the utilization rate from 2010 to 2019 and has now surpassed OBR in the utilization rate. ABB procedures are also being more frequently performed but only represent a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedures were male individuals and were aged < 25 years.

The Use of Multiple Imaging Studies Before Shoulder Stabilization Surgery Is Increasing

Purpose

To determine the incidence of preoperative shoulder imaging, explore the prevalence of obtaining multiple advanced imaging studies, and identify patient characteristics associated with specific imaging studies before anterior versus posterior shoulder stabilization surgery.

Methods

The PearlDiver database was queried for patients who underwent anterior or posterior shoulder stabilization surgery from 2010 to 2019. The incidence of imaging studies within a year of surgery was collected. Patient characteristics were compared between groups using one-way analysis of variance or χ² test.

Results

In total, 10,252 patients underwent anterior shoulder stabilization surgery, and 1,108 patients underwent posterior shoulder stabilization surgery. Imaging use before anterior and posterior shoulder stabilization surgery included plain radiographs (69%, 70%, respectively), magnetic resonance imaging (MRI; 43%, 33%), and computed tomography (CT; 22%, 22%). In total, 1,098 patients (11%) received MRI and CT before anterior stabilization surgery and 85 patients (8%) received MRI and CT before posterior stabilization surgery. Over time, the incidence of obtaining MRI and CT increased before anterior (z = 2.54, P = .011) and posterior (z = 2.36, P = .018) stabilization surgery.

Conclusions

This study highlights the increasing use of multiple imaging studies before shoulder stabilization surgery over recent years, including plain radiographs, MRI, and CT imaging. In total, 45% of anterior shoulder stabilization patients and 41% of posterior shoulder stabilization patients obtained more than 1 imaging study within a year of surgery, with a recent increase in patients obtaining both MR and CT scans preoperatively.

Statement of Clinical Relevance

The increasing use of multiple preoperative imaging studies observed in this study highlights an opportunity for new imaging technology to streamline and improve the preoperative workup.

No Difference in Outcomes After Arthroscopic Bankart Repair With Remplissage or Arthroscopic Latarjet Procedure for Anterior Shoulder Instability

Purpose

To evaluate the outcomes of arthroscopic Bankart repair with remplissage (ABRR) compared with the arthroscopic Latarjet (AL) procedure for anterior shoulder instability in patients with a labral tear and a concomitant engaging Hill-Sachs lesion.

Methods

A retrospective review of patients who underwent either ABRR or the AL procedure for a diagnosis of anterior shoulder instability with a concomitant engaging Hill-Sachs lesion between 2011 and 2019 was performed. Recurrent instability, the visual analog scale score, the Subjective Shoulder Value, the Western Ontario Shoulder Instability score, patient satisfaction, willingness to undergo surgery again, and return to work or sport were evaluated.

Results

Our study included 41 patients treated with ABRR and 26 treated with the AL procedure. At final follow-up, there was no difference between patients who underwent ABRR and those who underwent the AL procedure in the reported Western Ontario Shoulder Instability score (21.8% vs 28.2%, P = .33) or any of its components, the visual analog scale score (0.9 vs 1.4, P = .32), the Subjective Shoulder Value (78.4 vs 74.5, P = .6062), the rate of satisfaction (81.6% vs 85.6%, P = .54), or whether patients would undergo surgery again (81.6% vs 96.1%, P = .16). Overall, 5 patients in the ABRR group and 2 patients in the AL group had recurrent instability events (12.2% vs 7.8%, P = .70), with no significant difference in the rate of recurrent dislocation (12.2% vs 3.8%, P = .39).

Conclusions

In patients with anterior shoulder instability and a concomitant Hill-Sachs lesion, both ABRR and the AL procedure were shown to be reliable treatments, with a low rate of recurrent instability and excellent patient-reported outcomes in appropriately selected patients. However, our study could not determine whether there was critical glenoid bone loss in patients undergoing ABRR, and surgeons should still exercise caution in performing ABRR in patients with high-grade glenoid bone loss or in those with failed prior stabilizations.

Level of Evidence

Level III, retrospective cohort study.

Shoulder Latarjet Surgery Shows Wide Variation in Reported Indications, Techniques, Perioperative Treatment, and Definition of Outcomes, Complications, and Failure: A Systematic Review

PURPOSE

To systematically review and compare the surgical indications, technique, perioperative treatment, outcomes measures, and how recurrence of instability was reported and defined after coracoid transfer procedures.

METHODS

A systematic review of the literature examining open coracoid transfer outcomes was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the Cochrane registry, MEDLINE, and EMBASE databases from 2010 to 2020. Inclusion criteria included open coracoid transfer techniques, including the Bristow or Latarjet technique, full text availability, human studies, and English language.

RESULTS

A screen of 1,096 coracoid transfer studies yielded 72 studies, which met inclusion criteria with a total of 4,312 shoulders. One study was a randomized controlled trial, but the majority of them were retrospective. Of those, 65 studies reported on postoperative outcome scores, complication rates, revision rate, and recurrence rates. Forty-three reported on range of motion results. Thirty studies reported on primary coracoid transfer only, 7 on revision only, and 30 on both primary and revision, with 5 not reporting. Average follow-up was 26.9 months (range: 1-316.8 months). Indications for coracoid transfer, technique, perioperative care, complications, and how failure was reported varied greatly among studies.

CONCLUSIONS

Latarjet and coracoid transfer surgery varies greatly in its indications, technique, and postoperative care. Further, there is great variation in reporting of complications, as well as recurrence and failure and how it is defined. Although coracoid transfer is a successful treatment with a long history, greater consistency regarding these factors is essential for appropriate patient education and surgeon knowledge.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Intra-articular Versus Extra-articular Coracoid Grafts: A Systematic Review of Capsular Repair Techniques During the Latarjet Procedure

Background:

Various methods exist for managing the joint capsule during the Latarjet procedure. Repairing the capsule to the native glenoid rim results in an extra-articular bone block, while repairing it to the remnant coracoacromial ligament stump of the coracoid graft renders it intra-articular. The technique that optimizes patient outcomes is not well defined.

Purpose:

To compare the outcomes of intra-articular and extra-articular bone block techniques for the Latarjet procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Using PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines, we queried the PubMed, EMBASE, and the Cochrane Library for all studies reporting outcomes of the Latarjet procedure with a clearly defined method of capsular repair that rendered the coracoid graft intra-articular or extra-articular. The included levels of evidence and degree of heterogeneity in this study precluded meta-analysis. Outcomes of interest included preoperative variables, surgical technique, rehabilitation protocols, functional outcome assessments, recurrent instability, range of motion, and radiographic findings.

Results:

A total of 16 studies including 816 patients were included. A total of 8 studies employed an intra-articular bone block in 338 patients, while the other 8 employed an extra-articular technique in 478 patients. There was variation among studies in reference to baseline patient characteristics, surgical techniques, rehabilitation, methods for assessing patient outcomes, and follow-up times. Rates of postoperative instability were reported in 8 intra-articular (0%, 0%, 2.1%, 2.7%, 3.2%, 5%, 5.4%, 5.9%) and 7 extra-articular (0%, 0%, 1.2%, 2%, 3.9%, 6.3%, 14%) bone block studies. Postoperative osteoarthritis or progression of preoperative osteoarthritis was reported in 5 intra-articular bone block studies (0%, 5.6%, 23.5%, 23.5%, 25%) and 4 extra-articular bone block studies (0%, 1.9%, 5.2%, 8.6%).

Conclusion:

Varying capsular repair methods appeared to provide similar outcomes regarding stability. There was an apparent trend toward higher rates of post-traumatic arthritis among studies in which an intra-articular bone block technique was employed; however, it is possible that this was influenced by substantially different follow-up times between groups and other various sources of heterogeneity among the included studies. There were no studies in the literature directly comparing intra-articular and extra-articular bone block techniques. Large-scale randomized controlled trials or comparative studies are needed to draw stronger conclusions comparing the 2 techniques.

A biomechanical comparison of steel screws versus PLLA and magnesium screws for the Latarjet procedure

INTRODUCTION

The fixation of the coracoid process onto the glenoid is an important step of the Latarjet procedure, and implant-associated complications are a relevant and severe problem. This study compares the fixation strength and failure mode of two biodegradable materials with stainless-steel screws.

METHODS

24 Fresh-frozen cadaveric scapulae were divided into three groups of equal size and received a coracoid transfer. Cadavers were matched according to their bone mineral density (BMD). In group 1, small-fragment screws made of stainless steel were used. In the second group, magnesium screws were used, and in the third group, screws consisted of polylactic acid (PLLA). A continuously increasing sinusoidal cyclic compression force was applied until failure occurred, which was defined as graft displacement relative to its initial position of more than 5 mm.

RESULTS

At 5-mm displacement, the axial force values showed a mean of 374 ± 92 N (range 219-479 N) in group 1 (steel). The force values in group 2 (magnesium) had a mean of 299 ± 57 N (range 190-357 N). In group 3 (PLLA), failure occurred at 231 ± 83 N (range 109-355 N). The difference between group 1 (steel) and group 2 (magnesium) was not statistically significant (P = 0.212), while the difference between group 1 (steel) and group 3 (PLLA) was significant (P = 0.005).

CONCLUSION

Stainless-Steel screws showed the highest stability. However, all three screw types showed axial force values of more than 200 N. Stainless steel screws and PLLA screws showed screw cut-out as the most common failure mode, while magnesium screws showed screw breakage in the majority of cases.

EVIDENCE

Controlled laboratory study.

Early Complication Rates Following Total Shoulder Arthroplasty for Instability Arthropathy With a Prior Coracoid Transfer Procedure

The purpose of this study was to report early complications for anatomic total shoulder arthroplasty (aTSA) performed for instability arthropathy after a prior coracoid transfer procedure and compare them with those of a control group of patients following aTSA for primary osteoarthritis. A retrospective review was performed of 14 patients after aTSA with a prior coracoid transfer procedure. A control group of 42 patients with an aTSA for primary osteoarthritis were matched 3:1 according to age, sex, body mass index, comorbidities, and dominant shoulder. Chart reviews identified any complications within 1 year, in addition to blood loss and operative time in both groups. Preoperative computed tomography scans were used to determine Walch glenoid classification and Goutallier classification of the subscapularis. The mean operative time was not significantly different between the coracoid transfer cohort and the control group, and the mean estimated blood loss was only 6.9 mL greater in the coracoid transfer group. The coracoid transfer group had 2 (14.3%) patients with complications, with 1 early revision for an acute deep infection. The control group had 4 (9.5%) complications in 3 (7.1%) patients, with no early revisions. There was no statistical difference in complications between the groups (P=.618). Anatomic TSA for instability arthropathy after coracoid transfer had similar operative time, blood loss, and 1-year complication rates as those of the control group. These results provide some evidence to support the continued use of aTSA in select patients with instability arthropathy after prior coracoid transfer procedure. [Orthopedics. 2021;44(4):e482-e486.].

Anterior and posterior glenoid bone augmentation options for shoulder instability: state of the art

Bony lesions are highly prevalent in anterior shoulder instability and can be a significant cause of failure of stabilisation procedures if they are not adequately addressed. The glenoid track concept describes the dynamic interaction between the humeral head and glenoid defects in anterior shoulder instability. It has been beneficial for understanding the role played by bone defects in this entity. As a consequence, the popularity of glenoid augmentation procedures aimed to treat anterior glenoid bone defects; reconstructing the anatomy of the glenohumeral joint has risen sharply in the last decade. Although bone defects are less common in posterior instability, posterior bone block procedures can be indicated to treat not only posterior bony lesions, attritional posterior glenoid erosion or dysplasia but also normal or retroverted glenoids to provide an extended glenoid surface to increase the glenohumeral stability. The purpose of this review was to analyse the rationale, current indications and results of surgical techniques aimed to augment the glenoid surface in patients diagnosed of either anterior or posterior instability by assessing a thorough review of modern literature. Classical techniques such as Latarjet or free bone block procedures have proven to be effective in augmenting the glenoid surface and consequently achieving adequate shoulder stability with good clinical outcomes and early return to athletic activity. Innovations in surgical techniques have permitted to perform these procedures arthroscopically. Arthroscopy provides the theoretical advantages of lower morbidity and faster recovery, as well as the identification and treatment of concomitant pathologies.

Clinical Outcomes of Shoulder Stabilization in Females With Glenoid Bone Loss

Background

Nearly all studies describing shoulder stabilization focus on male patients. Little is known regarding the clinical outcomes of female patients undergoing shoulder stabilization, and even less is understood about females with glenoid bone loss.

Purpose

To assess the clinical outcomes of female patients with recurrent anterior shoulder instability treated with the Latarjet procedure.

Study Design

Case series; Level of evidence, 4.

Methods

All cases of female patients who had recurrent anterior shoulder instability with ≥15% anterior glenoid bone loss and underwent the Latarjet procedure were analyzed. Patients were evaluated after a minimum 2-year postoperative period with scores of the American Shoulder and Elbow Surgeons form, Simple Shoulder Test, and pain visual analog scale.

Results

Of the 22 patients who met our criteria, 5 (22.7%) were lost to follow-up, leaving 17 (77.2%) available for follow-up with a mean ± SD age of 31.7 ± 12.9 years. Among these patients, 16 (94.1%) underwent 1.6 ± 0.73 ipsilateral shoulder operations (range, 1-3) before undergoing the Latarjet procedure. Preoperative indications for surgery included recurrent instability with bone loss in all cases. After a mean follow-up of 40.2 ± 22.9 months, patients experienced significant score improvements in the American Shoulder and Elbow Surgeons form, Simple Shoulder Test, and pain visual analog scale (P < .05 for all). There were 2 reoperations (11.8%). There were no cases of neurovascular injuries or other complications.

Conclusion

Female patients with recurrent shoulder instability with glenoid bone loss can be successfully treated with the Latarjet procedure, with outcomes similar to those of male patients in the previously published literature. This information can be used to counsel female patients with recurrent instability with significant anterior glenoid bone loss.

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.

Surgical treatment for recurrent shoulder instability: factors influencing surgeon decision making

BACKGROUND

The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability.

METHODS

A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures.

RESULTS

Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48% <10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure.

CONCLUSION

The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

Opioid Use Is Reduced in Patients Treated with NSAIDs After Arthroscopic Bankart Repair: A Randomized Controlled Study

Purpose

To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids after arthroscopic shoulder capsulolabral (Bankart) repair for recurrent anterior shoulder instability.

Methods

This was a single-center, prospective, randomized controlled study. Patients aged 18 to 65 years indicated for arthroscopic shoulder capsulolabral repair for recurrent anterior shoulder instability were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) 30 ibuprofen (600 mg every 6 to 8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg every 6 hours as needed for breakthrough pain) or (2) 30 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 24, 48, and 96 hours and 1 week after surgery, which included questions about analgesic medication usage, visual analog scale (VAS) pain score, incidence of adverse events, and patient satisfaction.

Results

Between December 2017 and May 2019, 80 patients (mean age 31.3 ± 10.4 years) were enrolled. Overall there were no significant differences in VAS pain score or patient satisfaction between the 2 groups. Patients in the opioid-only group had a significantly higher mean opioid consumption on postoperative days (PODs) 2 to 4 (5.5 versus 2.9, P = .05) and after 1 week (11.7 versus 7.9 tablets, P = .05) compared with patients in the NSAID group. Of patients in the NSAID group, 17.5% experienced adverse effects, compared with 35% in the opioid-only group.

Conclusions

Use of oral NSAIDs with limited breakthrough opioids results in significantly less opioid use after arthroscopic Bankart repair in the first postoperative week compared with opioids only. Both groups used limited amounts of opioids to control postoperative pain. There were no differences in pain levels at any time point postoperatively or satisfaction between patient groups.

Level of Evidence

II, nonblinded randomized control trial.

Remplissage for anterior shoulder instability with Hill-Sachs lesions: a systematic review and meta-analysis

BACKGROUND

The purpose of this study was to perform a systematic review and meta-analysis of the current evidence in the literature to determine how arthroscopic Bankart repair (ABR) and remplissage compare with ABR alone and the open Latarjet procedure for anterior shoulder instability in patients with concomitant Hill-Sachs lesions.

METHODS

A literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Studies comparing ABR and remplissage vs. ABR alone or the Latarjet procedure for anterior shoulder instability in patients with Hill-Sachs lesions were included. Clinical outcomes were compared, with all statistical analysis performed using Review Manager (version 5.3). P < .05 was considered statistically significant.

RESULTS

Twelve clinical trials were included. There was a significant difference between ABR plus remplissage and ABR alone in total recurrence rate (3.2% vs. 16.8%, P < .05) but not the rate of revision due to recurrence (1.7% vs. 8.5%, P = .06). There was no significant difference between the Latarjet procedure and ABR plus remplissage in total recurrence rate (7.0% vs. 9.8%, P = .39), total revision rate (3.7% vs. 5.7%, P = .41), and rate of revision due to recurrence (1.6% vs. 2.1%, P = .79). There was a significantly lower rate of complications with ABR and remplissage compared with the Latarjet procedure (0.5% vs. 8.6%, P = .003).

CONCLUSION

In patients with Hill-Sachs lesions and subcritical glenoid bone loss, ABR with remplissage resulted in lower rates of recurrent instability compared with ABR alone while resulting in similar recurrence rates, as well as similar patient-reported outcomes, with lower morbidity and fewer complications, compared with the Latarjet procedure.

LEVEL OF EVIDENCE

Level III; Systematic Review.

Progression and projection for shoulder surgery in France, 2012-2070: Epidemiologic study with trend and projection analysis

INTRODUCTION

Shoulder surgery has been rapidly expanding over the past 20 years and now makes up a large share of orthopedic surgery practice. Data on how this activity has changed is not available in France due to a lack of registries. The study objectives were to: (1) quantify the number of shoulder surgeries in France, (2) predict how this activity will change over the next 50 years based on extreme scenarios.

METHODS

This study involved an analysis of shoulder surgery data taken from the French hospital discharge database (PMSI). Two mathematical scenarios were applied to define the change over time: the first only considered the evolution in the population and changes in the age brackets over time; the second extrapolated the trends observed over the past few years (2012 to 2018).

RESULTS

In 2018, there were 234,612 procedures coded as primary shoulder surgery procedures in France. This activity increased 24.5% between 2012 and 2018 and is projected to increase 18% to 161% from now to 2050, depending on the scenario (p<0.0001). Rotator cuff surgery procedures were done 173,799 times - of which 61,055 were tendon repair - representing 74% of all shoulder procedures. The scenarios point to an increase of 13.6% to more than 300% (p<0.0001). Primary shoulder arthroplasty corresponded to 17,043 procedures in 2018 (7.3% of all procedures), with a 47% increase between 2012 and 2018. Between 2018 and 2050, the number of total shoulder arthroplasty procedures is expected to increase 31% to 322% (p<0.0001). The total number of revision arthroplasty procedures was 1508, increasing by 39% from 2012 to 2018. There were 14,229 procedures done for anterior or posterior instability in 2018 (6% of total). Bone block procedures made up 53% of these cases. This increased 17% between 2012 and 2018, with a projected increase of 5% to 82% up to 2050 (p<0.01).

DISCUSSION

Shoulder surgery is the third largest activity in the orthopedic realm after hip and knee surgery, although it has seen the largest increases in recent years. This growth in shoulder procedures should continue over the next decades.

LEVEL OF EVIDENCE

IV, descriptive epidemiology study.

Surgical Stabilization of Shoulder Instability in Patients With or Without a History of Seizure: A Comparative Analysis

PURPOSE

To compare patients from a large multicenter cohort with a history of seizure and those without a history of seizure regarding preoperative and intraoperative findings and surgical procedures performed.

METHODS

Patients undergoing shoulder stabilization from 2011 to 2018 at 11 orthopaedic centers were prospectively enrolled. Those with a history of seizure were identified and compared with non-seizure controls. Preoperative demographic, history, physical examination, and imaging findings were collected. Intraoperative findings and surgical procedures performed were recorded. The Mann-Whitney test, χ² test, and logistic regression analysis were used to examine differences between the groups and define independent risk factors. Owing to the number of statistical tests performed, the false discovery method was used to determine adjusted P values to achieve α < .05.

RESULTS

During enrollment, 25 of 1,298 shoulder stabilization patients (1.9%) had a history of seizure. The sex ratio and age were similar between groups, as was posterior instability incidence (23.2% in control group vs 28.0% in seizure group). Seizure patients more frequently had more than 5 dislocations in the year preceding surgery (P = .016) and had increased preoperative radiographic evidence of bone loss (P < .001). Intraoperatively, seizure patients had a higher prevalence of reverse Hill-Sachs lesions (P < .001) and large (>30% of glenoid fossa) bony Bankart lesions (P < .001). Arthroscopic Bankart repair was the most common procedure in both groups. However, open procedures were performed in 15.6% of controls and 40.0% of seizure patients (P = .001). These procedures were most commonly bony procedures.

CONCLUSIONS

Seizure patients had more prior dislocations, had more preoperative bone loss, and underwent more open stabilization procedures than controls because of bone loss. Studies examining recurrence after stabilization will help establish appropriate management practices in this population.

LEVEL OF EVIDENCE

Level III, retrospective review of prospectively collected cohort.

Revision guided suture-button bone block stabilization of the shoulder in the presence of significant retained glenoid metalwork

Aim

Positioning and fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, can be challenging. We present the results of a series of patients who underwent a revision bone block procedure secured with double suture buttons using a drill guide system, the position of which was calculated from a preoperative computed tomography (CT) scan.

Materials and methods

We undertook a revision bone block stabilization of the shoulder, using a guided double suture-button fixation, in 10 patients with significant retained glenoid metalwork from previous procedures. A preoperative CT scan was used to determine a position for the guide to allow a safe drill trajectory that would avoid any retained metalwork. A coracoid transfer was undertaken in 4 patients and an Eden-Hybinette in 6. Patients were assessed preoperatively and at final follow-up clinically and using the Oxford Shoulder Instability Score and the Subjective Shoulder Value score. Bone block position and healing was assessed by a CT scan at 6 months. The median follow-up was 36 months (range, 24-47 months).

Results

There were 3 female and 7 male patients with a median age of 24.5 years (17-49 years). At final follow-up, the mean Oxford Shoulder Instability Score had decreased from 25.9 (range, 21-35) to 5.8 (range, 3-14) (P < .005). The mean Subjective Shoulder Value score had risen from 87.1 (range, 10-60) to 80 (range, 60-90) (P < .05). All of the patients considered their shoulder to be stable apart from 1 patient. There had been no redislocations. The bone block positioned in the glenoid lower quadrant had healed for all of the patients on CT at 6 months.

Conclusion

Guided suture-button fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, provides a satisfactory outcome in terms of shoulder stability, graft position, and healing.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Arthroscopic Latarjet for Shoulder Instability

Arthroscopic Latarjet is a relatively new, but viable option for the treatment of anterior shoulder instability. Arthroscopic Latarjet has the advantage of faster recovery, reduced stiffness, identification of additional shoulder pathology, and improved cosmesis when compared with open Latarjet. By the majority of clinical and radiographic parameters, arthroscopic Latarjet produces equivalent outcomes compared with open Latarjet. A relatively substantial learning curve for arthroscopic Latarjet exists at about 25 cases; however, multiple studies have demonstrated comparable outcomes and surgical time after the learning curve.

Opioid Use After Common Sports Medicine Procedures: A Systematic Review

CONTEXT

The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America.

OBJECTIVE

To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures.

DATA SOURCES

A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018.

STUDY SELECTION

Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies.

RESULTS

A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill.

CONCLUSION

Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.

Are Patients Who Undergo the Latarjet Procedure Ready to Return to Play at 6 Months? A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group Cohort Study

BACKGROUND

The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss.

PURPOSE

(1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports.

RESULTS

Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) (P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02).

CONCLUSION

A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.

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

Background:

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

Purpose:

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

Study Design:

Case-control study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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

Arthroscopic soft tissue reconstruction in anterior shoulder instability

Anterior glenohumeral instability remains a difficult problem in the athletic and working patient populations. Treatment strategies are variable and range from nonoperative approaches incorporating immobilization and rehabilitation to surgical management. Surgical decision-making can be challenging, especially with a high-level patient who wishes to return to high-demand activities. Operative options range from open soft tissue stabilization to arthroscopic soft tissue stabilization, with both open and arthroscopic options for bony reconstruction in the setting of clinically significant anterior glenoid bone loss. In all cases, understanding appropriate indications and utilizing sound surgical techniques are critical for achieving a successful result. For the majority of patients with anterior shoulder instability, arthroscopic soft tissue reconstruction with suture anchors is a successful, minimally invasive approach that results in a stable shoulder with excellent outcomes and low complication rates.

Traumatic Instability: Treatment Options and Considerations for Recurrent Posttraumatic Instability

Recurrent traumatic glenohumeral instability is a complex problem with multiple variables to consider, but patient demographics, activities, as well as clinical and radiographic findings provide significant information to help choose the best treatment option. Although nonoperative treatment is a viable option for primary glenohumeral instability and in-season instability, recurrent instability exhibits anatomic factors which render nonsurgical treatment limited in scope. A proper patient history, clinical examination, and standard and advanced imaging are necessary in the assessment of patients with recurrent traumatic instability. Age, activity, hypermobility, tissue quality, glenoid and humeral head bone stock, and any prior surgical treatment are factors that must be considered for surgical planning. Open and arthroscopic Bankart repairs are good surgical options when bone loss is not an issue but increasing glenoid or humeral osseous deficiency in this setting frequently warrants additional procedures which address bony insufficiency. Controversy remains concerning the threshold value for glenoid bony deficiency and combined, bipolar defects, but this critical number may be less than previously suspected. Despite this controversy, successful surgical treatment of recurrent glenohumeral instability is possible when properly assessed and the correct surgery applied.