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Zink S, Pfeiffenberger T, Müller A, Krisam R, Unglaub F, Pötzl W. The arthroscopic Bankart operation: a 10-year follow-up study. Arch Orthop Trauma Surg 2022; 142:3367-3377. [PMID: 34999993 DOI: 10.1007/s00402-021-04282-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/27/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Traumatic shoulder instability most frequently occurs in young people often during sports events. Currently, the arthroscopic Bankart repair is the therapy of choice in the absence of extensive glenoid bone loss and has proved to be a safe and effective procedure. Nevertheless, we see recurrence of instability-especially if new trauma happens-and further data are needed to guide the right decision-making for these often young patients. The purpose of this study was to determine the long-term outcome 10 years after arthroscopic Bankart operation in terms of satisfaction of the patient, functional result, complications, recurrent instability, and development of osteoarthritis, and to look after possible risk factors for recurrence of instability and statistical proof of these. MATERIALS AND METHODS Thirty-nine out of 49 patients underwent physical examination of both shoulders. We could perform a postoperative shoulder a-p X-ray in 28 patients. According to Samilson, [24] the extent of osteoarthritis was measured. The Constant score and the postoperative ROWE score were determined for both shoulders as well as the WOSI Score. In 25 cases, we calculated the ISIS Score. RESULTS We could reach out to 89.6% of patients and 79.6% could be physically examined. The vast majority of 95.5% are either very satisfied or satisfied with the result at the time we ended the follow-up. The mean Constant score of 95.5 reflects this result. In contrast to this, we found at the same time in 15.3% ongoing clinical signs of instability of the concerning shoulder, even though 9.1% had to be re-operated for recurrent instability in between the follow-up timeline and we found in the X-rays (57.1% of all patients) in 35.7% at least moderate and in 10.7% severe signs of osteoarthritis. The Constant score but not the ROWE score differed significantly in patients with no or mild compared to those with moderate-to-severe osteoarthritis. CONCLUSIONS The arthroscopic Bankart stabilization procedure showed after 10 years to be a very safe operation and to be able to produce a satisfying and functional very good long-term result-reflected by the Constant score. We assume that the extent of osteoarthritis seems to be the determining factor of the very good functional result, even though ongoing instability was present in 15.3% of the patients.
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Affiliation(s)
- S Zink
- Department of Shoulder and Ellbow Surgery, Vulpiusklinik, Vulpiusstrasse 29, 74906, Bad Rappenau, Germany.
| | - T Pfeiffenberger
- Department of Shoulder and Ellbow Surgery, Vulpiusklinik, Vulpiusstrasse 29, 74906, Bad Rappenau, Germany
| | - A Müller
- Department of Shoulder and Ellbow Surgery, Vulpiusklinik, Vulpiusstrasse 29, 74906, Bad Rappenau, Germany
| | - R Krisam
- Institute of Biometry, University of Heidelberg, Heidelberg, Germany
| | - F Unglaub
- Department of Hand Surgery, Vulpiusklinik, Bad Rappenau, Germany
- Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - W Pötzl
- Department of Shoulder and Ellbow Surgery, Vulpiusklinik, Vulpiusstrasse 29, 74906, Bad Rappenau, Germany
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Etzel CM, Bokshan SL, Forster TA, Owens BD. A quality assessment of YouTube content on shoulder instability. PHYSICIAN SPORTSMED 2022; 50:289-294. [PMID: 34121601 DOI: 10.1080/00913847.2021.1942286] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The Internet is a widely used resource for patients seeking health information, yet little editing or regulations are imposed on posted material. We sought to assess the quality and accuracy of information presented on shoulder instability on the online video platform YouTube. We hypothesize that YouTube videos concerning shoulder instability will be of little quality, accuracy, and reliability. METHODS The first 50 YouTube videos resulting from the keyword query 'shoulder instability' were analyzed. The Journal of American Medical Association (JAMA) benchmark criteria (score range, 0-4) was used to assess video accuracy and reliability, and the Global Quality Score (GQS; score range, 0-5) was used to assess the quality of the video's educational content along with a generated Shoulder-Specific Score (SSS). RESULTS The 50 videos observed collectively had 5,007,486 views, with the mean number of views being 100,149.72 ± 227,218.04. Of all videos observed, 32% were from a medical source and 56% had content relating to pathology information. The mean JAMA score was 2.84 ± 0.74, with the highest scores coming from academic sources. The mean GQS and SSS scores were 2.68 ± 0.84 and 5.30 ± 3.78. The mean GQS score was highest in videos from medical sources (3.3 ± 0.8) and videos about surgical technique/approach (3.2 ± 1.1). Advertisements were negative predictors of the JAMA score (β = -0.324, P = 0.014), and academic (β = 0.322, P = 0.015) and physician sources (β = 0.356, P = 0.008) were positive predictors. CONCLUSION YouTube videos on shoulder instability are of low quality and accuracy and are not reliable. Care providers should be aware of the overall low quality of information available on YouTube regarding shoulder instability.
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Affiliation(s)
| | - Steven L Bokshan
- Department of Orthopaedics, Brown University, Providence, RI, USA
| | - Timothy A Forster
- Health and Human Biology in Biology Department, Brown University, Providence, RI, USA
| | - Brett D Owens
- Department of Orthopaedics, Brown University, Providence, RI, USA
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3
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Cruz CA, Sy J, Miles R, Bottoni CR, Min KS. Surgical treatment of anterior shoulder instability with glenoid bone loss with the Latarjet procedure in active-duty military service members. J Shoulder Elbow Surg 2022; 31:629-633. [PMID: 34537338 DOI: 10.1016/j.jse.2021.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The arthroscopic Bankart repair in the setting of glenoid bone loss has high rates of failure. In patients with anterior glenoid bone loss, the Latarjet provides glenohumeral stability through restoration of the glenoid bone, the conjoint tendon acting as a sling on the subscapularis, and anterior capsulolabral repair. Active-duty military personnel are at high risk for glenohumeral instability and have been equated to the contact athlete; most are young, male, and engage in contact sports. The purpose of this study is to assess the return to full-duty rates in active-duty military personnel following the Latarjet for anterior glenohumeral instability with glenoid bone loss. METHODS A retrospective review of all glenohumeral instability procedures were reviewed at a tertiary training hospital from June 2014 to June 2019. The patient population consisted of active-duty military personnel with glenoid bone loss and anterior glenohumeral instability, who were treated with a Latarjet. The primary outcome was return to full-duty status. RESULTS There were 50 patients identified for the study. Four patients were lost to follow-up, leaving 46 of 50 patients (92.0%) eligible for this study. The average age at the time of the index procedure was 23.1 years. The average percentage bone loss was 18.4%. Forty-one patients (89.1%) were able to return to full-duty status. Four patients (8.7%) sustained a recurrent dislocation following the Latarjet; all 4 dislocations occurred during a combat deployment. Four patients (8.7%) reported episodes of subluxation without dislocation. Forty-one patients (89.1%) reported that their shoulders felt stable, and we found an average return to full duty at 5.3 months CONCLUSION: In our active-duty military cohort, we found an 8.7% rate of recurrent instability after a Latarjet procedure, and 41 patients (89.1%) were able to return to full-duty status. In conclusion, the Latarjet procedure in the active-duty military population with anterior glenoid bone loss resulted in a high rate of return to duty, excellent functional outcomes, low rate of recurrent instability, and a low overall complication rate.
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Affiliation(s)
- Christian A Cruz
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, USA
| | - Joshua Sy
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, USA
| | - Rebecca Miles
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, USA
| | - Craig R Bottoni
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, USA
| | - Kyong S Min
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, USA.
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Novakofski KD, Melugin HP, Leland DP, Bernard CD, Krych AJ, Camp CL. Nonoperative management of anterior shoulder instability can result in high rates of recurrent instability and pain at long-term follow-up. J Shoulder Elbow Surg 2022; 31:352-358. [PMID: 34454036 DOI: 10.1016/j.jse.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Data on the long-term outcomes of nonoperative treatment of anterior shoulder instability are lacking, particularly for the US population. The purpose was to (1) describe the characteristics of patients with anterior shoulder instability treated nonoperatively, (2) assess the long-term outcomes of nonoperative management in a US population, and (3) identify risk factors for poor outcomes following nonoperative management. METHODS A geographic cohort of >500,000 subjects was used to identify patients treated nonoperatively for anterior shoulder instability. Only patients aged <40 years at the time of initial instability with minimum 10-year follow-up were included. Medical records were reviewed to obtain demographic characteristics, physical examination findings, clinical history data, imaging results, treatment details, and clinical and/or radiographic progression. Recurrent pain, recurrent instability, and the development of symptomatic osteoarthritis (OA) were the primary outcomes evaluated. RESULTS The study included 254 patients (73% male) with a median age of 19 years (range, 16-26 years) at the time of initial instability. At median 17-year follow-up, 37.5% experienced recurrent instability, 58.4% had recurrent pain, and 12.2% had symptomatic OA development. Factors associated with recurrent pain at final follow-up were multiple instability events prior to presentation (hazard ratio [HR], 2.43; P < .01) and increased pain at the initial visit (HRs of 0.79 for mild, 1.74 for moderate, and 1.39 for severe; P < .01); patients with multiple instability events prior to presentation also had an increased risk of recurrence (P < .01). Factors increasing the risk of the development of symptomatic OA included increased pain at the initial visit (P = .05), seizure disorder (HR, 27.01; P < .01), and smoking (HR, 5.15; P < .01). CONCLUSIONS At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability. Overall, 37.5% of patients experienced recurrent shoulder instability, 58.4% had recurrent shoulder pain, and 12.2% had symptomatic OA development. Risk factors associated with adverse clinical outcomes included increased pain at the initial visit, recurrent instability prior to presentation, seizure disorder, and smoking.
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Affiliation(s)
- Kira D Novakofski
- Department of Family Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Heath P Melugin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Devin P Leland
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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5
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Donaldson O, Jones A. Shoulder Disorders. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1007/978-3-030-78529-1_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kelley TD, Clegg S, Rodenhouse P, Hinz J, Busconi BD. Functional Rehabilitation and Return to Play After Arthroscopic Surgical Stabilization for Anterior Shoulder Instability. Sports Health 2021; 14:733-739. [PMID: 34918564 DOI: 10.1177/19417381211062852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND There exists limited objective functional return-to-play criteria after surgical stabilization for anterior shoulder instability in the competitive athlete. HYPOTHESIS The proposed functional rehabilitation program and psychological evaluation after arthroscopic Bankart repair will help athletes return to sport with a decreased redislocation rate on return. STUDY DESIGN Case series. LEVEL OF EVIDENCE Level 4. METHODS Participants were contact or overhead athletes at the high school or collegiate level. Each underwent arthroscopic Bankart repair after a single dislocation event, with less than 10% glenoid bone loss. Western Ontario Shoulder Instability Index (WOSI) scores, Single Assessment Numeric Evaluation (SANE) scores, and American Shoulder and Elbow Surgeons (ASES) scores were evaluated pre- and postoperatively. Athletes were only allowed to return to competition after completing the proposed functional and psychological rehabilitation protocol. RESULTS A total of 62 participants were enrolled (52 male, 10 female; average age, 18.7 years (range 16-24 years); mean Instability Severity Index Score, 5.63 ± 0.55). All returned to sport for 1 full season and completed a minimum of 2 years of follow-up. The average time to pass functional testing was 6.2 ± 0.7 months, psychological testing was 5.2 ± 0.5 months, and return to sport was 6.5 ± 0.7 months. SANE scores improved from 44.3 to 90.0, ASES from 45.5 to 89.3, and WOSI from 1578.0 to 178.9 (all P < 0.001). Redislocation rate was 6.5% (4 of 62). CONCLUSION The proposed functional rehabilitation and psychological assessment protocol is safe and effective in returning athletes to sport after arthroscopic surgical intervention for anterior shoulder instability. This demonstrated a low redislocation rate after 2-year follow-up. CLINICAL RELEVANCE Most return-to-play protocols after arthroscopic Bankart repair are centered on recovery time alone, with limited focus on functional rehabilitation, psychological assessment, and return-to-play testing parameters. To our knowledge, this is the first study to propose a dedicated rehabilitation program incorporating functional testing, psychological readiness, and return-to-play criteria for competitive athletes recovering from arthroscopic shoulder stabilization.
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Affiliation(s)
- Timothy D Kelley
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Stephanie Clegg
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Paul Rodenhouse
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Jon Hinz
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Brian D Busconi
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
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7
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Lo EY, Montemaggi P, Majekodunmi T, Lund J, Krishnan SG. Comprehensive Modified Latarjet Technique: What the Masters Taught Us. JBJS Essent Surg Tech 2021; 11:ST-D-20-00049. [PMID: 34650829 DOI: 10.2106/jbjs.st.20.00049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The Latarjet surgical technique is one of the most effective and well-known techniques in the treatment of anterior shoulder instability1. The modified Latarjet technique is a history book of surgical details demonstrated by renowned masters of shoulder surgery. The procedure includes soft-tissue repair and osseous reconstruction to stabilize the glenohumeral joint in recurrent anterior instability. The procedure has been shown to have reliable success in reducing recurrent instability and minimizing risk of dislocation arthropathy2-4. Description The Latarjet technique can be performed via a cosmetic axillary-based approach. The subscapularis is split horizontally without detachment as described by Neer5. The capsule is released like in a medially based T-plasty as described by Altchek et al.6. The coracoid osteotomy is performed with a 90° oscillating saw and prepared for en-face implantation as described by Edwards and Walch7. The inferior surface of the coracoid is decorticated and prepared per Molé8. Coracoid fixation is performed with two 3.5-mm cortical screws. The soft-tissue reconstruction is selectively tensioned per Warner et al.9. The capsular shift is augmented with a pants-over-vest repair per Kim et al.10. Alternatives Nonoperative treatment in young patients with glenohumeral instability and bone loss can lead to recurrence rates as high as 87%11. Arthroscopic management with anterior capsulolabral repair and a remplissage procedure can be beneficial for patients with instability. In the setting of bone loss, arthroscopic repair is associated with failure rates as high as 75%12. Rationale In the setting of glenoid and/or humeral bone loss, there is a loss of native osseous anatomy, leading to a higher risk of instability. Gerber and Nyffeler reported a >30% loss of compressive force when the vertical edge of the glenoid defect is greater than one-half of the glenoid diameter13. The Latarjet procedure is a reliable procedure that reconstructs the anterior osseous anatomy as well as the capsular laxity, restoring glenohumeral stability. When compared with arthroscopic labral repair, the Latarjet procedure is superior with more consistent improvements in functional outcomes with low risk of recurrence, even in high-risk populations of young, active athletes in contact sports2,3. Expected Outcomes At our institution, a total of 34 patients underwent Latarjet reconstruction as described in the present article and videos from 2013 to 2018, with a minimum follow-up of 1 year. Among these patients, the mean Single Assessment Numeric Evaluation score was 90.7 (range, 70 to 100). There were 4 cases of recurrent instability with graft fracture or resorption (11.8%). Zimmermann et al. presented a series of Latarjet reconstructions with similar functional outcomes and a recurrence rate of 11%4. Meta-analysis of long-term Latarjet studies show high rates of return to sports and successful outcomes in 86% of cases, with an 8.5% recurrence rate2. Important Tips The Latarjet procedure can be consistently performed with a subscapularis-sparing approach, which minimizes adverse comorbidities.Splitting the subscapularis at the inferior one-third junction will position the surgical window directly over the bottom half of the glenoid, which optimizes coracoid implantation.A medially based T-plasty will maximize the glenoid exposure for direct coracoid implantation. Subsequently, the capsule may be shifted for capsular imbrication.Low-profile, non-bulky retractors will help to improve visualization.Adjusting the arm is a key technique in performing this surgical procedure. This adjustment will help to shift the surgical window, expose key anatomic structures, and allow a capsular shift without overtensioning. This cannot be overstated.
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Affiliation(s)
- Eddie Y Lo
- The Shoulder Center, Baylor Scott & White Research Institute, Dallas, Texas.,Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas
| | - Paolo Montemaggi
- Department of Orthopaedics and Trauma Surgery, AOUP-Cisanello Hospital, University of Pisa, Pisa, Italy
| | - Temilola Majekodunmi
- The Shoulder Center, Baylor Scott & White Research Institute, Dallas, Texas.,Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas
| | - Julia Lund
- The Shoulder Center, Baylor Scott & White Research Institute, Dallas, Texas.,Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas
| | - Sumant G Krishnan
- The Shoulder Center, Baylor Scott & White Research Institute, Dallas, Texas.,Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas
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8
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Fink Barnes LA, Jobin CM, Popkin CA, Ahmad CS. Athletes With Anterior Shoulder Instability: A Prospective Study on Player Perceptions of Injury and Treatment. Orthop J Sports Med 2021; 9:23259671211032239. [PMID: 34541015 PMCID: PMC8447104 DOI: 10.1177/23259671211032239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/30/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Many in-season athletes choose to delay or avoid surgery in order to continue
playing and avoid downtime such as missed games or seasons. Purpose: To learn about the attitudes toward the injury and treatment of in-season
shoulder instability in competitive athletes who have suffered a shoulder
dislocation. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A study-specific questionnaire about athletes’ perceptions of injury and
treatment was administered to injured players. Secondary outcomes included
the American Shoulder and Elbow Surgeons (ASES) score and the Western
Ontario Shoulder Instability Index (WOSI). Mean scores and standard
deviations were calculated, and between-group analyses with
t tests were performed to compare the ASES and WOSI
scores. The Mann-Whitney U test was used for analyses
performed on the following groups: early operative versus nonoperative
management; age <18 versus ≥18 years; first-time dislocators versus
recurrent dislocators; self-reducing subluxations versus dislocations
requiring assistance; and dominant arm affected versus nondominant arm. Results: There were 45 patients included in this study (33 male, 12 female) with a
mean age of 18 ± 2.8 years. Several sports were represented, with the most
common being football, baseball, soccer, and rugby. In this study of
in-season athletes with shoulder instability, 13 (28.9%) chose early
surgery, 4 (8.9%) chose surgery at season’s end, while 28 (62.2%) chose
physical therapy followed by a wait-and-see approach, with 13 (46.4%) of
these patients ultimately requiring surgery. Athletes who chose nonoperative
treatment were statistically more likely to believe that their shoulder
would heal on its own (P < .001) or with physical
therapy (P < .025); they were also more likely to agree
that they would rather stop sports than undergo surgery (P
< .04). Athletes with worse ASES and WOSI scores at injury were more
likely to choose surgery (P < .03 and P
< .05, respectively). Athletes with >1 dislocation were less likely to
believe that the shoulder would heal without surgery (P
< .025). Most athletes agreed that seasonal timing and recruitment
prospects were an important factor in their decision in favor of surgery
(P < .038), and most agreed that their doctor
influenced their ultimate treatment decision (P < .006).
Most athletes also agreed that a repeat dislocation would cause further
injury to the shoulder. Conclusion: Treatment decisions were most strongly related to the athletes’ perceptions
of injury severity and the influence of the treating surgeon.
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Affiliation(s)
- Leslie A Fink Barnes
- Department of Orthopedic Surgery and Sports Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Charles M Jobin
- Columbia University Center for Shoulder, Elbow and Sports Medicine, New York, New York, USA
| | - Charles A Popkin
- Columbia University Center for Shoulder, Elbow and Sports Medicine, New York, New York, USA
| | - Christopher S Ahmad
- Columbia University Center for Shoulder, Elbow and Sports Medicine, New York, New York, USA
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Duethman NC, Bernard CD, Leland D, Wilbur RR, Krych AJ, Dahm DL, Barlow JD, Camp CL. Multiple Instability Events at Initial Presentation Are the Major Predictor of Failure of Nonoperative Treatment for Anterior Shoulder Instability. Arthroscopy 2021; 37:2432-2439. [PMID: 33812027 PMCID: PMC8985112 DOI: 10.1016/j.arthro.2021.03.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To define the success rate of initial nonoperative treatment for traumatic anterior shoulder instability in a defined U.S. geographic population, describe factors that predict conversion to surgery after initial nonoperative management, and describe the long-term outcomes of nonoperative treatment after the index traumatic anterior instability event. METHODS The Rochester Epidemiology Project database was used to identify patients aged 14 to 39 years treated for anterior shoulder instability between 1994 and 2016. Patient demographic characteristics, comorbidities, injury characteristics, and imaging were evaluated. Patients treated nonoperatively for the first 6 months after the index instability event were analyzed to determine long-term outcomes (recurrence rate, pain at last follow-up, radiographic outcomes), the success rate of continued nonoperative treatment (no conversion to surgery), and factors associated with conversion to surgery (patient and injury characteristics). Survivorship free of surgery was reported with a Kaplan-Meier survival curve, and Cox proportional hazards models were used to evaluate association of variables with conversion to surgery. RESULTS A total of 379 patients met the study criteria, with an average follow-up period of 10.2 years (range, 0.53-25.00 years). The average age was 23.9 years, the mean body mass index was 26.2, and 100% of instability events were due to trauma. Of the shoulders, 79 (20.1%) ultimately failed initial nonoperative treatment and progressed to surgery. At final follow-up, the rate of recurrent instability was 52.3% in the group treated definitively without surgery, and the recurrence rate decreased from 92.4% to 10.1% in patients who underwent conversion to surgical treatment. Factors associated with conversion to surgery included 2 or more subluxations prior to the first evaluation (hazard ratio [HR], 1.82; P = .002), 2 or more dislocations prior to the first evaluation (HR, 1.76; P = .006), and recurrent instability at follow-up (HR, 4.21; P < .001). CONCLUSIONS Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. Ultimately, 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment. In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management. LEVEL OF EVIDENCE Level III, retrospective database review.
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Affiliation(s)
| | | | - Devin Leland
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Ryan R. Wilbur
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Diane L. Dahm
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Jonathan D. Barlow
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L. Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A.,Address correspondence to: Christopher L. Camp, M.D., Mayo Clinic, 200 First St SW, Rochester MN 55905, Ph: 507-284-8314, Fax: 507-266-1803, , Twitter: @ChrisCampMD
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Sheth U. Editorial Commentary: Management of First-Time Anterior Shoulder Instability Requires Risk Stratification and Surgery for Many, But Not All. Arthroscopy 2021; 37:2440-2443. [PMID: 34353554 DOI: 10.1016/j.arthro.2021.05.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 02/02/2023]
Abstract
The management of a patient with a first-time anterior shoulder dislocation has been the subject of longstanding debate among shoulder surgeons. A number of prognostic factors for recurrent instability have been proposed, including younger age, male sex, contact sports, and glenoid bone loss. Predictive tools and scores have been developed to assist in risk stratifying this patient population; however, no universally agreed upon, clinically validated algorithm exists. More recently, there has been emerging evidence favoring early surgical stabilization, as it has been shown to result in better overall outcomes compared with patients undergoing surgery following episodes of recurrent instability. With each subsequent dislocation or subluxation event, there is increased glenoid bone loss (and development of inverted-pear glenoid), a greater prevalence of engaging (i.e., off-track) Hill-Sachs lesions, more extensive labral tears, a greater risk of rotator cuff involvement (in the older patient), and increased plastic and/or permanent deformation, elongation, and compromise of the antero-inferior glenohumeral joint capsule and associated inferior glenohumeral ligament complex. Moreover, there is now sufficient evidence to suggest that recurrence comes at a cost, as it is a major risk factor for poor outcomes following arthroscopic stabilization. However, one risk is overtreatment, potentially exposing those individuals who would not have had another instability event due to an unnecessary procedure. We should continue to use the available evidence within the literature to help risk-stratify patients and develop an individualized treatment plan through a shared decision-making process with the patient.
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Dyrna FGE, Ludwig M, Imhoff AB, Martetschläger F. Off-track Hill-Sachs lesions predispose to recurrence after nonoperative management of first-time anterior shoulder dislocations. Knee Surg Sports Traumatol Arthrosc 2021; 29:2289-2296. [PMID: 32740876 DOI: 10.1007/s00167-020-06176-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 06/11/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE The purpose of this study was to evaluate whether the presence of an off-track Hill-Sachs lesion has an impact on the recurrence rate after nonoperative management of first-time anterior shoulder dislocations. METHODS A retrospective cohort study was planned with a follow-up via questionnaire after a minimum of 24 months. Fifty four patients were included in the study (mean age: 29.5 years; 16 female, 38 male). All of these patients opted for primary nonoperative management after first-time traumatic anterior shoulder dislocation, in some cases even against the clinician's advice. The glenoid track and the Hill-Sachs interval were evaluated in the MRI scans. The clinical outcome was evaluated via a shoulder-specific questionnaire, ASES-Score and Constant Score. Further, patients were asked to report on recurrent dislocation (yes/no), time to recurrent dislocation, pain, feeling of instability and satisfaction with nonoperative management. RESULTS In 7 (13%) patients, an off-track Hill-Sachs lesion was present, while in 36 (67%) the lesion was on-track and 11 (20%) did not have a structural Hill-Sachs lesion at all. In total, 31 (57%) patients suffered recurrent dislocations. In the off-track group, all shoulders dislocated again (100%), while 21 (58%) in the on-track group and 3 (27%) in the no structural Hill--Sachs lesion group had a recurrent dislocation, p = 0.008. The mean age in the group with a recurrence was 23.7 ± 10.1 years, while those patients without recurrent dislocation were 37.4 ± 13.1 years old, p < 0.01. The risk for recurrence in patients under 30 years of age was higher than in those older than 30 years (OR = 12.66, p < 0.001). There were no significant differences between patients with on- and off-track lesions regarding patients' sex, height, weight and time to reduction and glenoid diameter. Off-track patients were younger than on-track patients (24.9 ± 7.3 years vs. 29.6 ± 13.6 years). However, this difference was not statistically significant. CONCLUSION The presence of an off-track Hill-Sachs lesion leads to significantly higher recurrence rates compared to on-track or no structural Hill--Sachs lesions in patients with nonoperative management and should be considered when choosing the right treatment option. Therefore, surgical intervention should be considered in patients with off-track Hill-Sachs lesions. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Felix G E Dyrna
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Munich, Germany
| | - Marius Ludwig
- Department of Orthopaedic Sportsmedicine, Technical University, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sportsmedicine, Technical University, Munich, Germany
| | - Frank Martetschläger
- Department of Orthopaedic Sportsmedicine, Technical University, Munich, Germany. .,German Center for Shoulder Surgery, ATOS Clinic Munich, Effnerstraße 38, 81925, München, Germany.
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12
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Li RT, Kane G, Drummond M, Golan E, Wilson K, Lesniak BP, Rodosky M, Lin A. On-Track Lesions with a Small Distance to Dislocation Are Associated with Failure After Arthroscopic Anterior Shoulder Stabilization. J Bone Joint Surg Am 2021; 103:961-967. [PMID: 33764924 DOI: 10.2106/jbjs.20.00917] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Off-track lesions are strongly associated with failure after arthroscopic Bankart repair. However, on-track lesions with a small distance-to-dislocation (DTD) value, or "near-track lesions," also may be at risk for failure. The purpose of the present study was to determine the association of DTD with failure after arthroscopic Bankart repair. METHODS We performed a retrospective analysis of 173 individuals who underwent primary arthroscopic Bankart repair between 2007 and 2015. Glenoid bone loss and Hill-Sachs lesion size were measured with use of previously reported methods. Patients with failure were defined as those who sustained a dislocation after the index procedure, whereas controls were defined as individuals who did not. DTD was defined as the distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track. Receiver operating characteristic (ROC) curves were constructed for DTD to determine the critical threshold that would best predict failure. The study population was subdivided into individuals ≥20 years old and <20 years old. RESULTS Twenty-eight patients (16%) sustained a recurrent dislocation following Bankart repair. Increased glenoid bone loss (p < 0.001), longer Hill-Sachs lesion length (p < 0.001), and decreased DTD (p < 0.001) were independent predictors of failure. ROC curve analysis of DTD alone demonstrated that a threshold value of 8 mm could best predict failure (area under the curve [AUC] = 0.73). DTD had strong predictive power (AUC = 0.84) among individuals ≥20 years old and moderate predictive power (AUC = 0.69) among individuals <20 years old. Decreasing values of DTD were associated with a stepwise increase in the failure rate. CONCLUSIONS A "near-track" lesion with a DTD of <8 mm, particularly in individuals ≥20 years old, may be predictive of failure following arthroscopic Bankart repair. When using the glenoid track concept as the basis for surgical decision-making, clinicians may need to consider the DTD value as a continuous variable to estimate failure instead of using a binary on-track/off-track designation. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
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Affiliation(s)
- Ryan T Li
- Wake Orthopaedics, WakeMed Health and Hospitals , Raleigh , North Carolina
| | - Gillian Kane
- UPMC Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh , Pittsburgh , Pennsylvania
| | - Mauricio Drummond
- UPMC Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh , Pittsburgh , Pennsylvania
| | - Elan Golan
- Northside Orthopaedic Specialists , Snellville , Georgia
| | - Kevin Wilson
- Department of Orthopaedic Surgery, Mount Nittany Health, State College , Pennsylvania
| | - Bryson P Lesniak
- UPMC Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh , Pittsburgh , Pennsylvania
| | - Mark Rodosky
- UPMC Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh , Pittsburgh , Pennsylvania
| | - Albert Lin
- UPMC Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh , Pittsburgh , Pennsylvania
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13
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Imam MA, Shehata MSA, Martin A, Attia H, Sinokrot M, Bahbah EI, Gwilym S, Jacob J, Narvani AA, Meyer DC. Bankart Repair Versus Latarjet Procedure for Recurrent Anterior Shoulder Instability: A Systematic Review and Meta-analysis of 3275 Shoulders. Am J Sports Med 2021; 49:1945-1953. [PMID: 33264030 DOI: 10.1177/0363546520962082] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Little consensus is available regarding the standard treatment for recurrent anterior instability of the shoulder. Typically, treatment selection has been based on training and tradition rather than the available evidence. PURPOSE This study aimed to compare the clinical outcomes between arthroscopic Bankart procedure and the Latarjet procedure in the treatment of recurrent anterior shoulder instability with emphasis on follow-up time. STUDY DESIGN Systematic review and meta-analysis. METHODS We searched PubMed, Cochrane Central Register of Controlled Trials, Scopus, Ovid, and Web of Science up to January 2018 and included studies that compared arthroscopic Bankart versus Latarjet for treatment of anterior shoulder instability. Continuous data, such as operative time and patient-reported outcomes, were pooled as mean differences (MDs), whereas dichotomous data, such as recurrence, revision, redislocation, arthropathy, infection, and hematoma, were pooled as risk ratios (RRs), with 95% CIs. RESULTS Pooling data from 7 cohort studies (3275 patients) showed that arthroscopic Bankart was associated with a higher risk of redislocation (RR, 2.74; 95% CI, 1.48-5.06; P = .03), a higher risk of recurrence (RR, 2.87; 95% CI, 1.91-4.30; P < .0001), and a lower risk of infection (RR, 0.16; 95% CI, 0.06-0.43; P = .0002) compared with Latarjet, while the effect size did not favor arthroscopic Bankart or Latarjet in terms of Rowe score (MD, 0.22; 95% CI, -5.64 to 6.08; P = .94), revision (RR, 0.34; 95% CI, 0.08-1.39; P = .13), and hematoma (RR, 0.20; 95% CI, 0.03-1.19; P = .07). The effect estimate showed a pronounced advantage for Latarjet from 6 to 10 years postoperatively in terms of recurrence and redislocation (RR, 3.00; 95% CI, 1.98-4.56 and RR, 2.85; 95% CI, 1.51-5.38, respectively). CONCLUSION Our results showed that Latarjet had less risk of recurrence and redislocation with longer follow-up time. Both procedures were comparable in terms of Rowe score, the need for revision, and postoperative hematoma formation, whereas Bankart repair was associated with a lower risk of infection.
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Affiliation(s)
- Mohamed A Imam
- Rowley Bristow Orthopaedic Center, Ashford and St Peter's University Hospitals, Chertsey, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | | | | | - Hamdy Attia
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Eshak I Bahbah
- Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | - Stephen Gwilym
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joshua Jacob
- Rowley Bristow Orthopaedic Center, Ashford and St Peter's University Hospitals, Chertsey, UK
| | - A Ali Narvani
- Rowley Bristow Orthopaedic Center, Ashford and St Peter's University Hospitals, Chertsey, UK
| | - Dominik C Meyer
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Switzerland
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14
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Vopat ML, Coda RG, Giusti NE, Baker J, Tarakemeh A, Schroeppel JP, Mullen S, Randall J, Provencher MT, Vopat BG. Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:23259671211006437. [PMID: 34104660 PMCID: PMC8155769 DOI: 10.1177/23259671211006437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The glenohumeral joint is one of the most frequently dislocated joints in the
body, particularly in young, active adults. Purpose: To conduct a systematic review and meta-analysis to evaluate and compare
outcomes between anterior versus posterior shoulder instability. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed using the PubMed, Cochrane Library, and
MEDLINE databases (from inception to September 2019) according to PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
guidelines. Studies were included if they were published in the English
language, contained outcomes after anterior or posterior shoulder
instability, had at least 1 year of follow-up, and included arthroscopic
soft tissue labral repair of either anterior or posterior instability.
Outcomes including return-to-sport (RTS) rate, postoperative instability
rate, and pre- and postoperative American Shoulder and Elbow Surgeons (ASES)
scores were recorded and analyzed. Results: Overall, 39 studies were included (2077 patients; 1716 male patients and 361
female patients). Patients with anterior instability had a mean age of 23.45
± 5.40 years (range, 11-72 years), while patients with posterior instability
had a mean age of 23.08 ± 8.41 years (range, 13-61 years). The percentage of
male patients with anterior instability was significantly higher than that
of female patients (odds ratio [OR], 1.36; 95% CI, 1.04-1.77;
P = .021). Compared with patients with posterior
instability, those with anterior instability were significantly more likely
to RTS (OR, 2.31; 95% CI, 1.76-3.04; P < .001), and they
were significantly more likely to have postoperative instability (OR, 1.53;
95% CI, 1.07-2.23; P = .018). Patients with anterior
instability also had significantly higher ASES scores than those with
posterior instability (difference in means, 6.74; 95% CI, 4.71-8.77;
P < .001). There were no significant differences
found in postoperative complications between the anterior group (11
complications; 1.8%) and the posterior group (3 complications; 1.6%) (OR,
1.12; 95% CI, 0.29-6.30; P = .999). Conclusion: Patients with anterior shoulder instability had higher RTS rates but were
more likely to have postoperative instability compared with posterior
instability patients. Overall, male patients were significantly more likely
to have anterior shoulder instability, while female patients were
significantly more likely to have posterior shoulder instability.
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Affiliation(s)
- Matthew L Vopat
- University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| | - Reed G Coda
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nick E Giusti
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jordan Baker
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Armin Tarakemeh
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Scott Mullen
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey Randall
- University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| | | | - Bryan G Vopat
- University of Kansas Medical Center, Kansas City, Kansas, USA
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15
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Dong H, Jenner EA, Theivendran K. Closed reduction techniques for acute anterior shoulder dislocation: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2021; 47:407-421. [PMID: 32607775 DOI: 10.1007/s00068-020-01427-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Anterior shoulder dislocations are the most common type of joint dislocation with the majority treated with closed reduction. Reduction methods can be grouped into their principle mode of action: traction-countertraction, leverage and scapular manipulation. The best method has yet to be identified and our aim was to find the most effective, safe and least painful method of closed reduction for acute anterior shoulder dislocations. METHODS A search of the online databases of CENTRAL, MEDLINE and Embase was performed to identify randomised control trials (RCTs) comparing closed reduction methods for anterior shoulder dislocations. A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Twelve eligible RCTs were included with a total of 1055 patients. Our meta-analysis showed traction-countertraction methods are marginally less painful than leverage methods by 0.86 points on the VAS scale but leverage methods are quicker by 20 s. Amongst traction-countertraction methods, the Spaso technique was the least painful and quickest, albeit with no difference in overall success rate. A meta-analysis was not possible for comparisons involving scapular manipulation due to the paucity of studies, but within two studies, scapular manipulation was significantly less painful than both leverage and traction-countertraction methods by 1.5 and 2.3 points (VAS), respectively. CONCLUSION Traction-countertraction methods are less painful but slower than leverage methods with no difference in complication rates. However, there was no difference in overall reduction success rate between any of the groups. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Huan Dong
- Trauma and Orthopaedic Department, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, Birmingham, West Midlands, B71 4HJ, UK.
| | - Edward A Jenner
- Trauma and Orthopaedic Department, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, Birmingham, West Midlands, B71 4HJ, UK
| | - Kanthan Theivendran
- Trauma and Orthopaedic Department, Sandwell & West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, Birmingham, West Midlands, B71 4HJ, UK
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16
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Pougès C, Hardy A, Vervoort T, Amouyel T, Duriez P, Lalanne C, Szymanski C, Deken V, Chantelot C, Upex P, Maynou C. Arthroscopic Bankart Repair Versus Immobilization for First Episode of Anterior Shoulder Dislocation Before the Age of 25: A Randomized Controlled Trial. Am J Sports Med 2021; 49:1166-1174. [PMID: 33705240 DOI: 10.1177/0363546521996381] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The risk of recurrence after the first episode of anterior shoulder dislocation is high with nonoperative treatment in younger patients. PURPOSE/HYPOTHESIS The aim of this study was to compare the results of arthroscopic Bankart repair and nonoperative treatment for shoulder dislocation in patients younger than 25 years, with a minimum of 2 years of follow-up. The hypothesis was that surgery would decrease the risk of recurrence. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS We included patients aged between 18 and 25 years after a first episode of anterior shoulder dislocation and divided them into 2 groups. The first group was treated surgically with an arthroscopic Bankart repair within 2 weeks after the dislocation; the second group was treated nonoperatively. Both groups were immobilized for 3 weeks in internal rotation and followed the same physical therapy protocol. Standard radiography and computed tomography were performed immediately after reduction of the dislocation, and follow-up was performed at 3, 6, 12, and 24 months. The primary outcome measure was instability recurrence, defined as another anterior shoulder dislocation requiring closed reduction by another person (the patient was unable to reduce the dislocated joint themselves), a subluxation, or a positive apprehension test. Secondary outcome measures included range of motion, return to sport, and functional scores such as the short version of the Disabilities of the Arm, Shoulder and Hand score the Walch-Duplay score, and the Western Ontario Shoulder Instability Index (WOSI). RESULTS A total of 20 patients were included in each group. The mean ± SD age was 21 ± 1.8 years, and there were 33 men (82.5%) and 7 women (17.5%) in the total sample. Recurrence of instability was significantly decreased in the surgical treatment group compared with the nonoperative group (2 [10%] vs 14 [70%], respectively; P = .0001). Fewer patients in the surgical treatment group versus the nonoperative group had another episode of dislocation (0 vs 6 [30%], respectively), subluxation (2 [10%] vs 13 [65%], respectively; P = .003), or a positive apprehension test (1 [5%] vs 11 [58%], respectively; P = .0005). The Walch-Duplay score (88.4 vs 70.3 points; P = .046) and WOSI (11.5 vs 17.7 points; P = .035) were significantly better in the surgical group versus the nonoperative group after a 2-year follow-up. Level of sport was the same or better in 89% of the surgical treatment group vs 53% of the nonoperative treatment group (P = .012). No surgical complication was recorded. We did not find any significant difference in range of motion. CONCLUSION In patients with first-time shoulder dislocations, arthroscopic labral repair (Bankart procedure) reduced the risk of secondary shoulder dislocation and improved functional outcome versus nonoperative treatment after a 2-year follow-up. Surgical treatment after a first episode of shoulder dislocation could be offered as a primary treatment option in a younger population if these results are confirmed by larger studies with a longer follow-up. REGISTRATION NCT03315819 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Cécile Pougès
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Alexandre Hardy
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Thomas Vervoort
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France.,Arcachon Clinic, La Teste-de-Buch, France
| | - Thomas Amouyel
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Pauline Duriez
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Clément Lalanne
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Christophe Szymanski
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Valérie Deken
- Lille-Hauts de France University, Lille, France.,Methodology Unit-Biostatistics and Data Management, Lille University, France
| | - Christophe Chantelot
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
| | - Peter Upex
- Orthopedic Department, Saint Joseph Hospital, Paris, France
| | - Carlos Maynou
- Lille-Hauts de France University, Lille, France.,Department of Orthopaedic Surgery, Lille University Hospital Salengro, Lille, France
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17
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Olds M, Ellis R, Parmar P, Kersten P. The immediate and subsequent impact of a first-time traumatic anterior shoulder dislocation in people aged 16-40: Results from a national cohort study. Shoulder Elbow 2021; 13:223-232. [PMID: 33897854 PMCID: PMC8039766 DOI: 10.1177/1758573220921484] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 03/27/2020] [Accepted: 04/01/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Limited evidence exists which details changes in quality of life, shoulder activity level, kinesiophobia, shoulder pain and disability following a first-time traumatic anterior shoulder dislocation (FTASD) in people treated non-operatively. This study had three objectives: (1) to examine quality of life, pain, disability and kinesiophobia after an FTASD within 12 weeks, (2) to examine whether these variables were different in people with and without recurrent shoulder instability and (3) to assess how these variables changed over 12 months. METHODS A prospective cohort study was undertaken in people with an FTASD aged between 16 and 40 years. Measures of quality of life, kinesiophobia, shoulder activity, shoulder pain and disability were recorded within 12 weeks of an FTASD and at 3, 6, 9 and 12 months. RESULTS An FTASD negatively impacted quality of life, shoulder pain and function and these variables improved over time. People with recurrent shoulder instability had poorer quality of life 12 months after an FTASD. Across the entire cohort, kinesiophobia did not significantly change across time in people following an FTASD. CONCLUSIONS Quality of life was significantly affected by an FTASD in people with recurrent shoulder instability. Across the entire cohort of people with an FTASD, kinesiophobia remained elevated in people following an FTASD. LEVEL OF EVIDENCE Level 1 prognostic study.
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Affiliation(s)
- M Olds
- Flawless Motion Ltd, Auckland, New
Zealand,M Olds, Flawless Motion Ltd, 7/88 Cook St,
Auckland 1010, New Zealand.
| | - R Ellis
- Faculty of Health and Environmental
Sciences, Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of
Technology, Auckland, New Zealand
| | - P Parmar
- Department of Biostatistics and
Epidemiology, Faculty of Health and Environmental Sciences, School of Public Health
and Psychosocial Studies, Auckland University of
Technology, Auckland, New Zealand
| | - P Kersten
- School of Health Sciences, University of Brighton, Brighton, UK
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18
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Allahabadi S, Eftekhari A, Feeley SE, Feeley BT, Lansdown DA. Influential and Highest Cited Shoulder Instability Articles: A Bibliometric Analysis. Orthop J Sports Med 2021; 9:2325967121992577. [PMID: 34262975 PMCID: PMC8245668 DOI: 10.1177/2325967121992577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/03/2020] [Indexed: 11/15/2022] Open
Abstract
Background In orthopaedic surgery and other fields, the effect of influential journal articles has been evaluated by their citation counts and their correlation with methodological quality. Purpose To identify and characterize the 50 most cited articles on shoulder instability, examine trends in publication characteristics, and evaluate the correlation of citations with quality of evidence. Study Design Cross-sectional study. Methods The Web of Science and Scopus online databases were searched to identify the top 50 most cited articles on shoulder instability, based on the average number of citations from each database. Article characteristics were recorded, and level of evidence and methodological quality were assessed using the modified Coleman Methodology Score (mCMS), Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS). Spearman correlation was used to evaluate relationships between citations or citation density (citations/y) and level of evidence or methodological scoring. Top cited articles from recent years were also aggregated. Results The top 50 most cited papers had a mean ± SD number of citations of 381.5 ± 166.7, with a mean of 15.0 ± 8.8 citations/y. Overall, 15 articles (30%) were biomechanical/cadaveric studies, and 15 (30%) were case series. Only 3 (6%) were considered to have level 1 evidence. The mean ± SD mCMS was 54.4 ± 12.7, mean ± SD Jadad score was 3.1 ± 1.4, and mean ± SD MINORS score was 10.5 ± 3.3. There were no significant correlations between citation rank or density and methodological assessments. There were weak correlations between citation rank and publication year (r s = 0.32; P = .022) and between rank and level of evidence (r s = -0.38; P = .047). The correlation between citation density and publication year was moderate (r s = 0.70; P < .0001). There was no difference in citation density of the top 10 articles from 2010 to 2020 compared with the top 10 from the overall list (23.8 ± 5.3 vs 28.8 ± 9.5; P = .16). Conclusion Influential articles in shoulder instability included a high proportion of biomechanical/cadaveric studies. The majority of top cited articles had lower evidence levels and poorer methodological quality without strong correlation with citations or citation density. There was a moderate correlation between citation density and year of publication.
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Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San
Francisco, San Francisco, California, USA
- Sachin Allahabadi, MD, UCSF Department of Orthopaedic Surgery,
500 Parnassus Avenue, MU 320-W, San Francisco, CA 94143, USA (
) (Twitter: Sachin Allahabadi:
@sach_MD; Brian Feeley:
@DrBrianFeeley)
| | - Ava Eftekhari
- Department of Orthopaedic Surgery, University of California, San
Francisco, San Francisco, California, USA
| | - Sonali E. Feeley
- Department of Orthopaedic Surgery, University of California, San
Francisco, San Francisco, California, USA
| | - Brian T. Feeley
- Department of Orthopaedic Surgery, University of California, San
Francisco, San Francisco, California, USA
| | - Drew A. Lansdown
- Department of Orthopaedic Surgery, University of California, San
Francisco, San Francisco, California, USA
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19
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Chapter 6: Attritional Glenoid Bone Loss in the Shoulder: Operative Considerations. Sports Med Arthrosc Rev 2021; 28:159-166. [PMID: 33156231 DOI: 10.1097/jsa.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with recurrent anterior shoulder instability often have glenoid bone loss present in addition to soft tissue pathologies. It is known that patients with significant glenoid bone loss are best treated with a boney augmentation procedure as opposed to a soft tissue Bankart repair because of the high rate of recurrent instability that results from a Bankart repair. Although the Latarjet technique has been the gold-standard treatment for patients with glenoid bone loss because of the low incidence of recurrent instability, it has a high complication rate and a steep learning curve. Herein, the authors present the technique and outcomes for arthroscopic anatomic glenoid reconstruction that has a similar complication rate to the Bankart repair but with a low recurrence rate similar to the Latarjet. This procedure is safe, has a short learning curve, low recurrence rate, and positive patient-reported outcomes.
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20
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Guity MR, Khan FMY, Bagheri N. An exceptional case of posterior shoulder fracture dislocation in patient with recurrent anterior dislocation forming "Mirror Hill-Sachs lesion". Clin Case Rep 2021; 9:1193-1198. [PMID: 33768809 PMCID: PMC7981642 DOI: 10.1002/ccr3.3729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/04/2020] [Accepted: 12/14/2020] [Indexed: 12/02/2022] Open
Abstract
A posterior dislocation should be always kept in mind in a painful shoulder especially after trauma or seizure. Even in the presence of recurrent dislocation, the direction may be different from one episode to another.
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Affiliation(s)
- Mohammad Reza Guity
- Joint Reconstruction Research CenterTehran University of Medical SciencesTehranIran
| | | | - Nima Bagheri
- Joint Reconstruction Research CenterTehran University of Medical SciencesTehranIran
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21
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Lau BC, Hutyra CA, Gonzalez JM, Mather RC, Owens BD, Levine WN, Garrigues GE, Kelly JD, Kovacevic D, Abrams JS, Cuomo F, McMahon PJ, Kaar S, Dines JS, Miniaci A, Nagda S, Braman JP, Harrison AK, MacDonald P, Riboh JC. Surgical treatment for recurrent shoulder instability: factors influencing surgeon decision making. J Shoulder Elbow Surg 2021; 30:e85-e102. [PMID: 32721507 DOI: 10.1016/j.jse.2020.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 07/05/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Brian C Lau
- Duke Sport Science Institute, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Carolyn A Hutyra
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Juan Marcos Gonzalez
- Duke University School of Medicine, Department of Population Health Sciences, Durham, NC, USA
| | - Richard C Mather
- Duke Sport Science Institute, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - William N Levine
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Grant E Garrigues
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, IL, USA
| | - John D Kelly
- Penn Perelman School of Medicine, Philadelphia, PA, USA
| | - David Kovacevic
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | | | - Frances Cuomo
- Department of Orthopaedic Surgery, Montefiore, New York, NY, USA
| | | | - Scott Kaar
- Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO, USA
| | | | - Anthony Miniaci
- Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Jonathan P Braman
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Alicia K Harrison
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Peter MacDonald
- Orthopaedic Surgery, Pan Am Clinic, University of Manitoba, Winnipeg, MB, Canada
| | - Jonathan C Riboh
- Duke Sport Science Institute, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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22
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The Relationship Between Fear Avoidance Beliefs, Muscle Strength, and Short-Term Disability After Surgical Repair of Shoulder Instability. J Sport Rehabil 2021; 30:973-980. [PMID: 33503588 DOI: 10.1123/jsr.2020-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 08/23/2020] [Accepted: 11/03/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT Arthroscopic surgical repair of the shoulder is recommended when conservative treatment for shoulder instability (SI) fails. However, many patients undergoing this procedure do not return to same level of activity. Psychological factors and muscle strength have been shown to be associated with postoperative outcomes in other musculoskeletal conditions. OBJECTIVE To investigate the association between fear avoidance, muscle strength, and short-term function in patients after surgical SI repair. METHODS Twenty-five male patients who underwent shoulder surgery following at least one event of SI were included in this study. Evaluations of fear avoidance related to physical activity and disability were performed at baseline (during the first encounter with the physical therapist) and 7 to 8 weeks postsurgery. Fear avoidance beliefs were assessed using the Fear Avoidance Beliefs Questionnaire. Disability was assessed using the Disabilities of Arm, Shoulder, and Hand questionnaire and the Western Ontario SI index. The follow-up evaluation (weeks 7-8) included measurement of maximal isometric strength of the internal and external rotators. Nonparametric Kendall tau was used to determine the correlations between baseline fear avoidance, muscle strength, and disability at follow-up. RESULTS Disabilities of Arm, Shoulder, and Hand questionnaire at follow-up was significantly correlated with baseline Disabilities of Arm, Shoulder, and Hand questionnaire (τ = .520, P < .001), baseline fear avoidance (τ = .399, P = .008), and both internal rotator (τ = -.400, P = .005) and external rotator strength (τ = -.353, P = .014). Western Ontario SI index at follow-up was moderately correlated with baseline Western Ontario SI index (τ = .387, P = .007), internal rotator (τ = -.427, P = .003), and external rotator (τ = -.307, P = .032), but not with baseline Fear Avoidance Beliefs Questionnaire (τ = .22, P = .145). CONCLUSIONS The results indicate a possible association between fear avoidance beliefs and short-term disability. Further studies are warranted to better explore and understand these relationships.
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23
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Lau BC, Hutyra CA, Streufert B, Reed SD, Orlando LA, Huber JC, Taylor DC, Mather RC. Surgeon Applications of Patient Preferences in Treatment Decision Making for First-Time Anterior Shoulder Dislocation. Orthop J Sports Med 2020; 8:2325967120966145. [PMID: 33330735 PMCID: PMC7720322 DOI: 10.1177/2325967120966145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/15/2020] [Indexed: 11/16/2022] Open
Abstract
Background Treatment of a first-time anterior shoulder dislocation (FTASD) is sensitive to patient preferences. The operative or nonoperative management debate provides an excellent opportunity to learn how surgeons apply patient preferences in treatment decisions. Purpose To determine how patient preferences (repeat dislocation risk, recovery difficulties, fear of surgery, treatment costs) and surgeon factors influence a surgeon's treatment plan for FTASD. Study Design Cross-sectional study. Methods Eight clinical vignettes of hypothetical patients with FTASD (including age, sex, and activity level) were presented to members of the Magellan Society. A second set of matched vignettes with patient preferences and clinical variables were also presented. The vignettes represented scenarios in which evidence does not favor one treatment over another. Respondents were asked how they would manage each hypothetical case. Respondents also estimated the risk of redislocation for the nonoperative cases for comparison with the published rates. Finally, respondents completed a Likert-scale questionnaire to determine their perceptions on factors influencing their decisions. Results A total of 103 orthopaedic surgeons completed the survey; 48% practiced in an academic hospital; 79% were in practice for 10 years or longer; and 75% had completed a sports medicine fellowship. Patient preferences were the single most important factor influencing treatment recommendation, with activity type and age also important. Just 62% of the surgeon estimates of the risk of redislocation were consistent with the published rates. The inclusion of patient preferences to clinical variables changed treatment recommendations in 62.5% of our hypothetical cases. Respondents rated patient treatment preference as the leading factor in their treatment decision making. Conclusion Patient preferences were important when deciding the appropriate treatment for FTASD. Respondents were inconsistent when applying evidence in their decision making and estimates of recurrent instability. Decision support tools that deliver patient preferences and personalized evidence-based outcome estimates improve the quality of decision making at the point of care.
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Affiliation(s)
- Brian C Lau
- Duke Sport Science Institute, Division of Sports Medicine, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Carolyn A Hutyra
- Comprehensive Outcomes in Orthopaedics and Rehabilitation Data System, Duke Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Shelby D Reed
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Lori A Orlando
- Duke Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA
| | - Joel C Huber
- Duke Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - Dean C Taylor
- Duke Sport Science Institute, Division of Sports Medicine, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard C Mather
- Duke Sport Science Institute, Division of Sports Medicine, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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24
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Decision making in treatment after a first-time anterior glenohumeral dislocation: A Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg 2020; 29:2429-2445. [PMID: 32858192 DOI: 10.1016/j.jse.2020.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/27/2020] [Accepted: 08/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of patients who sustain a first-time anterior glenohumeral dislocation (FTAGD) is controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after an FTAGD. METHODS The Neer Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons. Consensus among 72 identified experts from this group was sought with a series of surveys using the Delphi process. The first survey used open-ended questions designed to identify patient-related features that influence treatment decisions after an FTAGD. The second survey used a Likert scale to rank each feature's impact on treatment decisions. The third survey used highly impactful features to construct 162 clinical scenarios. For each scenario, experts recommended surgery or not and reported how strongly they made their recommendation. These data were analyzed to find clinical scenarios that had >90% consensus for recommending treatment. These data were also used in univariate and multivariate mixed-effects models to identify odds ratios (ORs) for different features and to assess how combining these features influenced the probability of surgery for specific populations. RESULTS Of the 162 scenarios, 8 (5%) achieved >90% consensus for recommending surgery. All of these scenarios treated athletes with meaningful bone loss at the end of their season. In particular, for contact athletes aged > 14 years who were at the end of the season and had apprehension and meaningful bone loss, there was >90% consensus for recommending surgery after an FTAGD, with surgeons feeling very strongly about this recommendation. Of the scenarios, 22 (14%) reached >90% consensus for recommending nonoperative treatment. All of these scenarios lacked meaningful bone loss. In particular, surgeons felt very strongly about recommending nonoperative treatment after an FTAGD for non-athletes lacking apprehension without meaningful bone loss. The presence of meaningful bone loss (OR, 6.85; 95% confidence interval, 6.24-7.52) and apprehension (OR, 5.60; 95% confidence interval, 5.03-6.25) were the strongest predictors of surgery. When these 2 features were combined, profound effects increasing the probability of surgery for different populations (active-duty military, non-athletes, noncontact athletes, and contact athletes) were noted, particularly non-athletes. CONCLUSION Consensus for recommending treatment of the FTAGD patient was not easily achieved. Certain combinations of patient-specific factors, such as the presence of meaningful bone loss and apprehension, increased the probability of surgery after an FTAGD in all populations. Over 90% of shoulder instability experts recommend surgery after an FTAGD for contact athletes aged > 14 years at the end of the season with both apprehension and meaningful bone loss. Over 90% of experts would not perform surgery after a first dislocation in patients who are not athletes and who lack apprehension without meaningful bone loss.
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25
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Feng S, Xie Y, Chen M, Chen Y, Ding Z, Chen J, Chen S. Relationship Between Age at Initial Shoulder Instability and Overall Outcomes After Arthroscopic Bankart Repair: Mean 6-Year Follow-up. Orthop J Sports Med 2020; 8:2325967120964881. [PMID: 33283011 PMCID: PMC7682236 DOI: 10.1177/2325967120964881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 06/12/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Age at surgery plays a crucial role in the frequency of recurrent shoulder instability. However, there are few studies that evaluate the relationship between age at initial shoulder instability and overall outcomes after stabilization surgery. Purpose: To compare clinical outcomes and structural changes after arthroscopic Bankart repair in patients who experienced initial shoulder instability during adolescence versus those with later onset instability. Study Design: Cohort study; Level of evidence, 3. Methods: This study included patients who underwent arthroscopic Bankart repair at a single institution between 2007 and 2017. Comparisons were made between patients who experienced initial shoulder instability during adolescence (age 13-19 years; group A) and those with later onset instability (age 20-35 years; group B). Clinical outcomes (recurrence rate, postoperative pain, functional scores, active range of motion, and return to sports) and structural changes demonstrated by magnetic resonance imaging (MRI) were evaluated at minimum 2-year follow-up. In addition, functional outcomes within each group were compared between the patients with and without postoperative recurrence. Results: A total of 58 patients were included (24 patients in group A and 34 patients in group B). The mean follow-up was 72.1 months. Group A demonstrated a significantly higher recurrence rate than group B (41.7% vs 11.8%, respectively; P = .009; risk ratio, 5.36 [95% CI, 1.43-20.09]) as well as significantly lower Rowe (76.9 ± 20.1 vs 88.7 ± 13.2, respectively; P = .01) and Constant-Murley scores (92.2 ± 7.6 vs 96.3 ± 4.2, respectively; P = .01). Postoperative MRI revealed no significant structural differences between the groups regarding the glenoid labrum, glenohumeral cartilage, or osseous reaction around the implanted anchors. In group A, patients with recurrence had less satisfaction regarding postoperative sports level than those without recurrence, whereas in group B, patients with recurrence had more postoperative pain and functional impairment compared with those without recurrence. Conclusion: Initial shoulder instability during adolescence was associated with a higher recurrence rate and lower functional scores after arthroscopic Bankart repair compared with later onset instability, although no significant structural differences were found between the groups on MRI at a mean 6-year follow-up.
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Affiliation(s)
- Sijia Feng
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuxue Xie
- Department of Radiology & Institute of Medical Functional and Molecular Imaging, Huashan Hospital, Fudan University, Shanghai, China
| | - Mo Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuzhou Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Zheci Ding
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Shiyi Chen
- Sports Medicine Institute of Fudan University, Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
- Shiyi Chen, MD, PhD, Department of Sports Medicine, Huashan Hospital, Fudan University, No. 12 Urumq Middle Road, Shanghai 200040, China ()
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26
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Kraeutler MJ, Belk JW, Carver TJ, McCarty EC, Khodaee M. Traumatic Primary Anterior Glenohumeral Joint Dislocation in Sports: A Systematic Review of Operative versus Nonoperative Management. Curr Sports Med Rep 2020; 19:468-478. [PMID: 33156033 DOI: 10.1249/jsr.0000000000000772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Anterior shoulder (glenohumeral joint [GHJ]) dislocations are relatively common injuries in sports. Previous studies have evaluated clinical outcomes of operative and nonoperative management for primary traumatic anterior GHJ dislocations. The purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing closed reduction of a traumatic anterior GHJ dislocation, particularly among the athletic population. Two independent reviewers performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. Unfortunately, the quantity and quality of published articles on this subject is very limited. In many studies, younger age (between 21 and 30 years) was associated with greater risk for recurrence of GHJ dislocations. Twelve studies (total N = 753) directly compared outcomes of operative versus nonoperative management. It seems that operative management significantly reduces recurrence rates with patients treated operatively among the young and active population. Operative management should be considered as a treatment option for young and athletic patients presenting with a first-time anterior GHJ dislocation.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, NJ
| | | | | | | | - Morteza Khodaee
- Department of Family Medicine and Orthopedics, University of Colorado School of Medicine, Denver, CO
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27
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The Arthroscopic Bankart Repair: State of the Art in 2020: Decision-making and Operative Technique. Sports Med Arthrosc Rev 2020; 28:e25-e34. [PMID: 33156227 DOI: 10.1097/jsa.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Traumatic anterior shoulder instability is prevalent among young athletes, and recurrent dislocations can result in compromised upper extremity function, increasing glenohumeral bone loss, and ultimately, posttraumatic arthritis. Although management algorithms have evolved in response to contemporary data and technical innovation, the arthroscopic Bankart repair continues to be a mainstay for the primary surgical management of first-time or recurrent anterior shoulder instability with marginal attritional glenoid bone loss (ie, <10% to 15%) and/or "on track" Hill-Sachs defects. The advantages of arthroscopic stabilization include its minimally invasive technique, high cost effectiveness, and relatively low recurrence rates and propensity for perioperative complications. The current article reviews contemporary indications/contraindications, management of the first-time dislocator, critical glenoid bone loss, surgical technique, and reported clinical outcomes of the arthroscopic Bankart repair.
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28
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Yapp LZ, Nicholson JA, McCallum C, Macdonald DJ, Robinson CM. Latarjet as a primary and revision procedure for anterior shoulder instability - A comparative study of survivorship, complications and functional outcomes in the medium to long-term. Shoulder Elbow 2020; 12:338-348. [PMID: 33123223 PMCID: PMC7545525 DOI: 10.1177/1758573219864926] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/17/2019] [Accepted: 06/27/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND This retrospective study aims to compare the outcome of the Latarjet procedure when used as a primary or revision procedure for recurrent anterior gleno-humeral instability. METHODS One hundred and ninety-seven patients underwent 205 open Latarjet procedures during the period 2006-2015 (mean follow-up 5.6 years). Sixty shoulders had failure of a previous stabilisation requiring revision to the Latarjet procedure. Outcomes were measured using the Western Ontario Shoulder Instability Index and Quick Disabilities of the Arm, Shoulder and Hand score. Survival analyses were performed using Kaplan-Meier curves, and multiple linear regression modelling was utilised to identify predictors of functional outcome (p < 0.05). RESULTS Two shoulders had recurrent dislocations in the cohort of 205 (1.0%). Six shoulders underwent further surgery for non-instability complications (2.9%). There were no significant differences in the clinical or functional outcome between patients undergoing a primary Latarjet procedure and those who required revision of a failed soft-tissue stabilisation. Ninety-two per cent of patients were satisfied with their shoulder following surgery. Patient-reported instability and satisfaction was significantly associated with poorer functional scores. DISCUSSION The Latarjet procedure successfully prevents recurrent anterior instability and is associated with high levels of satisfaction. Patient-reported outcome measures suggest no difference between primary and revision procedures.
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Affiliation(s)
- Liam Z Yapp
- Royal Infirmary of
Edinburgh, NHS Lothian, Edinburgh, UK,Liam Z Yapp, Department of Trauma and
Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent,
Edinburgh EH16 4SY, UK.
| | - Jamie A Nicholson
- Royal Infirmary of
Edinburgh, NHS Lothian, Edinburgh, UK,Department of Orthopaedics and Trauma,
University of Edinburgh, Edinburgh, UK
| | - Charlotte McCallum
- Department of Orthopaedics and Trauma,
University of Edinburgh, Edinburgh, UK
| | - Deborah J Macdonald
- Department of Orthopaedics and Trauma,
University of Edinburgh, Edinburgh, UK
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29
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Comadoll SM, Landry Jarvis D, Yancey HB, Graves BR. The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization. JSES Int 2020; 4:584-586. [PMID: 32939490 PMCID: PMC7479037 DOI: 10.1016/j.jseint.2020.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Shoulder dislocation is a costly problem and can have a high risk for recurrent instability after initial dislocation based on well-defined patient characteristics. Patients with recurrent instability can be treated with shoulder stabilizing procedures. Although more costly, surgery may decrease the overall health care burden of managing a patient with multiple shoulder dislocations nonoperatively. Methods We performed a retrospective chart review of all patients who presented to the emergency department (ED) with a diagnosis of a shoulder dislocation at a level 1 academic trauma center during the year 2016. Patient information regarding the current dislocation episode, previous dislocations, shoulder surgeries, and postreduction follow-up was gathered. These data were then used to determine the average cost of an ED presentation for a shoulder dislocation episode as obtained from the hospital finance department. The average cost of shoulder stabilization surgery was used to conduct a cost-benefit analysis of operative vs. nonoperative management. Results Data were collected on 104 individuals who presented to the ED with shoulder dislocations. Of these, 65 were primary dislocations and 39 were recurrent dislocations. Twelve patients underwent shoulder stabilization surgery after their ED presentation. The average cost to the institution for an ED visit requiring the closed reduction of a shoulder dislocation was $2207 ($973.21 without sedation and $3744 with conscious sedation). The average cost of a shoulder stabilization procedure performed at this same institution was $7807. Discussion and conclusion Although shoulder stabilization has a higher cost on the front end, this intervention results in cost savings if it prevents 2-3 future shoulder dislocations resulting in ED visits. These findings suggest that, for patients with a high risk for recurrent instability, not only would stabilization surgery help prevent subsequent dislocation events but would also minimize health care costs.
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Affiliation(s)
- Shea M Comadoll
- Department of Orthopaedic Surgery, Wake Forest Baptist Hospital, Winston Salem, NC, USA
| | - D Landry Jarvis
- Department of Orthopaedic Surgery, Wake Forest Baptist Hospital, Winston Salem, NC, USA
| | - Hunter B Yancey
- Department of Orthopaedic Surgery, Wake Forest Baptist Hospital, Winston Salem, NC, USA
| | - Benjamin R Graves
- Department of Orthopaedic Surgery, Wake Forest Baptist Hospital, Winston Salem, NC, USA
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30
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Kwapisz A, Shanley E, Momaya AM, Young C, Kissenberth MJ, Tolan SJ, Lonergan KT, Wyland DJ, Hawkins RJ, Pill SG, Tokish JM. Does Functional Bracing of the Unstable Shoulder Improve Return to Play in Scholastic Athletes? Returning the Unstable Shoulder to Play. Sports Health 2020; 13:45-48. [PMID: 32880525 DOI: 10.1177/1941738120942239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Functional bracing is often used as an adjunct to nonoperative treatment of anterior shoulder instability, but no study has evaluated the effectiveness of in-season bracing. The purpose of this study was to examine successful return to play in a nonoperative cohort of adolescent athletes with in-season shoulder instability and compare those athletes treated with bracing to those who were not. HYPOTHESIS The use of functional bracing will improve success rates in a cohort of athletes treated nonoperatively for in-season shoulder instability. STUDY DESIGN Cohort study. LEVEL OF EVIDENCE Level 3. METHODS A total of 97 athletes with anterior shoulder instability were followed for a minimum of 1 year. The mean age was 15.8 ± 1.4 years (range, 12.0-18.0 years). All athletes were treated with initial nonoperative management. Twenty athletes (21%) were also treated with bracing while 77 (79%) were not. The athlete completing the current season and 1 subsequent season without surgery or time lost from shoulder injury was defined as a successful outcome. RESULTS There was no statistical difference in nonoperative success rates between the braced and nonbraced athletes (P = 0.33). Braced athletes (n = 20) returned to play 80% of the time, while nonbraced athletes (n = 77) returned at a rate of 88%. Of the braced athletes, 85% were football players (n = 17). A football-only comparison demonstrated no difference between braced failures (26%) and nonbraced failures (16%) (P = 0.47). CONCLUSION This is the first study to evaluate the utility of functional bracing in returning an athlete to sport and completing a full subsequent season without surgery or time loss due to injury of the shoulder. In adolescent athletes with shoulder instability treated nonoperatively, functional bracing did not result in increased success rates when compared with no bracing. CLINICAL RELEVANCE The data from this study indicate that functional bracing may not improve success rates for athletes with shoulder instability.
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Affiliation(s)
- Adam Kwapisz
- The Hawkins Foundation, Greenville, South Carolina.,Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Lodz, Lodz, Poland
| | | | - Amit M Momaya
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, South Carolina
| | - Chris Young
- Greenville County School System, Greenville, South Carolina
| | - Michael J Kissenberth
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, South Carolina
| | - Stefan J Tolan
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, South Carolina
| | - Keith T Lonergan
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, South Carolina
| | - Douglas J Wyland
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, South Carolina
| | | | - Stephan G Pill
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, South Carolina
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31
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Revisability of polyetheretherketone suture anchors utilised in primary and revision Bankart repair. J Orthop Sci 2020; 25:830-835. [PMID: 31839390 DOI: 10.1016/j.jos.2019.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/15/2019] [Accepted: 11/08/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Polyetheretherketone (PEEK) suture anchors are frequently used in Bankart shoulder stabilisation. This study analyzed the primary stability and revisability of PEEK anchors in-vitro in case of primary Bankart repair and revision Bankart repair after failed primary repair. METHODS To simulate primary Bankart repair, 12 anchors (Arthrex PEEK PushLock® 3.5 mm) were implanted in 1, 3, 5, 7, 9 and 11 o'clock positions in cadaveric human glenoids and then cyclically tested. To simulate revision Bankart repair, 12 anchors were implanted in the same manner, over-drilled and 12 new anchors of the same diameter were implanted into the same bone socket as the primary anchors and then cyclically tested. The maximum failure loads (Fmax), system displacements, force at clinical failure and modes of failure were recorded. RESULTS One primary anchor failed prematurely due to a technical problem. Three out of 12 revision anchors (25%) dislocated while setting the 25 N preload. The Fmax, the displacement and clinical failure of the remaining 9 revision anchors were non-significant when compared to the 11 primary repair anchors. The main mode of failure in the primary and revision Bankart surgery group was suture slippage. Anchor dislocations were observed four times in the primary and once in the revision repair groups. CONCLUSIONS Revision Bankart repair using PEEK anchors of the same diameter in a pre-existing bone socket is possible but bears high risk of premature anchor failure and can jeopardize the reconstruction. PEEK suture anchor in revision Bankart surgery should be implanted in a new bone socket if possible.
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Miskovsky SN, Sasala LM, Talbot CN, Knapik DM. Differences in Failure Mode Between Simple and Mattress Suture Configuration in Arthroscopic Bankart Repairs: A Cadaveric Study. Orthop J Sports Med 2020; 8:2325967120942133. [PMID: 32864384 PMCID: PMC7432985 DOI: 10.1177/2325967120942133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 03/20/2020] [Indexed: 11/17/2022] Open
Abstract
Background Traumatic anterior shoulder dislocations disrupt the anteroinferior labrum (Bankart lesion), leading to high rates of instability and functional disability, necessitating stabilization. Purpose To investigate modes and locations of repair failure between simple and horizontal mattress suture configurations after arthroscopic Bankart repair using suture anchors in a cadaveric model. Study Design Controlled laboratory study. Methods A total of 48 fresh-frozen human cadaveric shoulders from 48 specimens underwent creation of Bankart lesions from either the 3:00 to 6:00 o'clock position on the right glenoid or the 6:00 to 9:00 o'clock position on the left glenoid. Shoulder laterality between specimens was alternated and randomized to either simple or mattress suture repair configurations. In each shoulder, anchors were placed on the glenoid at the 3:00, 4:30, and 6:00 o'clock positions on the right or 6:00, 7:30, and 9:00 o'clock positions on the left and were secured via standard arthroscopic knot-tying techniques. Specimens were tested in the supine anterior apprehension position using a servohydraulic testing machine that was loaded to failure, simulating a traumatic anterior dislocation. After dislocation, open inspection of specimens was performed, and failure mode and location were documented. Differences in failure mode and location were compared using nominal multivariate generalized estimating equations. Results Simple suture repairs most frequently failed at the labrum, while mattress suture repair failed at the capsule. Regardless of configuration, repairs failed most commonly at the 3:00 o'clock position on the right shoulder and 9:00 o'clock position on the left shoulder. Compared with mattress suture repairs, simple suture repairs failed at a significantly higher rate at the 6:00 o'clock position. Conclusion Traumatic anterior shoulder dislocation after arthroscopic Bankart repair in a cadaveric model resulted in simple suture configuration repairs failing most commonly via labral tearing compared with capsular tearing in mattress repairs. Both repair configurations failed predominately at the anterior anchor position, with simple suture repairs failing more commonly at the inferior anchor position. Clinical Relevance Horizontal mattress suture configurations create a larger area of repair, decreasing the risk of repair failure at the labrum. The extra time required for mattress suture placement at the inferior anchor position is used effectively, resulting in lower biomechanical failure rates.
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Affiliation(s)
- Shana N Miskovsky
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,University Hospitals Sports Medicine Institute, Cleveland, Ohio, USA.,School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Lee M Sasala
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Derrick M Knapik
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,University Hospitals Sports Medicine Institute, Cleveland, Ohio, USA.,School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Predicting Recurrent Instability of the Shoulder (PRIS): A Valid Tool to Predict Which Patients Will Not Have Repeat Shoulder Instability After First-Time Traumatic Anterior Dislocation. J Orthop Sports Phys Ther 2020; 50:431-437. [PMID: 32736499 DOI: 10.2519/jospt.2020.9284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the sensitivity, specificity, and validity of the Predicting Recurrent Instability of the Shoulder (PRIS) tool in people with a first-time traumatic anterior shoulder dislocation. DESIGN Prospective cohort study. METHODS People with first-time traumatic anterior shoulder dislocation (n = 85), aged 16 to 40 years, were recruited within 12 weeks of their shoulder dislocation and followed prospectively for 1 year post injury. We calculated the sensitivity, specificity, negative predictive value, and positive predictive value of the PRIS tool. RESULTS Of the 75 participants available for 1-year follow-up, 57 (76%) did not have recurrent shoulder instability. With the PRIS tool cut point set at 0.895, the tool's sensitivity was 39% (95% confidence interval [CI]: 17.3%, 64.3%) and its specificity was 95% (95% CI: 85.4%, 98.9%). The area under the curve was 0.69 (95% CI: 0.55, 0.84; P = .01). The PRIS tool correctly identified 54 of the 57 (95%) who did not have recurrent instability (accuracy, 81%; 95% CI: 70.7%, 89.4%). Negative and positive predictive values were 83% (95% CI: 77.2%, 87.7%) and 70% (95% CI: 40.2%, 89.0%), respectively. CONCLUSION The PRIS tool can predict those who will not have further shoulder instability in the year following first-time traumatic anterior shoulder dislocation. The PRIS tool cannot accurately predict those who will have recurrent shoulder instability. J Orthop Sports Phys Ther 2020;50(8):431-437. doi:10.2519/jospt.2020.9284.
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Updegrove GF, Buckley PS, Cox RM, Selverian S, Patel MS, Abboud JA. Latarjet Procedure for Anterior Glenohumeral Instability: Early Postsurgical Complications for Primary Coracoid Transfer Versus Revision Coracoid Transfer After Failed Prior Stabilization. Orthop J Sports Med 2020; 8:2325967120924628. [PMID: 32587873 PMCID: PMC7294484 DOI: 10.1177/2325967120924628] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The Latarjet procedure (coracoid transfer) is often used to successfully treat failed instability procedures. However, given the reported increased complication rates in primary Latarjet surgery, there is a heightened concern for complications in performing the Latarjet procedure as revision surgery. PURPOSE To evaluate the early outcomes and complications of the Latarjet procedure as primary surgery compared with revision surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 157 patients were included and retrospectively reviewed: 103 patients in the revision group and 54 patients in the primary group. Patients were evaluated by physical examination findings as well as by documentation of complications and reoperations extracted from their electronic medical records. RESULTS The mean follow-up was 7.8 ± 11.0 months for the primary group and 7.0 ± 13.2 months for the revision group. There were no significant differences in overall complication rates between the primary and revision groups (16.7% vs 8.7%, respectively; P = .139). The complication rate was significantly higher in patients in the revision group who had undergone a prior open procedure compared with those who had undergone only arthroscopic procedures (30.0% vs 4.1%, respectively; P < .001). Of those patients who sustained a complication, 7 of the 9 underwent a reoperation in the primary group (13.0%), and 7 of the 9 did so in the revision group (6.8%); the risk of reoperations was not different between groups (P = .198). There were 4 patients in the primary group (7.4%) and 5 patients in the revision group (4.9%) who experienced recurrent dislocations during the follow-up period (P = .513). There was no difference in postoperative range of motion. CONCLUSION The Latarjet procedure is a reasonable option for the treatment of failed arthroscopic instability repair with an early complication rate similar to that found in primary Latarjet surgery.
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Affiliation(s)
- Gary F. Updegrove
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Patrick S. Buckley
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan M. Cox
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephen Selverian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Manan S. Patel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph A. Abboud
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Domos P, Chelli M, Lunini E, Ascione F, Bercik MJ, Neyton L, Godeneche A, Walch G. Clinical and radiographic outcomes of the open Latarjet procedure in skeletally immature patients. J Shoulder Elbow Surg 2020; 29:1206-1213. [PMID: 31812583 DOI: 10.1016/j.jse.2019.09.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 09/06/2019] [Accepted: 09/12/2019] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Recurrent anterior glenohumeral instability has been studied in the young population and limited evidence is available for adolescent patients. Our study is a retrospective review of patients aged <17 years who underwent open Latarjet procedure. METHODS Forty-five patients were available for review. Clinical outcomes were assessed by range of movements, stability, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), and return to sport. Radiographs were reviewed for osteoarthritis and complications. RESULTS The median age of patients was 15.7 years (13-17), and 56% had hyperlaxity. The median follow-up time was 6.6 years (3-26). The median postoperative movements showed recovered elevation (175°), external rotation (60°), and internal rotation (T9 level). Seventy-five percent of patients returned to the same level of sport, and 98% were satisfied. Clinical outcomes showed WDS, RS, and CMS scores of 85, 95, and 84 points, respectively, and an SSV of 95%. Twenty percent of patients described mild postoperative pain, and 1 had persistent stiffness. Other complications included 24% subjective apprehension, 4% redislocation, 4% wound problems, and 2% infection. Nine percent of cases had postoperative arthritis. The overall reoperation rate was 11%: 1 open washout for infection and 4 arthroscopic screw removal due to persistent pain. We found that hyperlaxity, female sex, and large or deep Hill-Sachs lesions were frequently associated with persistent apprehension at the last follow-up. CONCLUSIONS The open Latarjet procedure provides a low rate of recurrent instability with acceptable complication rates in the long term for skeletally immature patients. It is an effective, safe treatment option without any significant glenoid growth disturbance.
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Affiliation(s)
- Peter Domos
- Royal Free London NHS Foundation Trust, Barnet and Chase Farm Hospital, London, UK.
| | - Mikaël Chelli
- Institut Universitaire Locomoteur & Sport, Hôpital Pasteur 2, Nice, France
| | | | | | | | - Lionel Neyton
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz Ramsay GDS, Lyon, France
| | - Arnaud Godeneche
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz Ramsay GDS, Lyon, France
| | - Gilles Walch
- Centre Orthopédique Santy, Hôpital Privé Jean Mermoz Ramsay GDS, Lyon, France
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Bois AJ, Mayer MJ, Fening SD, Jones MH, Miniaci A. Management of bone loss in recurrent traumatic anterior shoulder instability: a survey of North American surgeons. JSES Int 2020; 4:574-583. [PMID: 32939489 PMCID: PMC7479034 DOI: 10.1016/j.jseint.2020.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Management of bone loss in recurrent traumatic anterior shoulder instability remains a topic of debate and controversy in the orthopedic community. The purpose of this study was to survey members of 4 North American orthopedic surgeon associations to assess management trends for bone loss in recurrent anterior shoulder instability. Methods An online survey was distributed to all members of the American Shoulder and Elbow Surgeons, American Orthopaedic Society for Sports Medicine, and Canadian Orthopaedic Association and to fellow members of the Arthroscopy Association of North America. The survey comprised 3 sections assessing the demographic characteristics of survey respondents, the influence of prognostic factors on surgical decision making, and the operative management of 12 clinical case scenarios of varying bone loss that may be encountered in clinical practice. Results A total of 150 survey responses were returned. The age of the patient and quantity of bone loss were consistently considered important prognostic criteria. However, little consensus was reached for critical thresholds of bone loss and how this affected the timing (ie, primary or revision surgery) and type of bony augmentation procedure to be performed once a critical threshold was reached, especially in the context of critical humeral and bipolar bone loss. Conclusions Consistent trends were found for the management of recurrent anterior shoulder instability in cases in which no bone loss existed and when isolated critical glenoid bone loss was present. However, inconsistencies were observed when isolated critical humeral bone loss and bipolar bone loss were present.
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Affiliation(s)
- Aaron J Bois
- Section of Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Michelle J Mayer
- Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Stephen D Fening
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Morgan H Jones
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anthony Miniaci
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Most first-time anterior glenohumeral dislocations occur as the result of trauma. Many patients suffer recurrent episodes of anterior shoulder instability (ASI). The anatomy and biomechanics of ASI is addressed, as is the pathophysiology of capsulolabral injury. The roles of imaging modalities are described, including computed tomography (CT) and MR imaging with the additional value of arthrography and specialized imaging positions. Advances in 3D CT and MR imaging particularly with respect to the quantification of humeral and glenoid bone loss is discussed. The concepts of engaging and nonengaging lesions as well as on-track and off-track lesions are examined.
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Affiliation(s)
- Christopher J Burke
- Department of Radiology, NYU Langone Health, NYU Langone Orthopedic Center, 333 East 38th Street, New York, NY 10016, USA.
| | - Tatiane Cantarelli Rodrigues
- Department of Radiology, NYU Langone Health, NYU Langone Orthopedic Center, 333 East 38th Street, New York, NY 10016, USA
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Di Giacomo G, Pugliese M, Lie DTT, Chou ACC, Chen J, Rosenberg N, Itoi E. How to handle minor and major bone loss in the shoulder? Current concepts. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000378] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Anterior shoulder instability is a significant problem in orthopaedic surgery. It carries a heavy burden on quality of life, especially in young, active patients. Surgical treatment is therefore often carried out in this population. Several strategies can effectively address this issue. Yet, the consensus is lacking on the parameters which favour one technique over another, especially when bone loss is present. This is because of the complex, dynamic interplay between bone loss on the humeral side (ie, Hill-Sachs lesion) and glenoid bone loss, which is a common occurrence and defined as ‘bipolar’. There is an ongoing debate over the percentage of glenoid bone loss warranting bone block procedures: 13.5–15% is an indicator for such procedures (ie, Latarjet), although this value is still considered controversial and not uniformly accepted. A multitude of other factors (ie, age, sex, level of activity and so on) come into play alongside bipolar bone loss and the weight of each factor has yet to be fully elucidated. Also, refining the algorithm for the right procedure in the right patients will reduce the number of side effects stemming from initial, suboptimal treatment choice. Knowing how to manage previous surgical treatment failure is also key for the treating orthopaedic surgeon, who must be able to address the root cause of failure and react accordingly and effectively. This paper analyses key factors in treatment choice, the current stance of the literature on varying degrees of bone loss and choices on surgical treatment failure, lack of evidence and need for future research.
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Panzram B, Kentar Y, Maier M, Bruckner T, Hetto P, Zeifang F. Mid-term to long-term results of primary arthroscopic Bankart repair for traumatic anterior shoulder instability: a retrospective study. BMC Musculoskelet Disord 2020; 21:191. [PMID: 32220253 PMCID: PMC7102425 DOI: 10.1186/s12891-020-03223-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/19/2020] [Indexed: 01/26/2023] Open
Abstract
Background The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. The aim of the study is to determine the mid−/long-term functional outcome, failure rates and predictors of failure after primary arthroscopic Bankart repair for traumatic anterior shoulder instability. Methods A total of 100 patients were primarily operated using arthroscopic Bankart repair after traumatic anterior shoulder instability. Medical records were retrospectively reviewed, and patients were assessed using postal questionnaire after a mean follow-up of 8.3 years [3–14]. Clinical assessment was performed using Constant score, Rowe score, and American Shoulder and Elbow Surgeons score. Results The overall recurrence rate was 22%. The Kaplan-Meier failure-free survival estimates. were 80% at 5 years and 70% at 10 years. Nearly half (54.5%) of recurrences occurred at 2 years postoperative. Compared with normal shoulder, there were statistical differences in all 3 scores. Failure rate was significantly affected by age at the time of surgery with 86% of recurrence cases observed in patients aged 30 years or younger. Nevertheless, Younger age at the time of surgery (P = 0.007) as well age at the time of initial instability (P = 0.03) was found to correlate negatively with early recurrence within 2 years of surgery. Among those with recurrent instability, recurrence rate was found to be higher if there had been more than 5 instability episodes preoperatively (P = 0.01). Return to the preinjury sport and occupational level was possible in 41 and 78%, respectively. Conclusion Failure-free survival rates dropped dramatically over time. Alternative reconstruction techniques should be considered in those aged ≤30 years due to the high recurrence rate.
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Affiliation(s)
- Benjamin Panzram
- Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury, University of Heidelberg, Heidelberg, Germany. .,Heidelberg University Hospital, Clinic for Orthopaedics and Trauma Surgery, Schlierbacher Landstraße 200A, 69118, Heidelberg, Germany.
| | - Yasser Kentar
- Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury, University of Heidelberg, Heidelberg, Germany
| | - Michael Maier
- Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury, University of Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Pit Hetto
- Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury, University of Heidelberg, Heidelberg, Germany
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Yapp LZ, Nicholson JA, Robinson CM. Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder: Long-Term Follow-up of a Randomized, Double-Blinded Trial. J Bone Joint Surg Am 2020; 102:460-467. [PMID: 31895236 DOI: 10.2106/jbjs.19.00858] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the long-term efficacy of arthroscopic Bankart repair (ABR). METHODS Eighty-eight patients with an age of ≤35 years who had sustained a primary anterior glenohumeral dislocation were enrolled in a single-center, double-blinded clinical trial. Subjects were randomized to receive either an arthroscopic washout (AWO) or ABR. Participants were reassessed after a minimum of 10 years postoperatively. Data regarding recurrent instability, revision surgery, satisfaction, and function (Disabilities of the Arm, Shoulder and Hand [DASH] and Western Ontario Shoulder Instability Index [WOSI]) scores were collected. RESULTS Sixty-five patients (74%; 32 in the AWO group and 33 in the ABR group) were included and had an average follow-up of 14.2 years (range,12 to 16 years). The rate of recurrent dislocation was significantly higher in the AWO group than the ABR group (47% and 12%, respectively; p = 0.002). Kaplan-Meier curves were plotted for event-free survival using recurrent instability and/or revision surgery as clinical end points. This analysis demonstrated a sustained significant difference between the groups at 10 years after surgery (58% for the AWO group versus 79% for the ABR group; log-rank test [Mantel-Cox]; p = 0.018). Long-term WOSI scores were significantly better in the ABR group. The presence of recurrent instability was associated with significantly poorer WOSI and DASH scores. CONCLUSIONS This study demonstrates a long-term benefit in overall shoulder stability and functional outcome in high-risk patients who have undergone ABR for first-time anterior dislocation. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Liam Z Yapp
- Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Cronin KJ, Wolf BR, Magnuson JA, Jacobs CA, Ortiz S, Bishop JY, Bollier MJ, Baumgarten KM, Bravman JT, Brophy RH, Cox CL, Feeley BT, Grant JA, Jones GL, Kuhn JE, Benjamin Ma C, Marx RG, McCarty EC, Miller BS, Seidl AJ, Smith MV, Wright RW, Zhang AL, Hettrich CM. The Prevalence and Clinical Implications of Comorbid Back Pain in Shoulder Instability: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study. Orthop J Sports Med 2020; 8:2325967119894738. [PMID: 32110679 PMCID: PMC7000858 DOI: 10.1177/2325967119894738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 10/10/2019] [Indexed: 01/28/2023] Open
Abstract
Background: Understanding predictors of pain is critical, as recent literature shows that
comorbid back pain is an independent risk factor for worse functional and
patient-reported outcomes (PROs) as well as increased opioid dependence
after total joint arthroplasty. Purpose/Hypothesis: The purpose of this study was to evaluate whether comorbid back pain would be
predictive of pain or self-reported instability symptoms at the time of
stabilization surgery. We hypothesized that comorbid back pain will
correlate with increased pain at the time of surgery as well as with worse
scores on shoulder-related PRO measures. Study Design: Cross-sectional study; Level of evidence, 3. Methods: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder
Instability cohort, patients consented to participate in pre- and
intraoperative data collection. Demographic characteristics, injury history,
preoperative PRO scores, and radiologic and intraoperative findings were
recorded for patients undergoing surgical shoulder stabilization. Patients
were also asked, whether they had any back pain. Results: The study cohort consisted of 1001 patients (81% male; mean age, 24.1 years).
Patients with comorbid back pain (158 patients; 15.8%) were significantly
older (28.1 vs 23.4 years; P < .001) and were more
likely to be female (25.3% vs 17.4%; P = .02) but did not
differ in terms of either preoperative imaging or intraoperative findings.
Patients with self-reported back pain had significantly worse preoperative
pain and shoulder-related PRO scores (American Shoulder and Elbow Surgeons
score, Western Ontario Shoulder Instability Index) (P <
.001), more frequent depression (22.2% vs 8.3%; P <
.001), poorer mental health status (worse scores for the RAND 36-Item Health
Survey Mental Component Score, Iowa Quick Screen, and Personality Assessment
Screener) (P < .01), and worse preoperative expectations
(P < .01). Conclusion: Despite having similar physical findings, patients with comorbid back pain
had more severe preoperative pain and self-reported symptoms of instability
as well as more frequent depression and lower mental health scores. The
combination of disproportionate shoulder pain, comorbid back pain and mental
health conditions, and inferior preoperative expectations may affect not
only the patient’s preoperative state but also postoperative pain control
and/or postoperative outcomes.
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Affiliation(s)
- Kevin J Cronin
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Brian R Wolf
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Justin A Magnuson
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Cale A Jacobs
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Shannon Ortiz
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | | | - Julie Y Bishop
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Matthew J Bollier
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Keith M Baumgarten
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Jonathan T Bravman
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Robert H Brophy
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Charles L Cox
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Brian T Feeley
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - John A Grant
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Grant L Jones
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - John E Kuhn
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - C Benjamin Ma
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Robert G Marx
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Eric C McCarty
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Bruce S Miller
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Adam J Seidl
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Matthew V Smith
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Rick W Wright
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Alan L Zhang
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
| | - Carolyn M Hettrich
- Investigation performed at the University of Kentucky Department of Orthopaedic Surgery & Sports Medicine, Lexington, Kentucky, USA
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Lemmex D, Cárdenas G, Ricks M, Woodmass J, Chelli M, Boileau P. Arthroscopic Management of Anterior Glenoid Bone Loss. JBJS Rev 2020; 8:e0049. [DOI: 10.2106/jbjs.rvw.19.00049] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Eshoj HR, Rasmussen S, Frich LH, Hvass I, Christensen R, Boyle E, Jensen SL, Søndergaard J, Søgaard K, Juul-Kristensen B. Neuromuscular Exercises Improve Shoulder Function More Than Standard Care Exercises in Patients With a Traumatic Anterior Shoulder Dislocation: A Randomized Controlled Trial. Orthop J Sports Med 2020; 8:2325967119896102. [PMID: 32064291 PMCID: PMC6993151 DOI: 10.1177/2325967119896102] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/25/2019] [Indexed: 12/26/2022] Open
Abstract
Background: There is an important gap in knowledge about the effectiveness of nonoperative treatment (exercise) for patients with traumatic primary and recurrent anterior shoulder dislocations (ASDs). Purpose/Hypothesis: The purpose of this study was to assess the efficacy and safety of physical therapist–supervised, shoulder instability neuromuscular exercise (SINEX) versus self-managed, home-based, standard care shoulder exercise (HOMEX) in patients with traumatic ASDs. The hypothesis was that SINEX would have a larger effect and fewer adverse events compared with HOMEX. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 56 participants with radiographically verified, trauma-initiated primary or recurrent ASDs and self-reported decreased shoulder function were randomized to 12 weeks of either SINEX or HOMEX. The SINEX program consisted of 7 exercises, individually progressing from basic (2 × 20 repetitions each day) to elite (2 × 10 repetitions, 3 times weekly). The HOMEX program included 5 shoulder exercises performed 3 times weekly (2 × 10 repetitions). The primary outcome was the Western Ontario Shoulder Instability Index (WOSI) score, ranging from 0 (best possible) to 2100. The between-group minimal clinically important difference at 12 weeks was 250 points. Secondary outcomes included WOSI subdomain scores, patient-reported ratings of kinesiophobia and pain, objective shoulder function, patient satisfaction, and number of adverse events. Results: The between-group mean difference in the WOSI total score at 12 weeks significantly favored SINEX over HOMEX (–228.1 [95% CI, –430.5 to –25.6]). SINEX was furthermore superior to HOMEX in most of the secondary outcomes (3/4 subdomains of the WOSI and pain level during the past 7 days as well as clinical signs of anterior shoulder instability). Also, although not statistically significant, less than half the proportion of the SINEX patients compared with the HOMEX patients (3/27 [11%] vs 6/24 [25%], respectively; P = .204) underwent or were referred for shoulder stabilizing surgery. Satisfaction with both exercise programs was high, and no serious adverse events were reported. Conclusion: Neuromuscular shoulder exercise (SINEX) was superior to standard care exercise (HOMEX) in patients with traumatic ASDs. Further long-term follow-ups on treatment effects are needed. Registration: NCT02371928 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Henrik Rode Eshoj
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Quality of Life Research Center, Department of Haematology, Odense University Hospital, Odense, Denmark
| | - Sten Rasmussen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Henrik Frich
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Inge Hvass
- Shoulder Section, Department of Orthopaedic Surgery, South-West Jutland Hospital, Esbjerg, Denmark
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark.,Rheumatology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Eleanor Boyle
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Steen Lund Jensen
- Shoulder Section, Department of Orthopaedic Surgery, Aalborg University Hospital, Farsoe, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Karen Søgaard
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Birgit Juul-Kristensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
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Beletsky A, Cancienne JM, Manderle BJ, Mehta N, Wilk KE, Verma NN. A Comparison of Physical Therapy Protocols Between Open Latarjet Coracoid Transfer and Arthroscopic Bankart Repair. Sports Health 2020; 12:124-131. [PMID: 31916920 DOI: 10.1177/1941738119887396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Recent studies examining return to sport after traumatic shoulder instability suggest faster return-to-sport time lines after bony stabilization when compared with soft tissue stabilization. The purpose of the current study was to define variability across online Latarjet rehabilitation protocols and to compare Latarjet with Bankart repair rehabilitation time lines. EVIDENCE ACQUISITION Online searches were utilized to identify publicly available rehabilitation protocols from Accreditation Council for Graduate Medical Education (ACGME)-accredited academic orthopaedic surgery programs. STUDY DESIGN Descriptive epidemiology study. LEVEL OF EVIDENCE Level 3. RESULTS Of the 183 ACGME-accredited orthopaedic programs reviewed, 14 institutions (7.65%) had publicly available rehabilitation protocols. A web-based search yielded 17 additional protocols from private sports medicine practices. Of the 31 protocols included, 31 (100%) recommended postoperative sling use and 26 (84%) recommended elbow, wrist, and hand range of motion exercises. Full passive forward flexion goals averaged 3.22 ± 2.38 weeks postoperatively, active range of motion began on average at 5.22 ± 1.28 weeks, and normal scapulothoracic motion by 9.26 ± 4.8 weeks postoperatively. Twenty (65%) protocols provided specific recommendations for return to nonoverhead sport-specific activities, beginning at an average of 17 ± 2.8 weeks postoperatively. This was compared with overhead sports or throwing activities, for which 18 (58%) of protocols recommended beginning at a similar average of 17.1 ± 3.3 weeks. CONCLUSION Similar to Bankart repair protocols, Latarjet rehabilitation protocols contain a high degree of variability with regard to exercises and motion goal recommendations. However, many milestones and start dates occur earlier in Latarjet protocols when compared with Bankart-specific protocols. Consequently, variability in the timing of rehabilitation goals may contribute to earlier return to play metrics identified in the broader literature for the Latarjet procedure when compared with arthroscopic Bankart repair. STRENGTH OF RECOMMENDATION TAXONOMY (SORT) Level C.
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Affiliation(s)
- Alexander Beletsky
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | | | - Brandon J Manderle
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Nabil Mehta
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Kevin E Wilk
- Champion Sports Medicine, American Sports Medicine Institute, Birmingham, Alabama
| | - Nikhil N Verma
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
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45
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Trojan JD, Meyer LE, Edgar CM, Brown SM, Mulcahey MK. Epidemiology of Shoulder Instability Injuries in Collision Collegiate Sports From 2009 to 2014. Arthroscopy 2020; 36:36-43. [PMID: 31864594 DOI: 10.1016/j.arthro.2019.07.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 02/09/2023]
Abstract
PURPOSE To describe the types, mechanisms, and severity of shoulder instability injuries in collegiate collision athletes during the 2009-2010 through 2013-2014 academic years using the National Collegiate Athletic Association Injury Surveillance Program; to compare the injury incidence between men's collision sports and their women's non-collision counterparts, when possible; and to compare injury outcomes between Divisions I, II, and III. METHODS Data regarding men's football, wrestling, ice hockey, and lacrosse, as well as women's ice hockey and lacrosse, were obtained. Injuries requiring attention from a health care provider were reported. Incidence rates per 100,000 athlete-exposures (AEs) were calculated with 95% confidence intervals (CIs). Analysis of variance was used to compare time loss (TL), and χ2 analysis was used to compare surgery rates between divisions. RESULTS A total of 445 shoulder instability injuries occurred in 1,421,561 AEs from 2009-2010 to 2013-2014 (incidence rate, 31.30 injuries/100,000 AEs; 95% CI, 28.4-34.21 injuries/100,000 AEs). Subluxation accounted for 59.1% of injuries, with anterior subluxation (35.3%) being the most common injury. Dislocation resulted in the most TL per injury (17.58 days). Mean TL for all injuries was 8.17 days (standard deviation, 7.21 days). When non-time-loss injuries were excluded from analysis, players experienced a mean TL of 18.34 days (standard deviation, 8.44 days). Divisions I (4.77 days), II (20.52 days), and III (11.23 days) differed significantly in mean TL (P = .01). Of the injuries, 29.3% required surgery. The surgery rates for Divisions I (32.9%), II (38.1%), and III (19.4%) also differed significantly (P = .04). Men's ice hockey and lacrosse players sustained a 2.17-fold (95% CI, 1.04-4.50) higher incidence of shoulder instability than their female counterparts. CONCLUSIONS Anterior subluxation and dislocation accounted for 52.1% of all shoulder instability injuries. Injured athletes missed 8 days on average, and nearly 30% of injuries required surgery. Surgery rates and TL were significantly different between Divisions I, II, and III. Female athletes playing non-collision ice hockey and lacrosse experienced significantly lower shoulder instability rates than their male counterparts. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Jeffrey D Trojan
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Lucy E Meyer
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Cory M Edgar
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Storrs, Connecticut, U.S.A
| | - Symone M Brown
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A..
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Leland DP, Bernard CD, Keyt LK, Krych AJ, Dahm DL, Sanchez-Sotelo J, Camp CL. An Age-Based Approach to Anterior Shoulder Instability in Patients Under 40 Years Old: Analysis of a US Population. Am J Sports Med 2020; 48:56-62. [PMID: 31756127 DOI: 10.1177/0363546519886861] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND While a large volume of literature has focused on risk factors for anterior shoulder instability, the rates of recurrence are inconsistent and require additional population-based epidemiologic data. PURPOSE/HYPOTHESIS The purpose was to report the effect of patient age on the number of instability events before physician consultation, rate of surgical stabilization, recurrent instability, and progression to osteoarthritis in patients <40 years old with anterior shoulder instability, utilizing an established US geographic population. We hypothesized that younger patients would be more likely to experience multiple episodes of instability before evaluation, undergo surgery, and experience recurrent instability after surgical intervention. STUDY DESIGN Descriptive epidemiologic study. METHODS An established geographic database of more than 500,000 patients was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient characteristics, history, imaging, surgical details, and outcomes. Patients were divided into 5 groups based on age (≤15, 16-20, 21-25, 26-30, and 31-40 years) at initial instability. Comparative analysis was performed to identify differences between groups. RESULTS The study population consisted of 654 patients with a mean follow-up of 11.1 years (range, 2.0-25.2 years). This resulted in 118 patients (18%) ≤15 years of age at initial instability; 250 (38%), 16 to 20 years; 110 (17%), 21 to 25 years; 80 (12%), 26 to 30 years; and 96 (15%), 31 to 40 years. Of patients ≤15 years old at initial instability 47% had 3+ instability events, compared with 12% of patients aged 31 to 40 years (P < .001). At 10 years of follow-up, patients ≤15 and 16 to 20 years old demonstrated the highest recurrent instability rates of 38.8% and 47.1% after nonoperative management, respectively. Patients 16 to 20 years old demonstrated the highest rates of both surgical intervention (40.4%) and recurrence after surgery (24.8%). Patients 31 to 40 years of age were significantly more likely to develop clinically symptomatic osteoarthritis (15.6%) than all other age groups. CONCLUSION In a US epidemiologic population of patients <40 years old, the rate of recurrent anterior shoulder instability was roughly one-third after initial physician consultation. Younger patients, particularly those ≤15 and 16 to 20 years of age, were more likely to have experienced multiple instability events at the time of initial evaluation, require surgery, and experience recurrent instability compared with older patients. For every year of decrease in age at initial instability, the risk of recurrent instability or surgical intervention after physician consultation increased by 4.1% and 2.8%, respectively.
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Affiliation(s)
- Devin P Leland
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Lucas K Keyt
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Diane L Dahm
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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47
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Dupley L, Funk L. The Latarjet Procedure: Effective and Safe. Open Orthop J 2019. [DOI: 10.2174/1874325001913010272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background:
The Latarjet procedure is used to treat recurrent anterior shoulder instability in patients with bony glenoid loss and/or failed previous stabilisation surgery. It has reportedly high success rates, but recent publications have reported concerns of high complication rates. This study aims to assess the complications and outcomes of the Latarjet procedure in our institution, with a minimum 2-year follow-up and compared it to the current literature.
Methods:
Patients who underwent the procedure over a 36-month period were included in this study (n=81). Seventy-three (90%) patients in our cohort competed in amateur to professional level sports. The indications for surgery were recurrent instability with associated bony glenoid deficiency and/or previous failed arthroscopic stabilisations. The Oxford Shoulder Instability, Constant Shoulder and QuickDASH scores were recorded pre- and post-operatively, along with post-operative complications and failures.
Results:
Eight (9.9%) complications were recorded: three re-dislocations, two deep infections, one haematoma, one screw breakage and one case of biceps tendinopathy. The mean pre-operative Oxford Shoulder Instability Score improved from 23.2 ± 10.1 to 37 ± 9.2 following the procedure. The mean Constant Shoulder and quickDASH scores also improved from 55.1 ± 21.2 and 30.3 ± 24.3 to 88.1 ± 9.2 and 17.7 ± 23.5 respectively. 98.6% of the patients returned to their pre-injury level of sports.
Conclusion:
From this study it can be concluded the Latarjet procedure is an effective surgical treatment for
recurrent anterior shoulder instability associated with bony glenoid loss, even in high contact professional athletes. Complication rates are lower than previous recent studies have stated.
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48
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An Algorithmic Approach to the Management of Shoulder Instability. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:JAAOSGlobal-D-19-00168. [PMID: 32072126 PMCID: PMC7004496 DOI: 10.5435/jaaosglobal-d-19-00168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The recurrence of anterior shoulder instability can be as high as 86.7% in high-risk patients who are treated nonoperatively after their first incident of instability. CT and MR arthrography are necessary for preoperative imaging and assessment of glenoid bone loss. Patient expectations in conjunction with appropriate preoperative imaging are critical for surgical planning. Arthroscopic shoulder stabilization is often sufficient in most cases where glenoid bone loss is minimal, with recurrent dislocation rates close to 4% in the literature. Open stabilization procedures are generally indicated in patients with greater than 20% glenoid bone loss.
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Williams HLM, Evans JP, Furness ND, Smith CD. It's Not All About Redislocation: A Systematic Review of Complications After Anterior Shoulder Stabilization Surgery. Am J Sports Med 2019; 47:3277-3283. [PMID: 30525905 DOI: 10.1177/0363546518810711] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The surgical treatment of recurrent shoulder instability has evolved in recent years to include a variety of soft tissue and bone block procedures, undertaken with either an open or arthroscopic approach. Although the utilization of such techniques has rapidly expanded, the associated risk of complications remains poorly defined. This information is vital for clinical decision making and patient counseling. PURPOSE To quantify the complication rate associated with all types of surgery for anterior glenohumeral joint dislocation. STUDY DESIGN Systematic review. METHODS A systematic search was undertaken of studies reporting complications from anterior shoulder stabilization surgery. Inclusion criteria were studies published in English between 2000 and 2017 with a minimum 2-year follow-up. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies criteria. Complication rates for all undesirable events contributing to the patient outcome were extracted and cumulative rates calculated. RESULTS Out of 1942 references, 56 studies were included, totaling 4362 procedures among 4336 patients. Arthroscopic soft tissue repair had a complication rate of 1.6% (n = 2805). When repair was combined with arthroscopic remplissage, the rate was 0.5% (n = 219). Open soft tissue repair had a complication rate of 6.2% (n = 219) and open labral repair with remplissage, a rate of 2.3% (n = 79). An open bone block procedure had a complication rate of 7.2% (n = 573) and an arthroscopic bone block procedure, a rate of 13.6% (n = 163). CONCLUSION This large systematic review demonstrates the overall complication rates (not purely recurrence rates) in modern shoulder stabilization surgery. With the growing interest in bone block stabilization procedures, including those performed arthroscopically, surgeons should be aware of the 10-fold increase in complications for these procedures over soft tissue arthroscopic surgery and counsel their patients accordingly.
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Lemme NJ, Kuczmarski AS, Goodman AD, Ready LV, Dickens JF, Owens BD. Management and Outcomes of In-Season Anterior Shoulder Instability in Athletes. JBJS Rev 2019; 7:e2. [DOI: 10.2106/jbjs.rvw.19.00010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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