Risk Factors for Failure of Arthroscopic Revision Anterior Shoulder Stabilization

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term results of arthroscopic capsulolabral revision repair for failed anterior shoulder instability repair using suture anchors at a minimum of 10 years follow-up

INTRODUCTION

Arthroscopic revision anterior shoulder instability repair has been proposed, and early clinical results have been promising. However, long-term results after this procedure and the probable risk factors for failure have not been sufficiently discussed in the literature.

MATERIALS AND METHODS

Thirty-eight patients who were diagnosed with recurrent anteroinferior shoulder instability after failed Bankart repair, treated with ACRR between September 1998 and November 2003 and able to be contacted were included. Of these patients, 2 were excluded from the study due to the use of SureTak anchors for fixation, and 5 other patients refused to participate in the study due to lack of interest (3 patients) or lack of time (2 patients). The remaining shoulders were clinically examined at a minimum of ten years after surgery via the ASES, Constant, AAOS, Rowe, Dawson and VAS scores for pain and stability. Degenerative arthropathy was assessed with the modified Samilson-Prieto score.

RESULTS

All 31 remaining shoulders were evaluated at a mean time of 11.86 years (142.4 months) after surgery. Six patients (19.35%) reported redisolcation after the revision procedure, 4 of whom were affected by a new significant shoulder trauma. The ROWE and Constant scores improved significantly. Moderate to severe dislocation arthropathy was observed in 19.4% of patients. Five patients (16.2%) were not satisfied with the procedure.

CONCLUSION

Long-term follow-up after ACRR shows predictable results, with a high degree of patient satisfaction, good to excellent patient-reported outcome scores and minimal radiological degenerative changes. However, with an average recurrence rate of 19.3% after 11.86 years, the redislocation rate appears high. With careful patient selection, recurrence rates can be significantly reduced.

Is Revision Arthroscopic Bankart Repair a Viable Option? A Systematic Review of Recurrent Instability following Bankart Repair

Background/Objectives: Recurrent shoulder instability following Bankart lesion repair often necessitates surgical revision. This systematic review aims to understand the failure rates of arthroscopic revision Bankart repair. Methods: Following the PRISMA guidelines and registered on PROSPERO, this systematic review examined twenty-five articles written between 2000 and 2024. Two independent reviewers assessed eligibility across three databases, focusing on recurrent instability as the primary endpoint, while also noting functional measures, adverse events, revision operations, and return-to-sport rates when available. Results: The key surgical techniques for recurrent instability post-Bankart repair were identified, with revision arthroscopic Bankart being the most common (685/1032). A comparative analysis revealed a significantly lower recurrence for open coracoid transfer compared to arthroscopic revision Bankart repair (9.67% vs. 17.14%; p < 0.001), while no significant difference was observed between remplissage plus Bankart repair and Bankart repair alone (23.75% vs. 17.14%; p = 0.24). The majority of studies did not include supracritical glenoid bone loss or engaging Hill-Sachs lesions, and neither subcritical nor non-engaging lesions significantly influenced recurrence rates (p = 0.85 and p = 0.80, respectively). Conclusions: Revision arthroscopic Bankart repair remains a viable option in the absence of bipolar bone loss; however, open coracoid transfer appears to have lower recurrence rates than arthroscopic Bankart repair, consistent with prior evidence. Further studies should define cutoffs and investigate the roles of critical glenoid bone loss and off-track Hill-Sachs lesions. Preoperative measurements of GBL on three-dimensional computed tomography and characterizing lesions based on glenoid track will help surgeons to choose ideal candidates for arthroscopic revision Bankart repair.

Location and size of the reverse Hill-Sachs lesion in patients with traumatic posterior shoulder instability

BACKGROUND

In patients with traumatic posterior shoulder instability, little is known about the precise location and size of the reverse Hill-Sachs lesion.

METHODS

Forty-nine shoulders of 47 patients with traumatic posterior instability were included in this study based on the following inclusion criteria: (1) a primary or recurrent traumatic posterior shoulder dislocation and (2) the initial event being caused by trauma. Patients were excluded if they had (1) no history of trauma, (2) prior shoulder surgery, (3) no computed tomographic (CT) examination, or (4) were seizure cases. Three-dimensional images of the humerus reconstructed from CT images were reviewed using an image analysis software. The location and size of the reverse Hill-Sachs lesion were measured and described on a clock face on the humeral head.

RESULTS

The reverse Hill-Sachs lesion was observed in 25 of 49 shoulders (51%). The reverse Hill-Sachs lesions were located between 1:37 and 2:48. The depth of the reverse Hill-Sachs lesion (mean ± standard deviation) was 5.8 ± 2.2 mm. The extent of the reverse Hill-Sachs lesion was 35° ± 12°. The average orientation of the reverse Hill-Sachs lesion, represented by an angle measured from the 12 o'clock position, was 64° ± 12° and pointing toward 2:09 on a clock face. The mean length and width of reverse Hill-Sachs lesions were 9.7 ± 4.7 mm and 11.1 ± 3.6 mm, respectively.

CONCLUSION

The reverse Hill-Sachs lesion was a semicircular compression fracture located on the anteromedial aspect of the humeral head. Compared with shoulders with anterior shoulder instability, the humeral defect was smaller and located more inferiorly in shoulders with posterior instability.

Glenoid Bone Loss in Recurrent Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review

BACKGROUND

Glenoid bone loss has been reported to occur in as many as 86% of patients with recurrent shoulder stability. This systematic review evaluated the amount of glenoid bone loss associated with recurrent shoulder dislocation or subluxation and with worse patient-reported outcomes after arthroscopic Bankart repair. We hypothesized that the percentage of glenoid bone loss associated with recurrent instability after arthroscopic Bankart repair is lower than the previously proposed critical value of 25%.

METHODS

The systematic review included 528 patients with glenoid bone loss from 3 clinical studies. The percentage of bone loss was the value quantified and reported in each study. Failure was defined as recurrent dislocation or subluxation. The percentage of glenoid bone loss associated with recurrent shoulder dislocation or subluxation after arthroscopic Bankart labral repair was analyzed with receiver operating characteristic (ROC) curve analysis.

RESULTS

Recurrent dislocation or subluxation occurred in 23.7% (125) of 528 patients in the pooled study cohort. There was a significant difference in age between those in whom the arthroscopic Bankart repair failed and those in whom it did not (22.9 versus 24.3 years; p = 0.009). The ROC curve analysis demonstrated that ≥16.0% glenoid bone loss was predictive of recurrent shoulder dislocation or subluxation (Youden index = 0.59, sensitivity = 80%, specificity = 80%). In patients who did not sustain a recurrent dislocation or subluxation, the ROC curve analysis demonstrated that 20.0% glenoid bone loss was predictive of a Single Assessment Numeric Evaluation (SANE) score of <85% (Youden index = 0.93, sensitivity = 93%, specificity = 100%).

CONCLUSIONS

The critical amount of glenoid bone loss associated with an increased risk of persistent instability was found to be less than previously reported. Glenoid bone loss of ≥16.0% was found to place patients at higher risk for recurrent shoulder dislocation or subluxation after treatment with arthroscopic Bankart repair alone.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Recurrent bilateral atraumatic shoulder dislocation in a young patient with bilateral shoulder multidirectional instability: Treatment consideration and description of a surgical technique

INTRODUCTION

Multidirectional instability is defined as symptomatic glenohumeral joint subluxation or dislocation occurring in more than one direction. Multidirectional shoulder instability with recurrent shoulder dislocation is a rare condition with controversies in the literature about the best treatment strategy. Physiotherapy remains the initial treatment of choice, and surgical intervention should be performed only if debilitating symptoms continue to be experienced.

CASE PRESENTATION

A young healthy male presented with bilateral shoulder multidirectional instability and recurrent shoulders atraumatic dislocation. The patient was treated with a supervised physiotherapy regimen, which succeeded on his non-dominant shoulder but failed on the contralateral dominant side. A surgical technique aimed at reducing the right shoulder capsule volume to gain stability was performed and described in detail in this paper. Patient was able to return to his normal daily activities, including sports, without new complaints.

DISCUSSION

The aim of surgery is to restore passive stability by reducing the shoulder capsular volume. Common surgical techniques for Multidirectional instability include an inferior capsular shift and open or arthroscopic capsular plication with variable outcomes have been proposed in the literature.

CONCLUSION

Surgical management should be individualized to address the anatomical cause of instability and should only be considered if conservative treatment with supervised physiotherapy fails. Using an arthroscopic grasper to apply appropriate capsule traction and tension while performing the plication and using an extra superior anchor contributed to attaining optimal capsular volume reduction.

Recurrent Instability After Arthroscopic Bankart Repair in Patients With Hyperlaxity and Near-Track Lesions

Background

Recurrent anterior shoulder instability after arthroscopic Bankart repair presents a challenging clinical problem, with the primary stabilization procedure often portending the best chance for clinical success.

Purpose

To determine if capsuloligamentous laxity affects failure (recurrent dislocation, subluxation, and/or perceived instability symptoms) after arthroscopic Bankart repair in patients with near-track lesions (ie, those with smaller distance to dislocation [DTD]).

Study Design

Case-control study; Level of evidence, 3.

Methods

The authors retrospectively reviewed consecutive patients who underwent primary arthroscopic Bankart repair for recurrent anterior glenohumeral instability at a single institution between 2007 and 2019 and who had at least 2 years of follow-up data. Patients with glenoid bone loss >20%, off-track lesions, concomitant remplissage, or rotator cuff tear were excluded. Capsuloligamentous laxity, or hyperlaxity, was defined as external rotation >85° with the arm at the side and/or grade ≥2 in at least 2 planes with the shoulder at 90° of abduction. Near-track lesions were defined as those with a DTD <10 mm.

Results

Included were 173 patients (mean age, 20.5 years; mean DTD, 16.2 mm), of whom 16.8% sustained a recurrent dislocation and 6.4% had recurrent subluxations (defined as any subjective complaint of recurrent instability without frank dislocation), for an overall recurrent instability rate of 23.1%. The rate of revision stabilization was 15.6%. The mean time to follow-up was 7.4 years. Independent predictors of recurrent instability were younger age (P = .001), smaller DTD (P = .021), >1 preoperative instability episode (P < .001), and the presence of hyperlaxity during examination under anesthesia (P = .013). Among patients with near-track lesions, those with hyperlaxity had a recurrent instability rate almost double that of patients without hyperlaxity (odds ratio, 34.1; P = .04). The increased rate of failure and recurrent dislocation in the near-track hyperlaxity cohort remained elevated, even in patients with no bone loss.

Conclusion

Capsuloligamentous shoulder laxity was a significant independent risk factor for failure after primary arthroscopic Bankart repair without remplissage and was more predictive of failure in patients with versus without near-track lesions.

Revision Arthroscopic Bankart Repair Results in High Failure Rates and a Low Return to Duty Rate Without Recurrent Instability

PURPOSE

The purpose of this study was to determine, in a military population without critical bone loss, the rate of recurrent instability after revision arthroscopic stabilization for failed primary arthroscopic Bankart repair.

METHODS

Forty-one revision arthroscopic stabilizations were performed at a single military institution between 2005 to 2016 for recurrent anterior shoulder instability after primary arthroscopic Bankart repair. Minimum follow-up was 2 years, and shoulders with glenoid bone loss >20% were excluded. The primary outcome of interest was the incidence of failure, defined by recurrent instability.

RESULTS

Age at revision surgery averaged 22.9 ± 4.3 years, and 88% were either service academy cadets or active duty combat arms soldiers. Mean follow-up was 7.8 years. Twenty-three patients (56%) returned to duty without recurrent instability after revision arthroscopic stabilization. Eighteen patients (44%) experienced recurrent instability after return to duty. Glenoid bone loss averaged 6.2% (95% confidence interval [CI], 3.2%-9.2%) in the successful group and 5.7% (95% CI, 3.1%-8.3%) in the failure group (P = .808).

CONCLUSIONS

Revision arthroscopic stabilization of failed primary arthroscopic Bankart repair has a failure rate of 44% in a young military population. The similar amounts of bone loss between groups indicates that bone loss is not the primary determinant of failure in revision arthroscopic stabilization.

LEVEL OF EVIDENCE

IV, Case Series.

Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation With Comparable Clinical Outcomes

PURPOSE

The purpose of this study was to compare rates of recurrent dislocation and postsurgical outcomes in patients undergoing arthroscopic Bankart repair for anterior shoulder instability immediately after a first-time traumatic anterior dislocation versus patients who sustained a second dislocation event after initial nonoperative management.

METHODS

A retrospective chart review was performed of patients undergoing primary arthroscopic stabilization for anterior shoulder instability without concomitant procedures and minimum 2-year clinical follow-up. Primary outcome was documentation of a recurrent shoulder dislocation. Secondary clinical outcomes included range of motion, Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Shoulder Activity Scale (SAS).

RESULTS

Seventy-seven patients (mean age 21.3 years ± 7.3 years) met inclusion criteria. Sixty-three shoulders underwent surgical stabilization after a single shoulder dislocation, and 14 underwent surgery after 2 dislocations. Average follow-up was 35.9 months. The rate of recurrent dislocation was significantly higher in the 2-dislocation group compared to single dislocations (42.8% vs 14.2%, P = .03). No significant difference was present in range of motion, VAS, ASES, and SAS scores. The minimal clinically important difference (MCID) was 1.4 for VAS and 1.8 for SAS scores. The MCID was met or exceeded in the primary dislocation group in 31/38 (81.6%) patients for VAS, 23/31 (74.1%) for ASES, and 24/31 for SES (77.4%) scores. For the second dislocation cohort, MCID was met or exceeded in 7/9 (77.8%) for VAS, 4/7 (57.1%) for ASES, and 5/7 for SES (71.4%) scores.

CONCLUSION

Immediate arthroscopic surgical stabilization after a first-time anterior shoulder dislocation significantly decreases the risk of recurrent dislocation in comparison to those who undergo surgery after 2 dislocation events, with comparable clinical outcome scores. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and sustain just 1 additional dislocation event are at increased risk of a failing arthroscopic repair.

STUDY DESIGN

Retrospective comparative study; Level of evidence, 3.

Revision Arthroscopic Labral Repair Using All-Suture Anchors in Patients With Subcritical Glenoid Bone Loss After Failed Bankart Repair: Clinical Outcomes at 2-Year Follow-up

Background

All-suture anchors have been used for primary arthroscopic Bankart repair because of their ability to minimize initial bone loss.

Purpose

To evaluate the clinical efficacy of using all-suture anchors in revision arthroscopic labral repair after failed Bankart repair.

Study Design

Case series; Level of evidence, 4.

Methods

Enrolled in this study were 28 patients who underwent revision arthroscopic labral repair with all-suture anchors after a failed primary arthroscopic Bankart repair. Revision surgery was determined for patients who had a frank redislocation history with subcritical glenoid bone loss (<15%), nonengaged Hill-Sachs lesion, or off-track lesion. Minimum 2-year postoperative outcomes were evaluated using shoulder range of motion (ROM), the Rowe score, the American Shoulder and Elbow Surgeons (ASES) score, apprehension, and the redislocation rate. Postoperative shoulder anteroposterior radiographs were assessed to evaluate arthritic changes in the glenohumeral joint.

Results

The mean patient age was 28.1 ± 6.5 years, and the mean time between primary Bankart repair and revision surgery was 5.4 ± 4.1 years. Compared with the number of suture anchors used in the primary operation, significantly more all-suture anchors were inserted in the revision surgery (3.1 ± 0.5 vs 5.8 ± 1.3, P < .001). During the mean follow-up period of 31.8 ± 10.1 months, 3 patients (10.7%) required reoperation because of traumatic redislocation and symptomatic instability. Of patients with symptoms that did not require reoperation, 2 patients (7.1%) had subjective instability with apprehension depending on the arm position. There was no significant change between preoperative and postoperative ROM. However, ASES (preoperative: 61.2 ± 13.3 to postoperative: 81.4 ± 10.4, P < .01) and Rowe (preoperative: 48.7 ± 9.3 to postoperative: 81.7 ± 13.2, P < .01) scores were significantly improved after revision surgery. Eight patients (28.6%) showed arthritic changes in the glenohumeral joint on final plain anteroposterior radiographs.

Conclusion

Revision arthroscopic labral repair using all-suture anchors demonstrated satisfactory 2-year clinical outcomes in terms of functional improvement. Postoperative stability was obtained in 82% of patients without recurrent shoulder instability after failed arthroscopic Bankart repair.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Management of Shoulder Instability in Patients with Underlying Hyperlaxity

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Outcomes After Arthroscopic Revision Bankart Repair: An Updated Systematic Review of Recent Literature

PURPOSE

To provide an update of recent literature with a specialized focus on clinical outcomes following arthroscopic revision Bankart repair (ARBR) by performing a systematic review of all available literature published between 2013 and 2020.

METHODS

A literature search reporting clinical outcomes after ARBR was performed. Criteria for inclusion consisted of original studies; Level of Evidence of I-IV; studies focusing on clinical outcomes after ARBR published between January 1, 2013, and January 4, 2021; studies reporting recurrent dislocation or instability rate after ARBR; reoperation/revision following ARBR, return to sport rates following ARBR; and patient-reported outcomes. The primary outcomes of interest were failure defined as recurrent instability or dislocation, return to sport rates, and patient-reported outcomes at follow-up.

RESULTS

A large proportion of patients undergoing arthroscopic revision Bankart repair were male, ranging between 67.7% and 93.8%. Failure rate and return to sports rate ranged between 6.1% and 46.8% and 25.9% and 88.3%, respectively, when patients with significant or greater than 20% glenoid bone loss was excluded. Patient-reported outcome scores, which included American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale, saw significant improvement over mean follow-up of ranging 21.64 to 60 months.

CONCLUSIONS

Both the failure rate and RTS rates after ARBR had a wide range, given the heterogeneity of the studies included, which varied in patient selection criteria pertaining to patients with greater than 20% glenoid bone. Although there have been advancements in arthroscopic techniques and a trend favoring arthroscopic stabilization procedures, there is a lack of consensus in recent literature for careful patient selection criteria that would minimize failure rates and maximize RTS rates after ARBR.

LEVEL OF EVIDENCE

Level IV, a systematic review of Level III-IV studies.

Shoulder Anteroinferior Glenoid Labrum Reconstruction With the Long Head of the Biceps Tendon Restores Glenohumeral Stability: A Cadaveric Biomechanical Study

PURPOSE

The purpose of this cadaveric study was to determine feasibility and assess biomechanical stability of glenoid labral reconstruction utilizing the long head of the biceps tendon (LHBT) as a local autograft for labral deficient shoulders.

METHODS

Ten cadaveric shoulders underwent resection of all soft tissue structures except the labrum and LHBT. The scapula and humerus were separately attached to a custom shoulder testing apparatus allowing for 22.5 N of compressive isotonic force across the joint. An Instron (Electroplus 1000) measured the peak force (N) as the humeral head was translated over the anteroinferior glenoid rim through 10 cycles. Shoulders were tested in 3 separate scenarios: intact labrum, resected labrum from 3- to 6-o'clock (for a right shoulder), and labral reconstruction with the LHBT. Reconstruction was performed by performing LHBT tenotomy at the level of the pectoralis major insertion. The proximal LHBT tendon, left attached to the supraglenoid tubercle, was then attached to the anteroinferior glenoid rim with suture anchors.

RESULTS

Mean (SD) length of the LHBT was 76.1 (12.9 mm) and the diameter was 5.9 (1.6) mm. Peak force for intact labrum was significantly greater than the deficient labrum state (14.06 vs 11.78 N; P = .012). Peak force for labral reconstruction (16.67 N) was significantly greater than both intact and deficient labral states (P < .001 and P = .011, respectively). In all specimens, the length for the LHBT to the pectoralis major insertion was sufficient for reconstruction of the labrum to the 6-o'clock position.

CONCLUSIONS

Glenoid labrum reconstruction with the LHBT is a feasible option to restore glenohumeral stability, with peak force to displacement significantly greater than the labral-intact and labral-deficient states.

CLINICAL RELEVANCE

This reconstruction may be an option for augmentation in the labral-deficient shoulder.

Arthroscopic-Assisted Anterior Glenoid Reconstruction Using Nonrigid Fixation With Distal Tibia Osteochondral Allograft

Introduction:

Traumatic anterior glenohumeral instability events result in a capsulolabral (Bankart lesion) and/or osseous injury with subsequent attritional bone loss, particularly with recurrence. Up to 88% of patients with recurrent instability experience glenoid bone loss, which predisposes to future dislocations and subluxations, even with arthroscopic capsulolabral repair. The surgical management of glenoid bone loss includes a number of different techniques such as the Latarjet or coracoid transfer as well as other osseous and osteoarticular autografts and allografts. However, operative management of shoulder instability has increasingly shifted toward arthroscopic approaches with preservation of anatomy when possible.

Indications:

Arthroscopic-assisted allograft distal tibia bone block augmentation to the anterior glenoid is indicated for revision anterior glenohumeral instability procedures with anterior bone loss and in primary cases of anterior instability with critical bone loss.

Technique:

Our technique for nonrigid arthroscopic anterior glenoid reconstruction with allograft distal tibia and anterior labral repair is performed preferentially in the lateral position without necessitating patient repositioning. The preplanned tibial bone block is prepared on a back table prior to the arthroscopic procedure. After creation of portals and elevation of labral tissue, a guide and drill are used to introduce a retrograde reamer which is deployed to create a perpendicular edge for apposition of the allograft tibia. The bone block is then introduced through a rotator interval portal by pulling sutures retrograde through glenoid bone tunnels and is secured to the prepared surface medial to the liberated labrum. The articular surface of the graft and glenoid are aligned and suture-based fixation is used to compress the bone block against the native glenoid. The anterior labral tissue is then mobilized over the graft and repaired to the native glenoid when possible.

Description/Conclusion:

The benefits of allograft tibia augmentation for anterior instability with glenoid bone loss include an anatomic joint surface restoration including articular cartilage, lack of donor site morbidity, and a minimally invasive arthroscopic approach. When performed arthroscopically and with nonrigid fixation, this technique permits concurrent anterior labral repair and anatomic reconstruction, safe graft passage without necessity of a far medial portal, and expeditious return to function.

Open anatomical glenoid reconstruction with an iliac crest bone autograft effectively resolves off-track Hill-Sachs lesions to on-track lesions

INTRODUCTION

The purpose of this study was to determine if "off-track" Hill-Sachs lesions in patients with dynamic anteroinferior instability were transformed into "on-track" lesions using iliac bone autografts with screw fixation. The secondary purpose was to observe if postoperative bony remodeling would occur over time, resulting in recurrent "off-track" Hill-Sachs lesions with corresponding instability.

MATERIALS AND METHODS

We retrospectively reviewed clinical and CT records of 8 patients with an "off-track" Hill-Sachs lesion who underwent open anatomical glenoid reconstruction with an iliac crest bone autograft. Hill-Sachs lesions, glenoid track widths, and glenoid surface areas were measured on a preoperative and two postoperative (6 weeks, ≥ 2 years) 3D-CT models to determine graft resorption over time. All patients were available for postoperative clinical and CT final follow-up 3 years (2-4 years) postoperatively.

RESULTS

In all patients, the Hill-Sachs lesions were "on-track" 6 weeks postoperatively and remained "on-track" at final-follow-up. Compared to preoperative values, the glenoid track width and glenoid surface area both were higher 6 weeks postoperatively (p < 0.001 and p = 0.023, respectively) and at final follow-up (p < 0.001 and p = 0.023, respectively). Whereas the glenoid track width between 6 weeks and final follow-up showed no decrease (p = 0.234), glenoid surface area tended to decrease (p = 0.055). The median SSV was 93 points (85-95 points), the Rowe score 90 points (80-100 points) and the WOSI 1980 points (1783-2067 points) at final follow-up. No recurrent dislocations or subluxations were observed.

CONCLUSIONS

An open anatomical glenoid reconstruction with an iliac crest bone autograft technique using screw fixation effectively transformed "off-track" Hill-Sachs lesions to "on-track" lesions, resulting in good short-term clinical outcomes. Whereas glenoid surface area tended to be reduced by bony remodeling processes over time, the glenoid track width did not decrease at final follow-up and consequently no recurrence of "off-track" lesions occurred.

LEVEL OF EVIDENCE

Case series; Level of evidence, IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies

BACKGROUND

The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair.

METHODS

Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability.

RESULTS

Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%).

CONCLUSIONS

Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

Glenoid track measurement using magnetic resonance imaging arthrography is predictive of recurrent instability following arthroscopic shoulder stabilisation

PURPOSE

The primary aim of this study was to investigate medium-term survivorship following arthroscopic Bankart repair (ABR) for anterior glenohumeral instability. The secondary aim was to determine whether the pre-operative magnetic resonance (MR) arthrography glenoid track measurement predicted recurrent instability following ABR.

METHODS

Over a 9-year period (2008-2017), 215 patients underwent ABR. Median age was 26 years (IQR 22-32.5; range 14-77). There were 173 males (81%). 175 patients (81%) had available pre-operative MR arthrography, which was used to determine the presence of "off-track" bone loss. Retrospective analysis was undertaken to determine recurrence of instability at a median follow-up of 76 months (range 21-125 months). Survivorship analysis was undertaken using Kaplan-Meier methodology: the endpoints examined were repeat dislocation, revision stabilisation, and symptomatic instability.

RESULTS

56 patients (26%) presented with further instability, including 29 patients with recurrent dislocation and 15 patients required revision stabilisation. Cumulative incidence of instability was 10% at 1 year, 27% at 5 years and 28% at 7 years. No significant difference in instability was seen between men and women 7 years after stabilisation (19% vs 17%; p = 0.87). Age at time of surgery did not predict recurrence. "Off-track" lesions were identified in 29 patients (16.1%). The incidence of redislocation was significantly higher in these patients (24% vs 3%; p = 0.01; relative risk 7.2; 95% CI 2.45-20.5; p = 0.001). Recurrent instability without frank redislocation was also significantly higher in this group (60% vs 18%; RR 3.33, 95% CI 2.02-5.20; p < 0.0001).

CONCLUSIONS

This study has reported a significant rate of recurrent instability in longer-term follow-up after ABR. It has also identified pre-operative MR arthrography as an important predictor of recurrent instability, which may be used to risk stratify patients with anterior instability in a typical UK population.

LEVEL OF EVIDENCE

III (cohort study).

Clinical Relevance of Persistent Off-Track Hill-Sachs Lesion After Arthroscopic Latarjet Procedure

BACKGROUND

The Latarjet procedure is often used to address off-track Hill-Sachs lesions (OFF-HS) in shoulders with anterior instability. There are concerns as to whether the Latarjet procedure is able to convert all OFF-HS into on-track Hill-Sachs lesions (ON-HS) and whether this limitation could explain the cases of recurrent postoperative instability.

HYPOTHESIS

Latarjet surgery converts many preoperative OFF-HS lesions, but not all of them, and there is a difference in the failure rate between shoulders with converted lesions and those with persistent OFF-HS lesions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients with anterior shoulder instability and an OFF-HS lesion treated with an arthroscopic classic Latarjet procedure between January 2010 and September 2017 were retrospectively evaluated. Patients with moderate or severe shoulder arthrosis, rotator cuff tears, or age older than 50 years were excluded. Glenoid track (GT), HS, HS interval (HSI), and the difference between HSI and GT (ΔHSI-GT) were measured preoperatively. A postoperative computed tomography scan and a clinical evaluation, including the Rowe and Western Ontario Shoulder Instability scores, were performed at a minimum 1- and 2-year follow-up, respectively. Postoperatively, 2 groups of patients were obtained: (1) patients with postoperative persistent OFF-HS; (2) patients with postoperative ON-HS. Clinical and imaging data were compared between the 2 groups.

RESULTS

A total of 51 patients (n = 51 shoulders), with a mean age of 29.8 ± 8.4 years (range, 15-50 years), met the inclusion criteria. Six shoulders (11.8%) still showed OFF-HS lesions despite Latarjet surgery. There were no postoperative dislocations, but 3 patients reported subluxations. The subluxation rate was significantly higher in the postoperative persistent OFF-HS group (2 [33%] vs 1 [2.2%]; P = .033). There was a wider preoperative HSI (29.8 ± 2.4 mm vs 22.9 ± 3.5 mm; P < .001) and a larger preoperative ΔHSI-GT (12.2 ± 3.8 mm vs 4.82 ± 3.2 mm; P < .001) in the persistent OFF-HS group. A receiver operating characteristic curve was performed based on preoperative ΔHSI-GT values. A preoperative ΔHSI-GT value ≥7.45 mm predicted a persistent OFF-HS after Latarjet surgery (sensitivity, 100%; specificity, 87%; positive predictive value, 50%; and negative predictive value, 100%).

CONCLUSION

Latarjet surgery converted many preoperative OFF-HS lesions into ON-HS lesions, but not all of them. Six patients (11.8%) retained an OFF-HS and had a statistically significantly higher failure rate after Latarjet surgery compared with those with postoperative ON-HS lesions. Because there were few postoperative OFF-HS lesions and few recurrences, findings are statistically fragile and should be confirmed with larger series.

On-Track Lesions with a Small Distance to Dislocation Are Associated with Failure After Arthroscopic Anterior Shoulder Stabilization

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, case-control study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III (Retrospective Case Series).

Failure Rates After Revision Arthroscopic Stabilization for Recurrent Anterior Shoulder Instability Based on Anterior Capsulolabral Complex Conditions

Background:

A labral retear is an important contributing factor to surgical failure after arthroscopic soft tissue stabilization for recurrent anterior shoulder instability. However, surgeons frequently encounter poor tissue conditions in the anterior capsule, such as capsular tears, during revision surgery.

Purpose:

To analyze the clinical outcomes and failure rates of revision arthroscopic stabilization after failed Bankart repair based on the tissue conditions of the anterior capsule and the labrum. Outcomes were compared for revision after failed Bankart repair because of a labral retear versus a healed labrum but with capsular tears.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 55 patients who underwent revision arthroscopic stabilization after failed Bankart repair were included. Revision surgery was indicated if patients had a history of recurrent instability with positive apprehension test results, regardless of magnetic resonance imaging (MRI) findings of a labral retear. Patients were allocated into 2 groups based on arthroscopic findings at the time of revision surgery: group 1 consisted of patients who had a healed labrum with definite anterior capsular tears, and group 2 comprised patients who had labral retears without capsular tears. Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons score, Rowe score, and surgical failure rate.

Results:

Overall, 10 patients were included in group 1, and 45 patients were included in group 2. No capsular tears were detected on preoperative MRI or magnetic resonance arthrography scans in either group, whereas all patients in group 2 had evidence of anterior labral retears on imaging scans. After revision surgery, 9 patients (16.4%) showed surgical failure by 25.6 months postoperatively. Patients in group 1 had a significantly higher surgical failure rate than did those in group 2 (4 patients [40.0%] vs 5 patients [11.1%], respectively; P = .04). The incidence of capsular tears was significantly higher in patients with surgical failure versus those without surgical failure (44.4% vs 13.0%, respectively; P = .04).

Conclusion:

A capsular tear of the anterior capsulolabral complex was an important indicator for surgical failure after revision arthroscopic stabilization. If patients demonstrate symptomatic instability after arthroscopic soft tissue stabilization without evidence of labral retears on imaging scans, an anterior capsular tear should be considered as a possible factor for recurrence.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

Level IV, systematic review.

Arthroscopic Iliac Crest Bone Allograft Combined With Subscapularis Upper-Third Tenodesis Shows a Low Recurrence Rate in the Treatment of Recurrent Anterior Shoulder Instability Associated With Critical Bone Loss

PURPOSE

To evaluate the clinical and radiologic outcomes of patients undergoing arthroscopic glenoid bone allograft combined with subscapularis upper-third tenodesis for anterior shoulder instability associated with clinically relevant bone loss and hyperlaxity.

METHODS

Between January 2016 and December 2017, patients with recurrent anterior shoulder instability associated with bone loss and hyperlaxity were selected and treated with arthroscopic iliac crest bone graft combined with subscapularis upper-third tenodesis. The selection criteria were as follows: more than 5 dislocations; positive apprehension, anterior drawer, and Coudane-Walch test results; glenoid bone defect between 15% and 30% and humeral bone defect with an engaging Hill-Sachs lesion; and no previous shoulder surgery. All patients were followed up with the Constant score, University of California-Los Angeles (UCLA) rating, Rowe score, and visual analog scale evaluation. Assessments were performed with plain radiographs and a PICO computed tomography scan before surgery and at 2 years of follow-up.

RESULTS

Nineteen patients were included in the study, with a mean follow-up duration of 34.6 months (range, 24-48 months). In 17 patients (89%), excellent clinical results were recorded according to the Rowe score. The Constant score improved from 82.9 (standard deviation [SD], 5.2) to 88.9 (SD, 4.3) (P = .002); Rowe score, from 25.3 (SD, 5.3) to 89.1 (SD, 21.8) (P < .001); UCLA score, from 23.7 (SD, 3) to 31.5 (SD, 4.8) (P < .001); and visual analog scale score, from 3.2 to 1.3 (P < .001). Patients met the minimal clinically important difference 94.7%, 89.5%, and 47.3% of the time for the Rowe score, UCLA score, and Constant score, respectively. Bone graft resorption was observed in all patients: partial in 9 and complete in 10. We recorded 2 recurrent traumatic dislocations (11%), with no case of persistent anterior apprehension or other complication.

CONCLUSIONS

An arthroscopic glenoid bone graft combined with subscapularis upper-third tenodesis may be a valid surgical option to treat recurrent anterior instability associated with both bone loss and hyperlaxity.

LEVEL OF EVIDENCE

Level IV, case series.

A Novel Technique for Labral Reconstruction Using Long Head of Biceps Tendon: Duru Technique

Arthroscopic capsulolabral repair is a well-established surgical treatment for traumatic anterior shoulder instability. When there is insufficient labral tissue during arthroscopic primary or revision Bankart repairs, various soft tissue procedures have been recommended. All these procedures aim to reattach glenohumeral ligaments to the glenoid rim and regain the tight anterior structures to prevent re-dislocation or subluxation. Some authors recommend the Latarjet procedure, even in the absence of critical bone loss in this patient group. The labrum increases the depth of the glenoid cavity, thereby, increasing the glenoid track. It behaves like a block for the humeral head. Reconstruction of the labral tissue may strongly contribute to shoulder joint stability when it is totally absent. In this article, we describe a novel labral reconstruction technique (Duru technique) using the long head of the biceps tendon in two patients without an existing labral tissue.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Therapeutic case series; Level of evidence, IV

[Short-term effectiveness of arthroscopically capsular vertical mattress suturing for shoulder recurrent anterior dislocation combined with joint laxity]

OBJECTIVE

To evaluate the short-term effectiveness of arthroscopically capsular vertical mattress suturing for shoulder recurrent anterior dislocation combined with joint laxity.

METHODS

A retrospective analysis was performed on 6 shoulder recurrent anterior dislocation patients combined with joint laxity treated with arthroscopically capsular vertical mattress suturing between January 2017 and December 2018. There were 5 males and 1 female with an average age of 20.8 years (range, 19-24 years). The number of shoulder dislocation was 3-18 times, with an average of 9.5 times. The disease duration ranged from 2 to 60 months, with an average of 25.3 months. The preoperative Beighton score was 4-7, with an average of 5.8; the Instability Severity Index Score (ISIS) was 2-5, with an average of 3.5. There were 5 cases of simple Bankart injury and 1 case of bony Bankart injury. The range of motion of shoulder joint (including active flexion and lifting, external rotation, abduction and external rotation, and internal ratation) was recorded before operation and at last follow-up; Oxford shoulder instability score, Rowe shoulder instability score, and Simple Shoulder Test (SST) score were used to evaluate shoulder joint function before operation, at 6 months after operation, and at last follow-up, and complications were recorded.

RESULTS

All patients were followed up 16-28 months (mean, 19.3 months). During the follow-up, all patients had satisfactory motor function, and no re-dislocation and postoperative neurovascular complications occurred. At last follow-up, the activities of active external rotation and abduction and external rotation were significantly improved when compared with those before operation ( P<0.05); the activities of active flexion and lifting and internal rotation were not limited before and after operation, and the difference was not significant ( P>0.05). The Oxford shoulder instability score, Rowe shoulder instability score, and SST score at 6 months after operation and at last follow-up were significantly improved when compared with those before operation ( P<0.05); there was no significant difference between at 6 months after operation and at last follow-up ( P>0.05).

CONCLUSION

The treatment of shoulder recurrent anterior dislocation combined with joint laxity by arthroscopically vertical matress suturing can achieve good short-term effectiveness.

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

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

Accuracy of Currently Available Methods in Quantifying Anterior Glenoid Bone Loss: Controversy Regarding Gold Standard-A Systematic Review

PURPOSE

To determine the accuracy of glenoid bone loss-measuring methods and assess the influence of the imaging modality on the accuracy of the measurement methods.

METHODS

A literature search was performed in the PubMed (MEDLINE), Embase, and Cochrane databases from 1994 to June 11, 2019. The guidelines and algorithm of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were used. Included for analysis were articles reporting the accuracy of glenoid bone loss-measuring methods in patients with anterior shoulder instability by comparing an index test and a reference test. Furthermore, articles were included if anterior glenoid bone loss was quantified using a ruler during arthroscopy or by measurements on plain radiograph(s), computed tomography (CT) images, or magnetic resonance images in living humans. The risk of bias was determined using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

RESULTS

Twenty-one studies were included, showing 17 different methods. Three studies reported on the accuracy of methods performed on 3-dimensional CT. Two studies determined the accuracy of glenoid bone loss-measuring methods performed on radiography by comparing them with methods performed on 3-dimensional CT. Six studies determined the accuracy of methods performed using imaging modalities with an arthroscopic method as the reference. Eight studies reported on the influence of the imaging modality on the accuracy of the methods. There was no consensus regarding the gold standard. Because of the heterogeneity of the data, a quantitative analysis was not feasible.

CONCLUSIONS

Consensus regarding the gold standard in measuring glenoid bone loss is lacking. The use of heterogeneous data and varying methods contributes to differences in the gold standard, and accuracy therefore cannot be determined.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

When to Abandon the Arthroscopic Bankart Repair: A Systematic Review

CONTEXT

Bone loss is a major factor in determining surgical choice in patients with anterior glenohumeral instability. Although bone loss has been described, there is no consensus on glenoid, humeral head, and bipolar bone loss limits for which arthroscopic-only management with Bankart repair can be performed.

OBJECTIVE

To provide guidelines for selecting a more complex repair or reconstruction (in lieu of arthroscopic-only Bankart repair) in the setting of glenohumeral instability based on available literature.

DATA SOURCES

An electronic search of the literature for the period from 2000 to 2019 was performed using PubMed (MEDLINE).

STUDY SELECTION

Studies were included if they quantified bone loss (humeral head or glenoid) in the setting of anterior instability treated with arthroscopic Bankart repair.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Study design, level of evidence, patient demographics, follow-up, recurrence rates, and measures of bone loss (glenoid, humeral head, bipolar).

RESULTS

A total of 14 studies met the inclusion criteria. Of these, 10 measured glenoid bone loss, 5 measured humeral head bone loss, and 2 measured "tracking" without explicit measurement of humeral head bone loss. Measurement techniques for glenoid and humeral head bone loss varied widely. Recommendations for maximum glenoid bone loss for arthroscopic repair were largely <15% of glenoid width in recent studies. Recommendations regarding humeral head loss were more variable (many authors providing only qualitative descriptions) with increasing attention on glenohumeral tracking.

CONCLUSION

It is essential that a standardized method of glenoid and humeral head bone loss measurements be performed preoperatively to assess which patients will have successful stabilization after arthroscopic Bankart repair. Glenoid bone loss should be <15%, and humeral head lesions should be "on track" if an arthroscopic-only Bankart is planned. If there is greater bone loss, adjunct or open procedures should be performed.

Outcomes After Revision Anterior Shoulder Stabilization: A Systematic Review

Background

Primary shoulder stabilization is successful, but there continues to be a risk of recurrence after operative repair, particularly in the young athlete. It is important for surgeons to understand the outcomes after various revision stabilization techniques to best counsel patients and manage expectations.

Purpose

To analyze recurrent instability and revision surgery rates in patients who underwent revision anterior glenohumeral stabilization procedures with either arthroscopic repair, open repair, coracoid transfer, free bone block, or capsular reconstruction.

Study Design

Systematic review; Level of evidence, 4.

Methods

We performed a systematic review of level 2 to 4 evidence studies using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical studies of revision anterior glenohumeral stabilization (arthroscopic repair, open repair, coracoid transfer, free bone block, or capsular reconstruction) with a minimum 2-year follow-up were analyzed. The rate of recurrent instability, rate of revision surgery, patient-reported outcomes, and range of motion were extracted and reported. Study methodological quality was evaluated using the Downs and Black quality assessment score.

Results

A total of 37 studies met inclusion criteria and were available for analysis: 20 studies evaluated arthroscopic repair, 8 evaluated open repair, 5 evaluated Latarjet procedure, 3 evaluated bone block, and 2 evaluated capsular reconstruction. There was 1 study included in both arthroscopic and Latarjet procedures, for a total of 1110 revision cases. There was 1 level 2 study, and the remainder were level 3 or 4 with poor Downs and Black scores. Participants analyzed were most commonly young (weighted mean age, 26.1 years) and male (78.4%). The weighted mean clinical follow-up after revision surgery was 47.8 months. The weighted mean rate of recurrent instability was 3.8% (n = 245) after the Latarjet procedure, 13.4% (n = 260) after open repair, 16.0% (n = 531) after arthroscopic repair, 20.8% (n = 72) after bone block, and 31.0% (n = 35) after capsular reconstruction. The weighted mean rate of additional revision surgery was 0.0% after bone block, 0.02% after the Latarjet procedure, 9.0% after arthroscopic repair, 9.3% after open repair, and 22.8% after capsular reconstruction. Patient-reported outcomes and objective measures of range of motion and strength improved with all revision techniques.

Conclusion

The current review identifies a deficiency in the literature pertaining to consistent meaningful outcomes and the effect of bone loss after revision shoulder stabilization. Published studies demonstrate, however, that revision shoulder stabilization using arthroscopic, open, coracoid transfer, or bone block techniques yielded satisfactory objective and patient-reported outcomes. The Latarjet procedure exhibited the lowest recurrent instability rate. This study confirms that recurrent instability remains a common problem, despite revision shoulder stabilization. The quality of research in revision shoulder stabilization remains poor, and higher quality studies are needed to establish best practices for treatment of this complex problem.

Predicting Failure After Primary Arthroscopic Bankart Repair: Analysis of a Statistical Model Using Anatomic Risk Factors

PURPOSE

The purpose of this study was to establish and analyze a simplified scoring system based on anatomic imaging measurements to predict recurrent instability after primary arthroscopic shoulder capsulolabral repair.

METHODS

All patients undergoing primary arthroscopic anterior capsulolabral repair of the shoulder were reviewed. Patients were contacted and charts were reviewed for endpoint of recurrent instability and return to prior level of activity. Predictive variables for recurrent instability studied included age, sex, amount of glenoid bone loss, intact anterior articular arc (IAAA), glenohumeral tracking (off-track), contact sports and overhead sports participation.

RESULTS

540 patients met inclusion criteria and follow-up data with magnetic resonance imaging data were available for 337 shoulders. Average follow-up was 6.2 years(range 3.4-9.3 years). Symptomatic recurrent instability occurred in 102 patients (30.3%) and 68% of contacted patients returned to pre-injury activities. In univariate analysis, age under 21 years, off-track lesions, IAAA <150°, and glenoid bone loss (GBL) of 10% or greater displayed an increased risk of recurrent instability. Multivariable analysis showed these factors remained significant: age <21 (odds ratio [ratio] 2.37), off-track glenoid (OR 2.86), IAAA <150 (OR 3.90), and GBL ≥10% (OR 7.47). A scoring system assigning 1 point each for age and off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10% yielded 79% sensitivity, 75% specificity, 58% positive predictive value, and 89% negative predictive value using a probability value of 20 percent for recurrent instability.

CONCLUSION

At mid-term follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series. Younger age, glenoid bone loss of 10% or more, IAAA <150° and off-track glenoid lesion conferred the greatest risk for postoperative instability. We propose a scoring system assigning 1 point for age, 1 point for off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10%. This schema demonstrated moderate accuracy for predicting recurrent instability when using a cutoff threshold score above 2 points for failure.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Management of Recurrent Anterior Shoulder Instability After Surgical Stabilization in Children and Adolescents

PURPOSE OF REVIEW

Recurrent shoulder instability after stabilization is common in pediatric and adolescent athletes. The purpose of this review is to understand the risk factors that lead to failure of primary surgery and management principles in the setting of recurrent instability following surgical stabilization.

RECENT FINDINGS

Rates of recurrence after primary and revision surgical stabilization remain higher than desirable. Risk factors for failure in include glenoid and humeral bone loss, capsular or ligamentous laxity, and young age though few studies have focused specifically on the adolescent population. Arthroscopic, open, and bone block techniques have been described in this population similar to adults. Failure after a primary shoulder stabilization remains a common problem in adolescents in no small part because a high proportion of these athletes return to high levels of activity. A thorough understanding of the index procedure and patient-specific risk factors for failure are key to successful planning of revision surgery. The current literature does not allow for firm treatment recommendations in individual pediatric or adolescent athletes, but the guiding principles are similar to those in adults. Specifically, all bony and soft tissue pathology should be identified and assessed, with an understanding that simply repeating the steps of the index procedure typically results in poor outcomes, and often an "escalation" of surgical complexity is required at the time of revision. When appropriately indicated, arthroscopic or open soft tissue procedures and Latarjet coracoid transfer can be safely and successfully implemented for revision shoulder stabilization in young athletes.

Biomechanical Comparison of the Long Head of the Biceps Tendon Versus Conjoint Tendon Transfer in a Bone Loss Shoulder Instability Model

Background:

Augmentation of Bankart repair with long head of the biceps tendon transfer has been previously described, although there is a paucity of literature describing its biomechanical effects.

Purpose/Hypothesis:

The purpose of this study was to assess the effect of augmenting Bankart repair with either the conjoint tendon or the long head of the biceps tendon, both with and without subcritical (13%) glenoid bone loss. We hypothesized that, in a cadaveric model, augmenting Bankart repair with the long head of the biceps tendon would restore a greater degree of stability compared with augmenting Bankart repair with the conjoint tendon.

Study Design:

Controlled laboratory study.

Methods:

A total of 12 cadaveric shoulders were tested on a 6-degrees-of-freedom robotic musculoskeletal simulator to measure the peak resistance force due to an anterior displacement of 1 cm. The rotator cuff muscles were loaded during testing to simulate physiological conditions. The following test conditions were used for each specimen: (1) intact shoulder, (2) Bankart lesion with 13% anterior bone loss, (3) 13% bone loss with Bankart repair (anchors placed at the 3-, 4-, and 5-o’clock positions), (4) 13% bone loss with both Bankart repair and transfer of the long head of the biceps tendon, and (5) 13% bone loss with Bankart repair and transfer of the conjoint tendon.

Results:

Labral repair with the addition of long head of the biceps tendon transfer had the greatest peak resistance force to anterior displacement among all groups (54.1 ± 5.5 N) and was significantly stronger than both standard Bankart repair by 16.3% (46.5 ± 7.6 N; P = .039) and the conjoint transfer procedure by 16.6% (46.4 ± 7.7 N; P = .008).

Conclusion:

Given the susceptibility of recurrent instability in shoulders with subcritical bone loss after isolated labral repair, it is important to consider augmenting Bankart repair in high-risk patients to avoid potential recurrence and the need for reoperations. Transferring the long head of the biceps tendon to the anterior glenoid represents one possible augmentation.

Clinical Relevance:

We present biomechanical data for a relatively novel technique for augmenting capsulolabral repair strength in an anterior instability model with subcritical bone loss. These data represent biomechanical justification for the utilization of this relatively novel technique.

All-Arthroscopic, 270° Reconstruction of the Inferior Glenohumeral Ligament With Palmaris Longus Autograft

Numerous factors play a role in anterior shoulder stability. The inferior glenohumeral ligament, especially the anterior band, is the main passive anterior stabilizer in the end range of motion. Surgical treatment of this pathology continues to be a challenge in patients with capsular deficiency, in whom the recurrence rate of soft-tissue arthroscopic repair increases significantly. There is not yet a fair solution for these patients without glenoid bone loss, in whom the poor tissue quality determines recurrent instability. We present an all-arthroscopic technique for reconstruction of the inferior glenohumeral ligament by means of palmaris longus autograft as an alternative to nonanatomic bone block procedures.

Multiple Subscapularis Tendon Sign: A New Risk Factor for Recurrence After Arthroscopic Anterior Shoulder Instability Surgery

Background:

Being able to predict recurrence after the treatment of shoulder instability would be helpful in planning the appropriate treatment.

Purpose:

To define the multiple subscapularis tendon sign (MSTS) as a novel anatomic variant and a possible risk factor for the recurrence of shoulder instability after anterior stabilization and to evaluate it, together with the other risk factors as described in the literature.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

A total of 87 patients met the study criteria and underwent arthroscopic stabilization for anterior shoulder instability. The MSTS was evaluated in this study group. Age, sex, hand dominance, number of preoperative shoulder dislocations, history of overhead or contact sports participation, type of labral lesion, number of anchors used in surgery, presence of the drive-through sign, presence of the MSTS, Oxford Shoulder Score results, and the association of these parameters with recurrence were assessed. The mean follow-up time was 81.0 ± 27.9 months (range, 48-139 months).

Results:

Nine (10.3%) patients experienced recurrent instability. The presence of the MSTS (P = .009), existence of an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion (P = .04), and history of overhead or contact sports participation (P = .04) were significant risk factors for recurrence. The recurrence rates were as follows: 30.7% with the MSTS; 40% with the MSTS and an ALPSA lesion; and 75% with the MSTS, an ALPSA lesion, and a history of overhead or contact sports participation.

Conclusion:

The MSTS is a variation of the anterior shoulder joint capsule. It is a sign of capsular insufficiency or thinning, which may be a risk factor for recurrence after anterior stabilization. Considering the low success rates of anterior capsulolabral repair in patients participating in overhead or contact sports, especially when an ALPSA lesion is present, encountering the MSTS during surgery in this at-risk group may be an indicator for the surgeon to choose the surgical procedure more carefully.