Operative Versus Nonoperative Treatment Following First-Time Anterior Shoulder Dislocation

Surgical Intervention Following a First Traumatic Anterior Shoulder Dislocation Is Worthy of Consideration

Up to 60% of patients experience recurrence after a first traumatic anterior shoulder dislocation (FTASD), which is often defined as having experienced either dislocation or subluxation. Thus surgical intervention after FTASD is worthy of consideration and is guided by the number of patients who need to receive surgical intervention to prevent 1 redislocation (i.e., number needed to treat), (subjective) health benefit, complication risk, and costs. Operative intervention through arthroscopic stabilization can be successful in reducing recurrence risk in FTASD, as has been shown in multiple randomized controlled trials. Nevertheless, there is a large "gray area" for the indication of arthroscopic stabilization, and it is therefore heavily debated which patients should receive operative treatment. Previous trials showed widely varying redislocation rates in both the intervention and control group, meta-analysis shows 2% to 19% after operative and 20% to 75% after nonoperative treatment, and redislocation rates may not correlate with patient-reported outcomes. The literature is quite heterogeneous, and a major confounder is time to follow-up. Furthermore, there is insufficient standardization of reporting of outcomes and no consensus on definition of risk factors. As a result, surgery is a reasonable intervention for FTASD patients, but in which patients it best prevents redislocation requires additional refinement.

Lesion prevalence and patient outcome comparison between primary and recurrent anterior shoulder instability

BACKGROUND

The purpose of this study was to compare lesion prevalence and treatment outcomes in patients with primary and recurrent anterior shoulder instability.

METHODS

Patients who were admitted to the institution with a diagnosis of anterior shoulder instability and who underwent arthroscopic surgery between July 2006 and February 2020 were retrospectively evaluated. Minimum follow-up duration of the patients was 24 months. The recorded data and magnetic resonance imaging (MRI) of the patients were examined. Patients aged ≥40 years, with a history of shoulder region fracture, inflammatory arthritis, a history of epilepsy, multidirectional instability, nontraumatic dislocation, and off-track lesions were excluded from the study. Shoulder lesions were documented and patient outcome evaluation was made with the Oxford Shoulder Score (OSS) and visual analog scale (VAS).

RESULTS

A total of 340 patients were included in the study. The mean age of patients was 25.6 years (±6.49). The recurrent instability group had a significantly higher rate of anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions compared to the primary instability group (40.6% vs. 24.6% respectively) (P = .033). Twenty-five patients (43.9%) had superior labrum anterior and posterior (SLAP) lesions in the primary instability group and 81 patients (28.6%) had SLAP lesions in the recurrent instability group (P = .035). OSS increased for both primary (from 35 [16-44] to 46 [36-48]) (P = .001) and recurrent instability groups (from 33 [6-45] to 47 [19-48]) (P = .001). There was no significant difference between the groups regarding postoperative VAS and OSS scores (P > .05).

CONCLUSIONS

Successful results were obtained in patients younger than 40 years with both primary and recurrent anterior shoulder instability after arthroscopic treatment. ALPSA lesion prevalence was higher whereas SLAP lesion prevalence was lower in patients with recurrent instability. Although the postoperative OSS was comparable between the patient groups, the failure rate was higher in the recurrent instability patients.

The Modified Tampa-Scale of Kinesiophobia for Anterior Shoulder Instability

Purpose

To assess content validity and to modify the Tampa Scale of Kinesiophobia (TSK) to make it suitable for application in patients with anterior shoulder instability.

Methods

A four-round Delphi method was performed to establish expert consensus on developing the Tampa Scale of Kinesiophobia for patients with anterior shoulder instability (TSK-SI) using an expert group of Dutch shoulder-specialized orthopedic surgeons and physiotherapists. During round 1, experts were asked to score the 17 items of the original TSK on relevance and construction using the COSMIN guidelines. With this feedback, questions were reviewed and modified. During round 2, experts were asked to score the modified items. This process was repeated until consensus was established. Then, patients were asked to participate in a moderator-guided, three-step-test interview using a Web-based platform to assess the modified scale. Sessions were recorded and evaluated by the working group. The modified scale was finally adjusted on the basis of the input of these patients.

Results

Thirty Dutch shoulder experts were included, of which 25 completed all 4 rounds, after which consensus was established. One question was added to the modified scale based on feedback in round 1, establishing the 18-item TSK-SI. Sixteen patients with shoulder instability were included, which all completed the three-step test interview. Following this, question 4 (changed to present tense) and question 7 (hypothetical component added) were adjusted, resulting in the final TSK-SI.

Conclusions

This consensus modification of the TSK to TSK-SI can support the content validity of the instrument to assess kinesiophobia in patients with anterior shoulder instability. These modifications may improve the responsiveness and validity of the TSK-SI, as it does not match all the items of the original TSK.

Level of evidence

Level V, consensus statement.

Gene Expression in Glenoid Articular Cartilage Varies Across Acute Instability, Chronic Instability, and Osteoarthritis

BACKGROUND

Shoulder instability is a common pathology associated with an elevated risk of osteoarthritis (OA). Little is known about gene expression in the cartilage of the glenohumeral joint after dislocation events, particularly as it relates to the risk of posttraumatic OA. This study tested the hypothesis that gene expression in glenoid cartilage varies among acute instability (<3 dislocations), chronic instability (≥3 dislocations), and OA.

METHODS

Articular cartilage was collected from the anteroinferior glenoid of consenting patients undergoing shoulder stabilization surgery (n = 17) or total shoulder arthroplasty (n = 16). Digital quantitative polymerase chain reaction was used to assess the relative expression of 57 genes (36 genes from OA risk allele studies, 21 genes from differential expression studies), comparing (1) OA versus instability (acute and chronic combined), (2) acute versus chronic instability, (3) OA versus acute instability, and (4) OA versus chronic instability.

RESULTS

The expression of 11 genes from OA risk allele studies and 9 genes from differential expression studies was significantly different between cartilage from patients with instability and those with OA. Pro-inflammatory genes from differential expression studies and genes from OA risk allele studies were more highly expressed in cartilage in the OA group compared with the instability group, which expressed higher levels of extracellular matrix and pro-anabolic genes. The expression of 14 genes from OA risk allele studies and 4 genes from differential expression studies, including pro-inflammatory genes, anti-anabolic genes, and multiple genes from OA risk allele studies, was higher in the acute instability group compared with the chronic instability group. Cartilage in the OA group displayed higher expression of CCL3, CHST11, GPR22, PRKAR2B, and PTGS2 than cartilage in the group with acute or chronic instability. Whereas cartilage in both the acute and chronic instability groups had higher expression of collagen genes, cartilage in the OA group had expression of a subset of genes from OA risk allele studies or from differential expression studies that was lower than in the acute group and higher than in the chronic group.

CONCLUSIONS

Glenoid cartilage has an inflammatory and catabolic phenotype in shoulders with OA but an anabolic phenotype in shoulders with instability. Cartilage from shoulders with acute instability displayed greater (cellular) metabolic activity compared with shoulders with chronic instability.

CLINICAL RELEVANCE

This exploratory study identified genes of interest, such as CCL3, CHST11, GPR22, PRKAR2B, and PTGS2, that have elevated expression in osteoarthritic glenoid cartilage. These findings provide new biological insight into the relationship between shoulder instability and OA, which could lead to strategies to predict and potentially modify patients' risk of degenerative arthritis due to shoulder instability.

"Nearly off-track lesions" or a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track does not seem to be accurate in predicting recurrence after an arthroscopic Bankart repair in a military population: a case-control study

BACKGROUND

On-track lesions with a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track (nearly off-track) may predispose recurrence after arthroscopic Bankart repair (ABR) in the general population. The aim of this study was to determine if a shorter distance between the medial edge of the Hill-Sachs lesion and the medial edge of the glenoid track could accurately predict recurrence after an ABR in a high-demand military population. It was hypothesized that a shorter distance would not accurately predict recurrence.

MATERIALS AND METHODS

A retrospective monocenter case-control study was performed at the Dutch Central Military Hospital. Patients with an on-track Hill-Sachs lesion who underwent a primary ABR between 2014 and 2019 with a minimal follow-up of 2 years and a preoperative magnetic resonance imaging (MRI) assessment received a questionnaire. The primary outcome was recurrence, defined as a complete dislocation or subluxation. Glenoid bone loss was assessed using a linear-based method on MRI. The distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track was defined as the distance to dislocation (DTD). A receiver operating characteristic curve was created to determine the predictive value of the DTD for recurrence. Logistic regression was used to determine preoperative risk factors that predispose recurrence. Covariates were selected based on univariable analysis and included gender, body mass index, age at surgery and first dislocation, laterality, smoking habits, overhead shoulder activity during work, preoperative dislocations, sports type and level, bony or labral lesions on MRI, and DTD.

RESULTS

In total, 80 patients with an average follow-up of 4.8 ± 1.9 years completed the questionnaire and were included in the analyses. Seventeen patients (21%) experienced recurrence at the final follow-up. No difference in DTD was observed among patients who experienced recurrence (9 ± 4 mm) compared with patients who did not (9 ± 5 mm; P = .81). The receiver operating characteristic curve demonstrated no predictive power of DTD for recurrence (area under the curve = 0.49). Smoking at the time of surgery (odds ratio: 3.9; confidence interval: 1.2-12.7; P = .02) and overhead shoulder movement during work (odds ratio: 9.3; confidence interval: 1.1-78.0; P = .04) were associated with recurrence according to the logistic regression analysis.

CONCLUSION

A shorter DTD demonstrated no accuracy in predicting recurrence in a military population. Smoking at the time of surgery and overhead shoulder activity during work were associated with recurrence; however, these analyses were underpowered to draw valid conclusions.

Assessment of Acute Lesions of the Biceps Pulley in Patients with Traumatic Shoulder Dislocation Using MR Imaging

Background: Shoulder dislocations represent common injuries and are often combined with rotator cuff tears and potentially damage to the biceps pulley. Purpose: To assess the occurrence and type of biceps pulley lesions in patients after traumatic anterior shoulder dislocation using 3T MRI. Methods: Thirty-three consecutive patients were enrolled between June 2021 and March 2022 (14 women, mean age 48.0 ± 19 years). All patients underwent MR imaging at 3 T within one week. Images were analyzed for the presence and type of pulley tears, subluxation/dislocation of the LHBT, rotator cuff lesions, joint effusion, labral lesions, and osseous defects. Results: Seventeen patients (52%) with traumatic anterior shoulder dislocation demonstrated biceps pulley lesions. Of those, eleven patients (33%) showed a combined tear of the sGHL and CHL. All seventeen patients with lesions of the biceps pulley showed associated partial tearing of the rotator cuff, whereas three patients showed an additional subluxation of the LHBT. Patients with pulley lesions after dislocations were significantly older than those without (mean age 52 ± 12 years vs. 44 ± 14 years, p = 0.023). Conclusion: Our results suggest an increased awareness for lesions of the biceps pulley in acute traumatic shoulder dislocation, particularly in patients over 45 years.

Development and training of a machine learning algorithm to identify patients at risk for recurrence following an arthroscopic Bankart repair (CLEARER): protocol for a retrospective, multicentre, cohort study

INTRODUCTION

Shoulder instability is a common injury, with a reported incidence of 23.9 per 100 000 person-years. There is still an ongoing debate on the most effective treatment strategy. Non-operative treatment has recurrence rates of up to 60%, whereas operative treatments such as the Bankart repair and bone block procedures show lower recurrence rates (16% and 2%, respectively) but higher complication rates (<2% and up to 30%, respectively). Methods to determine risk of recurrence have been developed; however, patient-specific decision-making tools are still lacking. Artificial intelligence and machine learning algorithms use self-learning complex models that can be used to make patient-specific decision-making tools. The aim of the current study is to develop and train a machine learning algorithm to create a prediction model to be used in clinical practice-as an online prediction tool-to estimate recurrence rates following a Bankart repair.

METHODS AND ANALYSIS

This is a multicentre retrospective cohort study. Patients with traumatic anterior shoulder dislocations that were treated with an arthroscopic Bankart repair without remplissage will be included. This study includes two parts. Part 1, collecting all potential factors influencing the recurrence rate following an arthroscopic Bankart repair in patients using multicentre data, aiming to include data from >1000 patients worldwide. Part 2, the multicentre data will be re-evaluated (and where applicable complemented) using machine learning algorithms to predict outcomes. Recurrence will be the primary outcome measure.

ETHICS AND DISSEMINATION

For safe multicentre data exchange and analysis, our Machine Learning Consortium adhered to the WHO regulation 'Policy on Use and Sharing of Data Collected by WHO in Member States Outside the Context of Public Health Emergencies'. The study results will be disseminated through publication in a peer-reviewed journal. No Institutional Review Board is required for this study.

Bony reconstruction after failed labral repair is associated with higher recurrence rates compared to primary bony reconstruction: a systematic review and meta-analysis of 1319 shoulders in studies with a minimum of 2-year follow-up

BACKGROUND

There is uncertainty with regard to the optimal revision procedure after failed labral repair for anterior shoulder instability. An overview of outcomes of these procedures with quantitative analysis is not available in literature. The aim of this review is (1) to compare recurrence rates after revision labral repair (RLR) and revision bony reconstruction (RBR), both following failed labral repair. In addition, (2) recurrence rates after RBR following failed labral repair and primary bony reconstruction (PBR) are compared to determine if a previous failed labral repair influences the outcomes of the bony reconstruction.

METHODS

Randomized controlled trials and cohort studies with a minimum follow-up of 2 years and reporting recurrence rates of (1) RBR following failed labral repair and PBR and/or (2) RLR following failed labral repair and RBR following failed labral repair were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics.

RESULTS

Thirteen studies met the inclusion criteria and comprised 1319 shoulders. Meta-analyses showed that RBR has a significantly higher recurrence rate than PBR (risk ratio [RR] 0.51, P < .008) but found no significant difference in the recurrence rates for RLR and RBR (RR 1.40, P < .49). Also, no significant differences were found between PBR and RBR in return to sport (RR 1.07, P < .41), revision surgery (RR 0.8, P < .44), and complications (RR 0.84, P < .53). Lastly, no significant differences between RLR and RBR for revision surgery (RR 3.33, P < .19) were found.

CONCLUSION

The findings of this meta-analyses show that (1) RBR does not demonstrate a significant difference in recurrence rates compared with RLR and that (2) RBR has a significantly higher recurrence rate than PBR.