Minimum 10-Year Clinical Outcomes After Arthroscopic Capsulolabral Repair for Isolated Posterior Shoulder Instability

BACKGROUND

Arthroscopic capsulolabral repair for posterior shoulder instability has been shown to improve patient-reported outcomes and return to sport at short-term and midterm follow-up, but long-term outcomes are unknown.

PURPOSE

To determine the objective and subjective clinical outcomes of shoulder function after arthroscopic posterior shoulder stabilization at a minimum 10-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 53 patients (55 shoulders) with unidirectional recurrent posterior shoulder instability who underwent arthroscopic capsulolabral repair were evaluated at a mean follow-up of 15.4 years. Outcomes such as the American Shoulder and Elbow Surgeons (ASES) shoulder score, Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score, and subjective strength, stability, range of motion, and pain were evaluated preoperatively and postoperatively at a minimum 10-year follow-up. Outcomes from the same patient cohort were previously collected at 3.0-year follow-up and were evaluated for longitudinal analysis. Subgroup analyses for sport type (contact vs noncontact), position (thrower vs nonthrower), and revision versus nonrevision were performed. Risk factors for revision surgery based on magnetic resonance imaging findings, patient characteristics, and surgical findings were investigated.

RESULTS

Arthroscopic capsulolabral repair for posterior shoulder instability led to a statistically significant improvement on all outcome measures, with similar values at short-term (3.0-year) and long-term (15.4-year) follow-up. Across the total population, patients with 19 of 55 shoulders (35%) returned to sport at the same preinjury level, and patients with 33 of 55 shoulders (60%) returned to sport at some level. At long-term follow-up, patients with only 22% of shoulders were involved in the primary sport in which the injury was sustained, with patients with 28% of shoulders discontinuing sporting participation because of ongoing shoulder issues. Throwers trended toward lower Kerlan-Jobe Orthopaedic Clinic scores than nonthrowers both preoperatively (36.5 ± 22.8 vs 48.7 ± 22.9, respectively; P = .10) and postoperatively (57.4 ± 27.0 vs 73.5 ± 26.8, respectively; P = .09) but had similar improvements. Contact and noncontact athletes had similar preoperative and postoperative values, with equal improvements after surgery. With failure defined as revision surgery, an ASES score <60, or a stability value >5, 19 of 55 shoulders (35%) met failure criteria at final follow-up. Overall, 7 of 55 shoulders (13%) underwent revision surgery. At long-term follow-up, patients who underwent revision surgery had worse outcomes than those who did not undergo revision (ASES score: 53.1 ± 25.9 vs 81.8 ± 19.4, respectively; P < .001). An acute injury in the postoperative period (P < .001) and a smaller glenoid bone width on magnetic resonance imaging (P = .02) were the only identified risk factors for revision surgery.

CONCLUSION

Arthroscopic capsulolabral repair for posterior shoulder instability was a durable treatment option that improved long-term shoulder pain and function and facilitated return to sport in the majority of patients at a mean follow-up of 15.4 years, although a notable proportion of patients met various criteria for failure.

Surgical Treatment of Iatrogenic Nerve Injury Following Arthroscopic Capsulolabral Repair

PURPOSE

Case reports of nerve injuries following arthroscopic capsulolabral repair emphasize the proximity of major nerves to the glenoid. This study describes preoperative localization using nerve-sensitive magnetic resonance imaging in a small cohort of patients with iatrogenic nerve injuries following arthroscopic capsulolabral repair and the outcomes of nerve repair in these patients.

METHODS

Cases of iatrogenic nerve injury following arthroscopic capsulolabral repair referred to 2 surgeons from January 2017 to December 2019 were identified. Clinical charts, electrodiagnostic testing, magnetic resonance imaging studies, and operative reports were reviewed.

RESULTS

Four cases of iatrogenic nerve injury were identified. The time to presentation to our institution ranged from 2 weeks to 8 years. The axillary nerves in 3 cases were tethered by a suture at the inferior glenoid, whereas 1 case had a suture tied around the radial and median nerves inferior to the glenohumeral joint capsule. One case underwent excision and nerve transfer, 1 underwent excision and nerve repair, and 2 underwent suture removal and neurolysis. Open and arthroscopic approaches, including a recently described approach to the axillary nerve in the "blind zone," were used. Three cases demonstrated good recovery of all affected motor and sensory functions after surgery. At the 10-month follow-up, 1 case had persistent weakness, but there was evidence of axonal regeneration on electrodiagnostic testing.

CONCLUSIONS

Arthroscopic capsulolabral repair places regional nerves, particularly the axillary nerve, at risk owing to their proximity to the joint capsule and inferior glenoid. Patients with neuropathic pain in the distribution of affected nerves with corresponding sensorimotor loss following arthroscopic capsulolabral surgery should undergo focused magnetic resonance imaging with nerve-sensitive sequences and electrodiagnostic testing to localize the injury. The use of multiple surgical windows to the axillary nerve in the "blind zone" enables full visualization for neurolysis, suture removal, and nerve repair or transfer.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Effect of Glenoid Version and Width on Outcomes of Arthroscopic Posterior Shoulder Stabilization

BACKGROUND

Despite an increased awareness of the condition, the diagnosis, classification, and treatment of recurrent posterior shoulder instability remain challenging. No clear relationship has been established between glenohumeral morphologic characteristics and the risk for posterior shoulder instability or with outcomes after treatment.

PURPOSE

To examine the structure of the glenoid in a large series of athletic patients with symptomatic unidirectional posterior instability and to correlate these findings with the objective and subjective clinical outcome of arthroscopic posterior capsulolabral repair.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 118 magnetic resonance arthrograms of athletes with unidirectional recurrent posterior shoulder instability treated with an arthroscopic posterior capsulolabral repair were reviewed, and measurements of glenoid labral, chondral, and bone version and labral and bone width were performed. The patients were evaluated preoperatively and postoperatively with the American Shoulder and Elbow Surgeons (ASES) scoring system and with standardized subjective pain and stability scales.

RESULTS

The mean glenoid labral, chondral, and bone versions were 10.8°, 10.1°, and 9.5°, respectively. The mean labral width was 30.9 mm and the mean bone width 28.9 mm. Patients with wider and more retroverted glenoid bone had better mean preoperative pain and ASES scores than did those with narrow and more anteverted glenoid bone. At final postoperative follow-up, patients with wider glenoids continued to have better pain and ASES scores and decreased risk of failure. In contrast, no significant differences in outcome scores were detected among subjects with regard to glenoid bone version. There was no correlation between chondral and labral width or version with any outcome measure preoperatively or postoperatively. Thirteen patients had unsuccessful initial capsulolabral repairs (ASES scores <60 and stability scores ≥6), demonstrating a 3.0-mm smaller overall labral width and 3° less labral retroversion but no bony version differences when compared with the successful cohort.

CONCLUSION

Although higher glenoid retroversion was noted in this patient population as compared with previous studies in normal populations, there were no significant differences in outcomes after treatment among subjects with regard to glenoid version. However, increased glenoid width did predict better outcomes after posterior capsulolabral repair.