Anterior Shoulder Stabilization Research Articles

Glenoid Concavity Affects Anterior Shoulder Stability in an Active-Assisted Biomechanical Model.

The treatment of bony glenoid defects after anteroinferior shoulder dislocation currently depends on the amount of glenoid bone loss (GBL). Recent studies have described the glenoid concavity as an essential factor for glenohumeral stability. The role of glenoid concavity in the presence of soft tissue and muscle forces is still unknown. Glenoid concavity would have a major impact on glenohumeral stability in an active-assisted biomechanical model including soft tissue and the rotator cuff's compression forces. Controlled laboratory study. In 8 human shoulder specimens, individual coordinate systems were calculated based on anatomic landmarks. The glenoid concavity was measured biomechanically and based on computed tomography. Static load was applied to the rotator cuff tendons and the deltoid muscle. In a robotic test setup, anteriorly directed force was applied to the humeral head until translation of 5 mm (Nant) was achieved. Nant was used as a parameter indicating shoulder stability. This was performed in the following testing stages: (1) intact joint, (2) labral lesion, (3) 10% GBL, and (4) 20% GBL. The 8 specimens were divided equally into 2 subgroups (low concavity [LC] versus high concavity [HC]), with 4 specimens each, according to the previously measured concavity. Anterior glenohumeral stability was highly correlated with the native glenoid concavity (R 2 = 0.8). In the testing stages 1 to 3, we found a significantly higher mean stability in the HC subgroup compared with the LC subgroup (P≤ .0142). The HC subgroup still showed higher absolute Nant values with 20% GBL; however, there was no significant difference from the LC subgroup. The loss of stability in 20% GBL was correlated with the initial concavity (R 2 = 0.86). Thus, a higher loss of Nant in the HC subgroup was observed (P = .0049). In an active-assisted model with intact soft tissue surrounding and muscular compression forces, the glenoid concavity correlates with shoulder stability. In bony defects, loss of concavity is an essential factor causing instability. Due to their significantly higher native stability, glenoids with HC can tolerate a higher amount of GBL. Glenoid concavity should be considered in an individualized treatment of bony glenoid defects. Further studies are required to establish reference values and develop therapeutic algorithms.

Current Evidence Based Recommendations on Rehabilitation following Arthroscopic Shoulder Surgery: Rotator Cuff, Instability, Superior Labral Pathology, and Adhesive Capsulitis.

Arthroscopy has become increasingly popular for a addressing a wide variety of shoulder pathology. However, despite increasing interest, there is still much uncertainty and variability amongst providers regarding optimal post-operative rehabilitation. This review provides an overview of the evidence underlying common rehab protocols used following arthroscopic interventions for rotator cuff disease, shoulder instability, superior labral anterior to posterior (SLAP) tears and adhesive capsulitis. For small and medium sized rotator cuff tears, early motion protocols do not seem to affect healing or retear rates, however there is no difference with regards to long term functional outcomes when compared to standard motion protocols. For larger tears (> 3cm), early active motion may be associated with impaired tendon integrity. Early range of motion following arthroscopic Bankart repair has not been shown to increase rate of recurrence, however the data on return to sport requires more granularity to effectively guide care. Further research needs to be done to compare rehab protocols following SLAP repair and arthroscopic capsular release. Rehabilitation protocols following rotator cuff surgery and anterior shoulder stabilization have garnered the most research interest. However, there is still a need for larger higher-level studies examining the long-term effects of different rehab protocols. Regarding the arthroscopic management of other types of shoulder instability, SLAP tears and adhesive capsulitis, there is paucity of high-quality evidence. This knowledge gap likely underpins the variability in different rehab protocols seen in clinical practice, highlighting the need for more research.

High Rates of Return to Play and Low Recurrence Rate After Arthroscopic Latarjet Procedure for Anterior Shoulder Instability in Rugby Players

PurposeTo analyze the rate of return to play, changes in athletic level, recurrence rate and to report subjective outcomes in a series of rugby players with anterior shoulder instability that underwent an arthroscopic Latarjet procedure. MethodA multicenter retrospective study done in 2 centers on rugby players who were operated on between January 2011 and December 2020 was performed. Rugby players who underwent arthroscopic Latarjet procedure for anterior shoulder stabilization with a minimum follow-up period of two years were included. Rugby players were grouped according to their competitive level in their country (recreative, regional, national, and international level). Data collected included return to sport after surgery, time to return to rugby, athletic level before and after surgery, patient satisfaction, and subjective scores. Recurrence and apprehension rates were also evaluated. ResultsA total of 73 subjects were included. Mean age at time of surgery was 23 ± 5 years. Mean duration of follow-up was 5 years ±2.6. Eighty-four percent of rugby players returned to rugby within a mean period of 6.6 months. Initial athletic level was a significant factor (p=0.012) for not returning to sport, with 67% of patients not returning to rugby who initially played at a recreational level, and 33% at a regional league level. All national and international players returned to play. Of the 12 non returning rugby players, only 30% did not return because of their shoulder. Mean SSV was 90% ± 9. Recurrence rate was 7%. ConclusionOur study confirmed the efficacy of Arthroscopic Latarjet procedure in managing recurrent anterior instability in rugby players, leading to patient satisfaction. Return to play was achieved in almost all cases with low recurrence rate. Despite high global return to the same level of sports, the higher the level of competition is, the harder it is to resume sport at the same level for rugby players. Level of EvidenceLevel IV, therapeutic case series.

Cross-education effects on shoulder rotator muscle strength and function after shoulder stabilization surgery: a randomized controlled trial

To investigate the effects of cross-education on RC muscle strength recovery and shoulder function in patients with arthroscopic anterior shoulder stabilization surgery. Twenty-eight patients with shoulder stabilization surgery were included in the study (age: 25±6 years and body-mass index: 24.8±3.6 kg/m2). The patients were randomly divided into either cross-education (n=14) or control (n=14) groups. All patients received a standardized rehabilitation program until the end of the postoperative 12th week. The cross-education group also received an isokinetic training with the non-operated shoulder focusing on the RC muscles (twice a week, 3 sets of 10 repetitions). RC muscle strength was measured preoperatively and three, and six months postoperatively using an isokinetic dynamometer at 60°/sec and 180°/sec angular velocities. Shoulder function was assessed with Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) and Y-balance Test for Upper Quarter (YBT-UQ). Analyses of covariance were used for the statistical analyses. At the postoperative six months and at 60°/sec angular velocity, there was higher IR strength in the cross-education group (p=0.02) and similar ER strength (p=0.62) between the groups. At 180°/sec angular velocity, both IR (p=0.04) and ER (p=0.02) strength were higher in the cross-education group. The CKCUEST (p=0.47), YBT-UQ (p=0.95) and WOSI (p=0.12) scores were similar between the groups at six months after the surgery. Cross-education in the early periods of the postoperative rehabilitation following the stabilization surgery improves the RC strength recovery. However, it has no effects on the functional outcomes. Integrating the cross-education program to the postoperative rehabilitation may help to improve dynamic shoulder stability but not the functional capacity.

Beach-Chair Versus Lateral Decubitus Positioning for Primary Arthroscopic Anterior Shoulder Stabilization: A Consecutive Series of 641 Shoulders

Background: There are limited data comparing the beach-chair (BC) versus lateral decubitus (LD) position for arthroscopic anterior shoulder stabilization. Purpose: To identify predictors of instability recurrence and revision after anterior shoulder stabilization and evaluate surgical position and glenoid bone loss as independent predictors of recurrence and revision at short- and midterm follow-ups. Study Design: Cohort study; Level of evidence, 3. Methods: A consecutive series of 641 arthroscopic anterior stabilization procedures were performed from 2005 to 2019. All shoulders were evaluated for glenohumeral bone loss on magnetic resonance imaging. The primary outcomes of interest were recurrence and revision. Multivariable logistic regression models were used to assess the relationships of outcomes with age, position, glenoid bone loss group, and track. Results: A total of 641 shoulders with a mean age of 22.3 years (SD, 4.45 years) underwent stabilization and were followed for a mean of 6 years. The overall 1-year recurrent instability rate was 3.3% (21/641) and the revision rate was 2.8% (18/641). At 1 year, recurrence was observed in 2.3% (11/487) and 6.5% (10/154) of BC and LD shoulders, respectively. The 5-year recurrence and revision rates were 15.7% (60/383) and 12.8% (49/383), respectively. At 5 years, recurrence was observed in 16.4% (48/293) and 13.3% (12/90) of BC and LD shoulders, respectively. Multivariable modeling demonstrated that surgical position was not associated with a risk of recurrence after 1 year (odds ratio [OR] for LD vs BC, 1.39; P = .56) and 5 years (OR for LD vs BC, 1.32; P = .43), although younger age at index surgery was associated with a higher risk of instability recurrence (OR, 1.73 per SD [4.1 years] decrease in age; P < .03). After 1 and 5 years, surgical position results were similar in a separate multivariable logistic regression model of revision surgery as the dependent variable, when adjusted for age, surgical position, bone loss group, and track. At 5 years, younger age was an independent risk factor for revision: OR 1.68 per SD (4.1 years) decrease in age (P < .05). Conclusion: Among fellowship-trained orthopaedic surgeons, there was no difference in rates of recurrence and revision surgery after performing arthroscopic anterior stabilization in either the BC or the LD position at 1- and 5-year follow-ups. In multivariable analysis, younger age, but not surgical position, was an independent risk factor for recurrence.

Outcomes at Long-term Follow-up After Open Latarjet Versus Open Bankart Repair in Rugby Players.

Because rugby is a collision sport, it exposes players to a high risk of recurrence after anterior shoulder stabilization. Therefore, the choice of surgical procedure warrants close attention in order to optimize the time to return to sport and the stability of the shoulder throughout the player's career. The open Latarjet procedure would allow for a faster return to play and provide a lower rate of recurrence than the open Bankart repair at long-term follow-up. Cohort study; Level of evidence, 3. The study retrospectively enrolled 62 competitive rugby players who had undergone an anterior shoulder instability procedure and had at least 5 years of follow-up data. A total of 32 players treated with an open Bankart repair (BK group) were compared with 30 players (31 shoulders) treated with an open Latarjet procedure (LT group). Outcomes between groups were compared with the Rowe score, Walch-Duplay score, recurrence rate, and osteoarthritis evaluation on plain radiograph (Samilson classification). The recurrence rate was significantly higher at 18.8% for the BK group (mean follow-up, 6.9 ± 1.7 years) compared with 3.3% for the LT group (mean follow-up, 6.2 ± 1.4 years) (P = .04). No postoperative complications occurred in the BK group, whereas 1 infection and 1 hematoma required a second surgery in the LT group (P = .14). In the BK and LT groups, 97% and 90% of players, respectively, were able to return to rugby at the same level or higher (P = .27), at a mean time of 8 and 6.3 months, respectively (P = .03). The mean Rowe and Walch-Duplay scores were not significantly different between the groups; however, the osteoarthritis rate was significantly higher in the BK versus the LT group (68% vs 38%, respectively; P = .03); 23% of patients, all in the BK group, had Samilson grade 2 osteoarthritis. The open Latarjet procedure outperformed the open Bankart procedure in terms of stability, time to return to play, and radiological outcomes at long-term follow-up in competitive rugby players.

Glenoid Concavity Affects Anterior Shoulder Stability In A Biomechanical Model Including Soft Tissue and The Rotator Cuff’s Compressing Forces

Glenoid Concavity Affects Anterior Shoulder Stability In A Biomechanical Model Including Soft Tissue and The Rotator Cuff’s Compressing Forces

Lateral Decubitus Positioning For Shoulder Arthroscopy

Background: Lateral decubitus positioning is a frequently employed technique to perform shoulder arthroscopy. Proper patient positioning and equipment setup is crucial to ensure a safe and efficient surgery. Indications: The common indications for performing a shoulder arthroscopy in the lateral decubitus position include anterior shoulder stabilization, posterior shoulder stabilization, superior labrum anterior to posterior (SLAP) repair, diagnostic arthroscopy for internal impingement, and arthroscopic capsular release for adhesive capsulitis. Technique Description: After undergoing general endotracheal anesthesia in the supine position on a standard operating room table, the patient is rotated into the lateral decubitus position with the operative arm facing upward. The patient’s head is supported with a pillow to ensure a neutral position. The nonoperative arm is flexed forward and rests on a padded arm board. The sides of a bean bag are applied to the patient’s torso to maintain the lateral decubitus position, and the bean bag is deflated to remain rigid. An axillary roll is placed under the axilla, and foam pads are placed below the “down leg” and between both legs. A commercial arm jack is positioned on the anterior, proximal side of the operating room table to allow for 20° of shoulder abduction, which maximizes the glenohumeral joint space. Results: Advantages of the lateral decubitus position over the beach chair position include improved access to the anterior, inferior, and posterior glenoid; more ergonomic positioning for the operating surgeon; lower risk for patient cerebral hypoperfusion; and reduced rates of recurrent instability following arthroscopic stabilization in comparison to procedures performed in the beach chair position. Disadvantages of the lateral decubitus position include risk of traction-related neurovascular injury, requirement of an arm suspension device, and increased difficulty in rotating the shoulder intraoperatively. Discussion/Conclusion: Lateral decubitus positioning is commonly used to achieve a circumferential view of the glenohumeral joint in shoulder arthroscopy. This surgical position yields several advantages for the operating surgeon and has been shown to be associated with improved clinical outcomes after shoulder instability surgery. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Paper 01: Capsuloligamentous Laxity is a Risk Factor for Failure in Near Track Lesions Following Arthroscopic Anterior Shoulder Stabilization

Objectives: 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. While the glenoid track concept continues to evolve, a limitation of the glenoid track is that it relies on bony anatomy without specific considerations for capsuloligamentous integrity or the effect that capsular laxity may have on the glenohumeral contact points throughout shoulder range of motion. The purpose of the study was to determine if capsuloligamentous laxity has a modifying effect on the glenoid track, specifically for on-track lesions with a small distance to dislocation (DTD) from being an off-track lesion or the so-called “near-track” lesion. This may explain why some on-track lesions are at an increased risk of recurrent instability. We hypothesized that patients with ligamentous laxity and “near track” lesions would be at increased risk of recurrent instability following arthroscopic Bankart repair. Methods: Consecutive patients with on-track Hill-Sachs lesions who underwent primary arthroscopic Bankart repair alone without remplissage for recurrent anterior glenohumeral instability between January 2007 and December 2015 at a single institution were retrospectively reviewed. Patients with less than 2-year follow up, glenoid bone loss &gt; 20%, off-track lesions, concomitant remplissage, and atraumatic instability were excluded. Determination of shoulder laxity was based on exam under anesthesia (EUA), including anterior load and shift, posterior load and shift, and sulcus testing at the time of surgery before arthroscopy. Capsuloligamentous shoulder hyperlaxity was defined as external rotation of &gt;85o and/or grade of 2+ or greater load and shift in two or more planes. Measurements of glenoid bone loss, Hill-Sachs interval (HSI), and glenoid track (GT) were performed based on prior described methods. DTD was calculated (DTD=GT-HSI, with DTD&gt;0 classified as on-track lesions). Near track lesions were defined as 0&lt;DTD&lt;8mm. Failure was defined as recurrent dislocation. Results: A total of 173 patients were initially identified, of which 151 met inclusion criteria and were included for analysis. 72.8% of patients were males and mean age was 20.1 ± 5.7 years. Patients were divided into two groups based on shoulder laxity; group 1 consisted of 74 patients with hyperlaxity, and group 2 consisted of 77 patients without hyperlaxity. Overall, 21 patients (13.9%) sustained a recurrent dislocation and 35 patients (23.2%) had recurrent instability episodes. Failure was associated with glenoid bone loss (p&lt;0.001 ), longer HS length ( p=0.007), occurrence of &gt;1 instability episode preoperatively (p=0.018 ), and smaller DTD ( p=0.0008). Hyperlaxity was associated with the use of more anchors ( p=0.0001). Shoulder laxity was not independently predictive of overall failure (Figure 1, p=0.18); however, DTD was significantly associated with failure risk and recurrent instability in patients with hyperlaxity ( p=0.006) specifically in younger patients with hyperlaxity (Figure 1, Table 1). Conclusions: Our study suggests that while capsuloligamentous laxity is not independently predictive of failure after arthroscopic Bankart repair for on-track lesions, laxity may play a significant role in clinical outcomes in patients with a small DTD or near-track lesions. In younger patients with near-track lesions, hyperlaxity may be particularly predictive of failure after arthroscopic Bankart repair. As our understanding of the glenoid track continues to evolve, surgeons may need to consider the track concept as a continuum with evolving surgical algorithms other than an arthroscopic Bankart alone in young patients with near track lesions and hyperlaxity. [Table: see text]

The Glenoid Track Paradigm Does Not Reliably Affect Military Surgeons’ Approach to Managing Shoulder Instability

To report the frequencies of surgical stabilization procedures performed by military shoulder surgeons and to use decision tree analysis to describe how bipolar bone loss affects surgeons' decision to perform arthroscopic versus open stabilization procedures. The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database was queried for anterior shoulder stabilization procedures from 2016 to 2021. A nonparametric decision tree analysis was used to generate a framework for classifying surgeon decision making based on specified injury characteristics (labral tear location, glenoid bone loss [GBL], Hill-Sachs lesion [HSL] size, and on-track vs off-track HSL). A total of 525 procedures were included in the final analysis, with a mean patient age of 25.9 ± 7.2 years and a mean GBL percentage of 3.6% ± 6.8%. HSLs were described based on size as absent (n= 354), mild (n= 129), moderate (n= 40), and severe (n= 2) and as on-track versus off-track in 223 cases, with 17% (n= 38) characterized as off-track. Arthroscopic labral repair (n= 428, 82%) was the most common procedure, whereas open repair (n= 10, 1.9%) and glenoid augmentation (n= 44, 8.4%) were performed infrequently. Decision tree analysis identified a GBL threshold of 17% or greater that resulted in an 89% probability of glenoid augmentation. Shoulders with GBL less than 17% combined with a mild or absent HSL had a 95% probability of an isolated arthroscopic labral repair, whereas a moderate or severe HSL resulted in a 79% probability of arthroscopic repair with remplissage. The presence of an off-track HSL did not contribute to the decision-making process as defined by the algorithm and data available. Among military shoulder surgeons, GBL of 17% or greater is predictive of a glenoid augmentation procedure whereas HSL size is predictive of remplissage for GBL less than 17%. However, the on-track/off-track paradigm does not appear to affect military surgeons' decision making. Level III, retrospective cohort study.

Rate and time to return to shooting following arthroscopic and open shoulder surgery

There is limited information on return to shooting following shoulder surgery. The purpose of this study is to determine the rate and timing for resuming shooting a rifle following shoulder surgery. We performed a retrospective review of prospectively collected data. The study included patients undergoing arthroscopic and open shoulder stabilization for unidirectional shoulder instability, and arthroscopic surgery for rotator cuff tears, SLAP lesions, biceps tendinopathy, and acromioclavicular pathology. Data collected included the laterality of surgery, shooting dominance, and patient-reported outcome measures at the preoperative and postoperative visits. Starting at the 4.5-month clinic visit, patients were asked if they could shoot a military rifle. One hundred patients were identified with arthroscopic and open shoulder surgery with a mean age of 30 years (range, 18-45) and a mean follow-up of 24 months (range, 12-32). The cohort consisted of patients undergoing arthroscopic Bankart repair (n=23), arthroscopic posterior labral repair (n=18), open Latarjet (n=16), mini-open subpectoral biceps tenodesis (OBT) (n=25), OBT with open distal clavicle resection (DCR) (n=10), open DCR (n=4), and arthroscopic rotator cuff repair with concomitant OBT (n=4). Significant improvement in SSV, VAS, ASES, and WOSI was shown at 1-year postoperative, SSV 85, VAS 2, ASES 85, WOSI 239, P=.001. The percentage of patients reporting the ability to shoot a military rifle postoperatively were 47%, 63%, 85%, and 94% at 4.5 months, 6 months, 1 year, and 2 years, respectively. At 4.5 months postoperatively, patients who underwent surgery ipsilateral to their shooting dominance (n=59) had a rate of return to shooting (33%) versus shoulder surgery on the contralateral side of shooting dominance (n=41) (60%), P=.04. However, there was no significant difference in the groups at 6 months and 1 year. Additionally, there was a significant difference in the rate of return to shooting at 6 months in patients undergoing arthroscopic posterior labral repair versus the remainder of the cohort (posterior instability (33%) vs. (69%), P=.016), and a significant difference between posterior shoulder stabilization and anterior shoulder stabilization (70%), P=.03. Patients undergoing arthroscopic and open shoulder surgery have a high rate of return to shooting. Approximately 60% of patients resume shooting at 6 months postoperatively and 85% return at 1 year. Patients undergoing shoulder surgery on the contralateral side of their shooting dominance return to shooting significantly faster than those with shoulder surgery ipsilateral to their shooting dominance. Additionally, those undergoing arthroscopic posterior shoulder stabilization return to shooting at a slower rate than anterior stabilization surgery.

Biomechanical analysis of anterior stability after 15% glenoid bone loss: comparison of Bankart repair, dynamic anterior stabilization, dynamic anterior stabilization with Bankart repair, and Latarjet.

Dynamic anterior shoulder stabilization (DAS) with Bankart repair is a recently described stabilization technique thought to be more robust than an isolated Bankart repair while avoiding many coracoid transfer-related complications and technical demands. DAS involves transfer of the long head biceps through a subscapularis split to the anterior glenoid to create a sling effect. We hypothesize that DAS with Bankart repair will restore anterior stability in a human-cadaveric model with subcritical (15%) glenoid bone loss. Eight cadaveric shoulders were tested using an established shoulder simulator to record glenohumeral translations with an accuracy of ±0.2 mm. Shoulders were tested in 5 states-intact soft tissues, Bankart defect with 15% bone loss, isolated Bankart repair, DAS with Bankart repair, isolated DAS, and Latarjet. A 45 N anterior force was applied through the pectoralis major tendon, and translation of the humeral head was recorded and compared with repeated measures analysis of variance. The anterior translation in the intact (native) glenoid was 4.7 mm at neutral position and 4.6 mm at 45° external rotation. Anterior translation significantly increased after introducing a Bankart defect with 15% glenoid bone loss to 9.1 mm (neutral, P=.002) and 9.5 mm (45° external rotation, P<.001). All repair conditions showed a significant decrease in anterior translation relative to Bankart defect. DAS with Bankart repair decreased anterior translation compared with the Bankart defect: 2.7 mm (neutral, P<.001) and 2.1 mm (45° external rotation, P<.001). DAS with Bankart repair significantly decreased anterior translation compared with the isolated Bankart repair (2.7 mm vs. 4.7 mm, P=.023) and the isolated DAS (2.7 mm vs. 4.3 mm, P=.041) in neutral position. The Latarjet procedure resulted in the greatest reduction in anterior translation compared with the Bankart defect: 1.2 mm (neutral, P<.001) and 1.9 mm (45° external rotation, P<.001). DAS with Bankart repair is a viable alternative to restore anterior glenohumeral stability with a 15% glenoid defect at a greater degree than either DAS or Bankart repair alone. The Latarjet procedure was the most effective in reducing anterior translation but restrained the anterior translation significantly more than the native glenoid.

Effect of Anterior Glenoid Chondrolabral Defects on Anterior Glenohumeral Stability: A Biomechanical Study.

It is well known that glenoid osseous defects >13.5% of the glenoid width critically destabilize the shoulder, as do labral tears. Chondrolabral defects often occur with anterior dislocation of the shoulder. It is unclear whether glenoid chondrolabral defects contribute to shoulder stability and, if so, at what size they become critical. The purpose of this study was to determine the effect of incremental chondrolabral defect sizes on anterior shoulder stability in the setting of labral deficiency. The hypothesis was that chondrolabral defects ≥13.5% of the glenoid width will decrease anterior shoulder stability. Controlled laboratory study. This controlled laboratory study tested 12 fresh-frozen shoulders. Specimens were attached to a custom testing device in abduction and neutral rotation with 50-N compression applied to the glenoid. The humeral head was translated 10 mm anterior, anteroinferior, and anterosuperior with the conditions of intact cartilage and labrum and anterior full-thickness chondrolabral defects of 3-, 6-, and 9-mm width. Translation force was measured continuously. Peak translation force divided by 50-N compressive force defined the stability ratio. Data were analyzed using analysis of variance. The anterior stability ratio decreased between the intact state (36% ± 7%) and all defects ≥3 mm (≤32% ± 8%; P ≤ .023). The anteroinferior stability ratio decreased between the intact state (52% ± 7%) and all defects ≥3 mm (≤47% ± 7%; P ≤ .006). The anterosuperior stability ratio decreased between the intact state (36% ± 4%) and all defects ≥6 mm (≤33% ± 4%; P ≤ .006). A 3-mm defect equated to 10% of the glenoid width. There were moderate to strong negative correlations between chondrolabral defect size and stability ratio in the anterior, anteroinferior, and anterosuperior directions (r = -0.79, -0.63, and -0.58, respectively; P ≤ .001). There were moderate to strong negative correlations between the percentage of glenoid chondrolabral defect size to the glenoid width and the stability percentage in all directions (r = -0.81, -0.63, and -0.61; P ≤ .001). An anterior glenoid chondrolabral defect ≥3 mm (>10% of the glenoid width) significantly decreased anterior and anteroinferior stability. Chondrolabral defect size negatively correlated with stability. To fully restore glenohumeral stability, in addition to labral repair, it may be necessary to reconstruct chondrolabral defects as small as 3 mm (10% of the glenoid width).

Clinical outcomes of shoulder arthroplasty for post-instability arthropathy after open anterior bone block stabilization

BackgroundPost-instability glenohumeral arthropathy can occur after nonanatomic instability repairs. With advanced secondary arthritis, subsequent shoulder arthroplasty may be complicated by altered surgical anatomy, poor range of motion, subscapularis deficiency, unique glenoid wear patterns, and/or aberrant neurovascular anatomy. The purpose of this study was to evaluate the clinical outcomes of patients undergoing shoulder arthroplasty after previous open nonanatomic anterior shoulder stabilization, particularly glenoid bone block procedures. MethodsBetween 2008 and 2014, all patients with shoulder arthroplasty for symptomatic post-instability glenohumeral arthropathy after prior open stabilizations were identified from surgical case logs of two senior shoulder surgeons. Demographic variables were extracted from electronic medical records, operative reports, and preoperative and postoperative radiographs, and a minimum 24-month follow-up with completion of patient-reported questionnaires was required. Postoperative active forward elevation and active external rotation were recorded. The primary outcome measures were the visual analog scale for pain, American Shoulder and Elbow Surgeons Shoulder score, and the Simple Shoulder Test. Perioperative complications and rates of secondary reoperation were extracted. ResultsA total of 12 patients were identified with an average age of 63 ± 12 years (range, 46-83), including 7 males and 5 females, and index surgery included open Bristow (n = 7), open Latarjet (n = 2), iliac crest bone graft (n = 1), and Putti-Platt procedure (n = 2). Seven patients underwent anatomic TSA, 4 reverse TSA, and 1 hemiarthroplasty. At an average of 44 ± 21 months follow-up, average active forward elevation and active external rotation improved from 100 ± 36 preoperatively to 132 ± 41 (P = .12) postoperatively and 19 ± 15 to 49 ± 11 (P < .01), respectively. The average visual analog scale decreased from 5 ± 3 to 1 ± 2 (P < .01) and mean American Shoulder and Elbow Surgeons improved from 44 ± 23 to 79 ± 17 (P < .01); and the average Simple Shoulder Test improved from 4 ± 2 to 9 ± 3 (P < .01). No perioperative complications or secondary reoperations were required, and only one patient experienced subsequent instability due to subsequent shoulder trauma. ConclusionDespite the surgical complexity and unique challenges associated with post-instability arthropathy, shoulder arthroplasty after prior open anterior bone block procedure or nonanatomic reconstruction is a safe procedure with low risk of perioperative complication, subsequent shoulder instability, or secondary revision surgery. All patients experienced significant improvements in pain, range of motion, and self-reported function at short- to mid-term follow-up.

Poster 182: Beach Chair vs Lateral Decubitus Surgical Positioning for Arthroscopic Anterior Shoulder Stabilization: A Retrospective Comparison of Clinical and Patient-Reported Outcomes

Objectives:Surgical positioning can affect intra- and post-operative complication rates for many reasons, including potential differences in anatomic approaches and proximity to nearby nerves. The beach chair and lateral decubitus positions are the two most common positions for shoulder arthroscopy, and each offers their own unique advantages and disadvantages for surgeons. Beach chair allows for an easier transition to open surgery if necessary, and also has a lower incidence rate of neuropathies, relative to lateral decubitus. However, the lateral decubitus positioning allows for better access to the glenohumeral joint, easier visualization of the labrum, and greater circumferential access to the joint. The surgical position is often selected according to each individual surgeon’s preference, with no clear superiority of one position over the other. This study was conducted to compare clinical and patient-reported outcomes between patients who underwent arthroscopic anterior shoulder stabilization in beach chair vs. lateral decubitus positions.Methods:A list of all patients diagnosed with the CPT codes 29806 and 29807 from 2015-2019 was obtained from the medical records. Patients were only included if anterior instability was confirmed, arthroscopic surgery was performed in response to shoulder instability, and a minimum of 2-year follow-up was available. Data collected for eligible patients includes: pathology present (Hill-Sachs lesion, bony Bankart lesion), number and location of anchors used, surgery duration, intra-operative and post-operative complications, recurrent instability, reoperation, and revision. Patients were also contacted to complete patient-reported outcome surveys including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score, Single Assessment Numeric Evaluation (SANE), and a return to sport (RTS) questionnaire. Demographic, intra-operative data, and post-operative outcomes were compared between patients who underwent surgery in beach chair vs lateral decubitus positioning.Results:294 patients were included in this study, 162 patients who underwent surgery in the lateral decubitus position and 132 in beach chair position with an average follow-up of 3.3 years. There were no significant differences in demographics, concomitant surgeries, prevalence of Hill-Sachs and bony Bankart lesions, surgery duration, or intra-operative complications between groups (all p>0.05). Beach chair was associated with an increased number of anchors used (4.0 vs. 3.3, p=0.01) and a smaller proportion of inferior anchors being placed at the 6 o’clock position (8.3% vs. 25.0%, p=0.022) (Table 1). Rates of post-operative dislocations, recurrent instability, reoperations, all complications, and RTS also did not differ between groups (all p>0.05). Beach chair position had a trend for increase in revision rate but was not significant (beach chair 6.1% vs. lateral decubitus 1.9%, p=0.069). Finally, there was no difference between groups regarding post-operative ASES, SANE, and Oxford Shoulder Scores (all p>0.05).Conclusions:Surgical positioning for arthroscopic anterior shoulder stabilization did not affect post-operative clinical and patient-reported outcomes. Lateral decubitus patient positioning was associated with the use of fewer anchors and an increased proportion of inferior anchors placed at the 6 o’clock position of the labrum.Table 1.Comparison of intra-operative data and post-operative outcomes between patients who underwent shoulder stabilization surgery in the beach chair vs. lateral decubitus position. SLAP=superior labral tear anterior to posterior, RTS=return to sport, ASES=American Shoulder and Elbow Surgeons, SANE=Single Assessment Numeric Evaluation. Categorical data is presented as n (%), and continuous data is presented as mean ± standard deviation. Statistically significant differences are in bold.

Clinical outcomes following open anterior shoulder stabilization for glenohumeral instability in the young collision athlete.

Anterior glenohumeral instability occurs most commonly in those aged 15-29, with 72% of individuals younger than 22 years suffering recurrent episodes; collision athletes are at particular risk. In the setting of subcritical glenoid bone loss, arthroscopic Bankart repair is widely used despite concerns of recurrent dislocations when compared with open techniques. Furthermore, indications for bone-block procedures are evolving with the Latarjet procedure being favored amongst recent authors as a primary stabilization method in elite and contact athletes. To determine the efficacy of open modified Bankart stabilization in treating anterior glenohumeral instability in young collision athletes. This was a retrospective review of outcomes of consecutive patients aged 15-20 years who underwent unilateral or bilateral open stabilization for recurrent anterior glenohumeral instability over a 7-year period (2007-2015). The cohort was selected as recent literature suggests that this is the group with the highest redislocation rate and poorest outcomes. Outcome assessments included redislocation rate, return to sport, pain score, patient-related satisfaction scores, and the Western Ontario Shoulder Instability Index. A total of 60 patients (55 male: 5 female) of mean age 18 years (range: 15-20 years) were available for follow-up at 7 years. All but 3 were competitive athletes with 18 competing regionally and 9 internationally; rugby union and rugby league represent the most common sports. Fifty-five of 60 (92%) have returned to their desired level of sport with 62% of athletes returning to their previous level of competition sport and 1 retuning at a higher level. The mean postoperative pain score was 2.5/10. The mean time to return to play was 14 months (range: 5-48 months). Eight of 60 shoulders reported redislocation (13%), 7 of these being traumatic dislocations after return to high-impact sporting activities. At 7 years of follow-up, 4 of 60 shoulders (7%) had undergone revision surgery. Young collision athletes represent a challenging cohort of instability patients. This study of open modified Bankart in young collision sport athletes revealed excellent outcomes with 92% return to sport and a low revision rate. The results from this cohort rival those of arthroscopic repair. The open procedure described here in this 7-year series represents a robust, reliable technique that could be considered as an alternative to arthroscopic Bankart due to concern for recurrence, while avoiding potential morbidity and complication of bone-block procedures. There is still a role for the open modified Bankart procedure in treating traumatic anterior instability.

Beach Chair Versus Lateral Decubitus Surgical Positioning for Arthroscopic Anterior Shoulder Stabilization: A Retrospective Comparison of Clinical and Patient-Reported Outcomes.

Background:Surgical positioning can affect both perioperative and postoperative complication rates. It is unclear whether beach-chair versus lateral decubitus positioning affects outcomes in patients undergoing arthroscopic anterior shoulder stabilization surgery.Purpose:The purpose of this study was to compare recurrent instability, complications, and patient-reported outcomes between patients who underwent arthroscopic anterior shoulder stabilization in the beach-chair versus the lateral decubitus positions. It was hypothesized that recurrent instability, complications, and patient-reported outcomes would not be affected by surgical positioning.Study Design:Cohort study; Level of evidence, 3.Methods:The authors reviewed the medical records of patients who underwent shoulder stabilization (Current Procedural Terminology codes 29806 and 29807) from 2015 to 2019. Patients were included only if anterior instability was confirmed, arthroscopic surgery was performed in response to shoulder instability, and a minimum of 2 years of follow-up data were available. Data collected for eligible patients included perioperative and postoperative complications, recurrent instability, reoperation, and revision. Patients also completed surveys for the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Oxford Shoulder Instability (OSI) score, and a return to any level of sport (RTS) questionnaire.Results:Overall, 294 patients (162 lateral decubitus and 132 beach-chair positions) were included, with an average follow-up of 2.4 ± 1.6 years. There were no significant differences in demographics between groups, nor were there differences in the rates of postoperative dislocations, subjective instability, reoperations, revisions, or complications. There was a trend toward a higher revision rate in the beach-chair group (beach-chair, 6.1% vs lateral decubitus, 1.9%; P = .069). There was no significant difference between groups regarding RTS rates or postoperative ASES, SANE, and OSI scores at 3.3 ± 1.1 years postoperatively.Conclusion:Surgical positioning for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, and patient-reported outcomes. Both beach-chair and lateral decubitus positioning provided good outcomes for anterior shoulder stabilization, with an overall recurrent dislocation rate of 7.8% at a mean of 3.3 years after surgery.

Primary Distal Tibia Allograft for Restoration of Glenohumeral Stability with Anterior Glenoid Bone Loss

Recurrent shoulder instability with glenoid bone deficiency remains an increasing risk for failed shoulder stabilization surgery. Numerous free bone block procedures for primary treatment of anterior shoulder stability have been introduced as an alternative for the Latarjet procedure, including both autografts and allografts. Among such options is the fresh distal tibial allograft (DTA), a dense weightbearing bone without donor site morbidity and excellent conformity to the native glenoid. The aim of this Technical Note is therefore to describe our surgical technique for use of fresh DTA as a free bone block choice in the setting of primary anterior glenoid reconstruction in a patient with recurrent shoulder instability.

Paper 06: The Effect of Anterior Glenoid Cartilage Defects on Anterior Glenohumeral Instability: A Biomechanical Study

Objectives:While it is well-known that a glenoid osseous defect of >25% glenoid width or 20% of the glenoid length critically destabilizes the shoulder, it is unclear whether glenoid cartilage defects contribute to the shoulder stability, and if so at what size defect the shoulder is critically destabilized. The purpose of this study was to determine the effect of incremental cartilage defect sizes on the anterior shoulder stability. We hypothesized that cartilage defects of equal to or greater than 25% of the glenoid width or 20% of the glenoid length will significantly the decrease the anterior shoulder stability ratio.Methods:This was a controlled laboratory study testing 12 fresh-frozen shoulders. Specimens were attached to a custom testing device in abduction and neutral rotation with 50N compression applied to the glenoid. The humeral head was translated 10 mm anteriorly, anteroinferiorly, and anterosuperiorly with conditions of intact cartilage and labrum and anterior cartilage defects of 3, 6, and 9 mm width. Translation force was measured continuously. Peak translation force divided by 50 N compression force was defined as the stability ratio. Data were analyzed using ANOVA tests.Results:In the anterior direction, the stability ratio decreased between intact cartilage (36±7%) and all defects 3-mm or larger (32±8%, p=0.023.) In the anteroinferior direction, the stability ratio decreased between intact cartilage (52±7%) and all defects 3-mm or larger (47±7%, P=0.006). In the anterosuperior direction, the stability ratio decreased between intact cartilage (36±4%) and all defects larger than 6-mm (32.6±4%, P = 0.006.) A 3-mm cartilage defect was equivalent to 10% of the glenoid width and 7% of the glenoid length. There were strong negative correlations between the glenoid cartilage defect size and the stability ratio in the anterior direction, the anteroinferior direction and the anterosuperior direction (r= -0.79, -0.63, and -0.58, respectively, P≤0.001). There were strong negative correlations between the ratio of glenoid cartilage defect size to the glenoid width and the stability ratio in all directions (r= -0.81, -0.63, and -0.61, respectively, P≤0.001.)Conclusions:An anterior cartilage defect of >3 mm or >10% of the glenoid width or 7% of the glenoid length significantly decreases anterior and anteroinferior stability and may require further treatment to restore stability. Cartilage defect size negatively correlates with stability.

Criteria for Return-to-Play (RTP) after Rotator Cuff Surgery: A Systematic Review of Literature.

This systematic review of the literature aimed to highlight which criteria are described in the literature to define when a patient, after rotator cuff repair (RCR), is ready for return-to-play (RTP), which includes return to unrestricted activities, return to work, leisure, and sport activities. An online systematic search on the US National Library of Medicine (PubMed/MEDLINE), SCOPUS, Web of Science (WOS), and the Cochrane Database of Systematic Reviews, was performed with no data limit until December 2021. A total of 24 studies that reported at least one criterion after RCR were included. Nine criteria were identified and among these, the most reported criterion was the time from surgery, which was used by 78% of the studies; time from surgery was used as the only criterion by 54% of the studies, and in combination with other criteria, in 24% of the studies. Strength and ROM were the most reported criteria after time (25%). These results are in line with a previous systematic review that aimed to identify RTP criteria after surgical shoulder stabilization and with a recent scoping review that investigated RTP criteria among athletes after RCR and anterior shoulder stabilization. Compared to this latest scoping review, our study adds the methodological strength of being conducted according to the Prisma guidelines; furthermore, our study included both athletes and non-athletes to provide a comprehensive view of the criteria used after RCR; moreover, ten additional recent manuscripts were examined with respect to the scoping review.