Anterior Shoulder Stabilization Research Articles

Clinical outcomes following revision anterior shoulder arthroscopic capsulolabral stabilization.

Traditionally surgeons have treated failed shoulder instability with open capsulolabral repair. Despite improved instrumentation, technique and familiarity in shoulder arthroscopy, few studies have reported the outcomes of arthroscopic revision shoulder instability repair. The purpose of this study was to assess clinical outcomes in patients following revision shoulder arthroscopic anterior capsulolabral stabilization. Sixty-two patients (63 shoulders) with failure of primary instability repairs were treated with revision arthroscopic anterior shoulder stabilization at a mean follow-up of 46.9 ± 16.8 months (range 18-78). Clinical outcomes were evaluated using validated patient-reported outcome questionnaires including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, visual analog pain scale and Western Ontario Shoulder Instability Index. In addition, patients were queried for recurrent instability events (subluxation or dislocation) or revision surgery. At final follow-up, the mean postoperative Western Ontario Shoulder Instability normalized score was 80.1 ± 18.7 (range 15.0-100). There were clinically significant improvements in American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores and ten-point visual analog scale for pain (P < 0.001). Recurrent instability occurred in 12 shoulders (19.0 %), with number of prior surgeries and hyperlaxity found to be significant risk factor for failure (P < 0.001 and P = 0.04, respectively). Revision arthroscopic anterior stabilization of the shoulder can result in satisfactory outcomes in appropriately selected patients who have failed previous capsulolabral repair. An increased number of prior surgeries and hyperlaxity are predictive of poor outcome. Case series, LOE IV.

Loss of Anterior Stability of Shoulder Across a Range of Motion Due to Combined Bony Defects: A Cadaveric Study

Objectives:Previous studies have analyzed only the effects of isolated glenoid or humeral head defects at limited arm positions. Literature data also suggests that instability might vary for envelop of motion. The aim of this study was to evaluate the effect of combined bony lesions on shoulder instability through varying glenohumeral positions. We hypothesized that the shoulder stability would significantly decrease with increasing defect size, and in the presence of combined defects. Furthermore, instability secondary to a humeral head defect will be magnified at functional arm positions.Methods:All experiments were performed at glenohumeral abduction angles (ABD) of 20°, 40°, and 60° and external rotations (ER) of 0°, 40°, and 80° for 18 specimens. Each experiment comprised of translating the glenoid in a posterior direction in order to cause an anterior dislocation under a 50N load. Translational distance of the glenoid and medial-lateral displacement of the humeral head, along with horizontal reaction force were recorded for every trial. Since it was not possible to test every defect combination in a single specimen, three different pathways were chosen (4 levels of glenoid defect and 5 levels of humeral defect) to maximize defect combinations. The sizes of humeral head lesions and glenoid defect were chosen similar to previous studies.Results:At 60° ABD and 80° ER, stability decreased from 100% to 85.2% and 73.7 % with isolated glenoid defect sizes of 10% and 20%, respectively. A combination of a 44% humeral head defect with 20% and 30% glenoid defect resulted in 1.6% and 1.4% intact translation, respectively. At 20° ABD and 0° ER, % intact translations were 69.0 ± 9.7, 64.3 ±12.9, 64.9 ± 11.1, 66.7 ± 8.8, 69.3 ± 13.9 for humeral defect sizes of 0%, 6%, 19%, 31%, 44% with a 20% glenoid defect, respectively. However, at a functional position of 60° ABD and 80° ER these values were significantly different (p < 0.05) for humeral head defects of size 19%, 31%, and 44% with translation values of 48.6 ± 24.2, 26.6 ± 25.2, and 1.6 ± 3.6, respectively. The % intact translation values for glenoid defects sizes 20% and 30% were significantly different (p < 0.05) for all arm positions. Combination of a smaller 6% humeral defect with increasing glenoid defects of size 0%, 10%, 20% and 30% has translation values 103.0 ± 2.9, 82.6 ± 16.4, 65.2 ± 12.9, and 40 ± 20.7, respectively. These values were similar at different arm positions.Conclusion:This study demonstrated that a smaller glenoid defect size of 10% combined with a 19% humeral head defect, can lead to a significant instability. Additionally, it was shown that a significant glenoid defect would lead to loss of translation independent of changes in the arm position. However, the loss of stability from a humeral head defect would lead to loss of translational stability significantly at a functional arm position of increased abduction and external rotation rather than a resting arm position. This rotational dependency of a humeral head defect further leads to a magnified instability during combined defects.

Clinical Outcomes Following Revision Anterior Shoulder Stabilization

Objectives:The purpose of this study was to determine the clinical outcomes following revision anterior shoulder stabilization performed either via all-arthroscopic soft tissue repair or via Latarjet coracoid transfer.Methods:A retrospective review of prospectively collected data on 91 shoulders undergoing revision anterior shoulder stabilization was performed. All patients underwent prior soft tissue stabilization; those with prior open bone grafting procedures were excluded. For patients with 25% glenoid bone loss, Latarjet was performed (n=28). Patients were queried regarding recurrent instability (subluxation or dislocation). Clinical outcomes were evaluated using validated patient reported outcome questionnaires including the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), visual analog scale (VAS) for pain, and Western Ontario Shoulder Instability Index (WOSI).Results:A total of 63 shoulders in 62 patients (46 males, 16 females) with an average age of 23.2 ± 6.9 years were included in the revision arthroscopy group. At an average follow-up of 46.9 ± 16.8 months (range, 15 to 78), the mean WOSI score was 80.1 (range, 15.0 to 100), and there were significant improvements (p<0.001) in ASES (63.7 to 85.1), SST (6.2 to 9.1), and VAS pain scores (2.89 to 0.81). Recurrent instability occurred in 12 of 63 shoulders (19%); the number of prior surgeries and baseline hyperlaxity were significant risk factors for failure (p<0.001 and p=0.04, respectively). No patients developed clinical or radiographic evidence of arthritis. A total of 28 shoulders in 28 patients (21 male, 7 female) with an average age of 27.5 years (range 14 to 45) were included in the Latarjet group. Thirteen (46%) had more than one previous stabilization attempt. ), the average WOSI score was 71.9, and there were significant improvements (p<0.001) in ASES (65.7 to 87.0), SST (7.2 to 10.3), and VAS (3.1 to 1.1). Recurrent instability occurred in 2 of 28 shoulders (7%), including 1 patient with symptomatic subluxation and 1 patient with a recurrent dislocation resulting in rapid arthrosis requiring revision to hemiarthroplasty at 20 months after Latarjet.Conclusion:Both arthroscopic revision stabilization and Latarjet coracoid transfer result in satisfactory outcomes in patients who have failed previous arthroscopic capsulolabral repair. Recurrent instability rates were higher in the all-arthroscopic group (19% versus 7%). Longer-term studies are required to determine whether similar results are maintained over time, and to provide guidance on focused clinical indications for this challenging patient population.

Utility of the Instability Severity Index Score in Predicting Failure After Arthroscopic Anterior Stabilization of the Shoulder

Background: The redislocation rate after arthroscopic stabilization for anterior glenohumeral instability is up to 30%. The Instability Severity Index Score (ISIS) was developed to preoperatively rationalize the risk of failure, but it has not yet been validated by an independent group. Purpose: To assess the utility of the ISIS in predicting failure of arthroscopic anterior shoulder stabilization and to identify other preoperative factors for failure. Study Design: Case-control study; Level of evidence, 3. Methods: A case-control study was performed on 141 consecutive patients, comparing those who suffered failure of arthroscopic stabilization with those who had successful arthroscopic stabilization. The mean follow-up time was 47 months (range, 24-132 months). The ISIS was applied retrospectively, and an analysis was performed to establish independent risk factors for failure. A receiver operator coefficient curve was constructed to set a threshold ISIS for considering alternative surgery. Results: Of 141 patients, 19 (13.5%) suffered recurrent instability. The mean ISIS of the failed stabilization group was higher than that of the successful stabilization group (5.1 vs 1.7; P < .001). Independent risk factors for failure were Hill-Sachs lesion (P < .001), glenoid bone loss (P < .001), age <21 years at the time of surgery (P < .001), age at first dislocation (P = .01), competitive-level participation in sports (P < .001), and participation in contact or overhead sports (P = .03). The presence of glenoid bone loss carried the highest risk of failure (70%). There was a 70% risk of failure if the ISIS was ≥4, as opposed to a 4% risk of failure if the ISIS was <4. Conclusion: This is the first completely independent study to confirm that the ISIS is a useful preoperative tool. It is recommended that surgeons consider alternative forms of stabilization if the ISIS is ≥4.

Loss of Anterior Stability of Shoulder Across a Range of Motion Due to Combined Bony Defects: A Cadaveric Study

Loss of Anterior Stability of Shoulder Across a Range of Motion Due to Combined Bony Defects: A Cadaveric Study

Identification and Treatment of Existing Copathology in Anterior Shoulder Instability Repair

Recurrent anterior instability is a common finding after traumatic glenohumeral dislocation in the young, athletic patient population. A variety of concomitant pathologies may be present in addition to the classic Bankart lesion, including glenoid bone loss; humeral head bone loss; rotator interval pathology; complex/large capsular injuries including humeral avulsions of the glenohumeral ligaments (HAGL lesions), SLAP tears, near circumferential labral tears, and anterior labral periosteal sleeve avulsions (ALPSA lesions); and rotator cuff tears. Normal anatomic variations masquerading as pathology also may be present. Recognition and treatment of these associated pathologies are necessary to improve function and symptoms of pain and to confer anterior shoulder stability. This review will focus on the history, physical examination findings, imaging findings, and recommended treatment options for common sources of copathology in anterior shoulder instability repair.

Results of Revision Anterior Shoulder Stabilization Surgery in Adolescent Athletes

The purpose of this study was to determine failure rates, functional outcomes, and risk factors for failure after revision anterior shoulder stabilization surgery in high-risk adolescent athletes. Adolescent athletes who underwent primary anterior shoulder stabilization were reviewed. Patients undergoing subsequent revision stabilization surgery were identified and analyzed. Failure rates after revision surgery were assessed by Kaplan-Meier analysis. Failure was defined as recurrent instability requiring reoperation. Functional outcomes included the Marx activity score; American Shoulder and Elbow Surgeons score; and University of California, Los Angeles score. The characteristics of patients who required reoperation for recurrent instability after revision surgery were compared with those of patients who required only a single revision to identify potential risk factors for failure. Of 90 patients who underwent primary anterior stabilization surgery, 15 (17%) had failure and underwent revision surgery (mean age, 16.6 years; age range, 14 to 18 years). The mean follow-up period was 5.5 years (range, 2 to 12 years). Of the 15 revision patients, 5 (33%) had recurrent dislocations and required repeat revision stabilization surgery at a mean of 50 months (range, 22 to 102 months) after initial revision. No risk factors for failure were identified. The Kaplan-Meier reoperation-free estimates were 86% (95% confidence interval, 67% to 100%) at 24 months and 78% (95% confidence interval, 56% to 100%) at 48 months after revision surgery. The mean final Marx activity score was 14.8 (range, 5 to 20); American Shoulder and Elbow Surgeons score, 82.1 (range, 33 to 100); and University of California, Los Angeles score, 30.8 (range, 16 to 35). At 5.5 years' follow-up, adolescent athletes had a high failure rate of revision stabilization surgery and modest functional outcomes. We were unable to convincingly identify specific risk factors for failure of revision surgery. Level IV, retrospective therapeutic case series.

Motions and functional performance after supervised physical therapy program versus home-based program after arthroscopic anterior shoulder stabilization: A randomized clinical trial

ObjectiveTo compare the effects of a standardized supervised physical therapy versus a controlled home-based programs on the rate of shoulder motion and functional recovery after arthroscopic anterior shoulder stabilization. MethodsTwenty-seven patients (18–35years) underwent arthroscopic anterior shoulder stabilization. Patients were randomized into two groups. A supervised group (n=14) received a rehabilitation program, 3 sessions/week for 24 weeks and a controlled home treated group (n=13) who followed a home-based program for same period. Range of motion (ROM) of the shoulder was assessed 4 times after each phase of rehabilitation and function was assessed after the 3rd and 4th phase of rehabilitation. ResultsBoth groups achieved a significant progressive increase in all shoulder motions throughout the study period. Patients in the supervised group achieved 92.6% and 94.2% of the contralateral side in abduction and forward elevation respectively. The controlled home-based group achieved 87.1% and 94.7% of abduction and forward elevation respectively. For external rotation, the percentage ROM achieved was 81.1% for the supervised group and 76.4% for the controlled home-based group. For function assessment, the two groups showed a significant improvement. However, the two groups were not significantly different from each other in all measured variables. ConclusionA controlled home-based physical therapy program is as effective as a supervised program in increasing shoulder range of motion and function after arthroscopic anterior shoulder stabilization.

Primary open anterior shoulder stabilization: a long-term, retrospective cohort study on the impact of subscapularis muscle alterations on recurrence

BackgroundPost-traumatic anterior shoulder instability patients may present histopathologic lesions within the subscapularis muscle compatible with a scarring process associated with disuse atrophy. We hypothesized that such lesions identified on intraoperative biopsy at the time of primary anterior shoulder stabilization would predict a higher risk of postoperative instability recurrence.MethodsOf 52 eligible patients (52 shoulders) who had undergone subscapularis muscle biopsy during primary anterior open labral repair and capsulorrhaphy, 35 (mean age at surgery, 27.2 years; male sex, 71.4%) were retrospectively evaluated (mean follow-up, 12.9 years; range, 10.9-14.5 years). Primary outcome was shoulder instability recurrence. Secondary outcomes included shoulder range of motion, functional scores, and radiological analysis of glenohumeral joint degenerative changes.ResultsOverall five patients (14.3%) presented shoulder instability recurrence. Twelve patients with histopathologic lesions had significantly more instability recurrence than 23 without histopathologic changes (33.3% vs. 4.3%; risk difference, 29% [95% CI 1; 57]; p = 0.038). Patients without histopathologic changes had significantly reduced external rotation with arm at side (ER1; -11.9°; p = 0.001) and with shoulder abducted to 90° (ER2; -14.9°; p = 0.001) on the operated side when compared to the contralateral side. Patients with histopathologic lesions had only ER2 significantly reduced (-8.9°; p = 0.031). There was no substantial difference regarding functional and quantitative radiological scores between both patients’ groups.ConclusionsHistopathologic changes within the subscapularis muscle at the time of primary open labral repair and capsulorrhaphy were associated with an increased risk of shoulder instability recurrence. Further investigations are needed to assess the impact of dedicated postoperative rehabilitation programs for patients presenting these lesions. Their recognition on preoperative magnetic resonance imaging should also be investigated; non-anatomical repairs could be an option in these cases.

The Arthroscopic Rotator Interval Closure: Why, When, and How?

The contribution of the rotator interval (RI) to the overall stability of the glenohumeral joint remains under debate. With improvements in the interpretation of both physical examination and diagnostic imaging findings, the diagnosis of RI pathology is becoming easier to identify. The clinical implications of RI pathology, however, still remain controversial. Injury to RI may contribute to glenohumeral instability, and both biomechanical and clinical studies have shown improvements in anterior shoulder stabilization following RI closure. The benefits of RI repair in the setting of posterior shoulder and multidirectional instability, however, are unclear. The optimal surgical technique is also unclear, and a variety of open and arthroscopic methods have been described. The purposes of this article are to review the surgical anatomy relevant to RI closure, discuss the biomechanical rationale for repairing the RI, and provide our preferred technique for performing arthroscopic RI closure.

Outcomes After Bankart Repair in a Military Population: Predictors for Surgical Revision and Long-Term Disability

To quantify the rate of surgical failure after anterior shoulder stabilization procedures, as well as to identify demographic and surgical risk factors associated with poor outcomes. All Army patients undergoing arthroscopic or open Bankart repair for shoulder instability were isolated from the Military Health System Management Analysis and Reporting Tool between 2003 and 2010. Demographic variables (age, gender) and surgical variables (treatment facility volume, admission status, surgical technique) were extracted. Rates of surgical failure, defined as subsequent revision surgery or medical discharge with persistent shoulder complaints, were recorded from the electronic medical record and US Army Physical Disability Agency database. Risk factor analysis was performed with univariate t tests, χ(2) tests, and a multivariable logistic regression model with failure as the outcome. A total of 3,854 patients underwent Bankart repair during the study period, with most procedures having been performed arthroscopically (n = 3,230, 84%) and on an outpatient basis (n = 3,255, 84%). Patients were predominately men (n = 3,531, 92%), and the mean age was 28.0 years (SD, 7.5 years). A total of 193 patients (5.0%) underwent revision stabilization whereas 339 patients (8.8%) were medically discharged with complaints of shoulder instability, for a total combined failure rate of 13.8% (n = 532). Univariate analyses showed no significant effect for gender; however, younger age, higher facility volume, open repair, and inpatient status were significant factors associated with subsequent surgical failure. Multivariable analyses confirmed that young age (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.91 to 0.96; P < .001), open repair (OR, 0.52; 95% CI, 0.36 to 0.75; P = .001), and inpatient status (OR, 0.58; 95% CI, 0.40 to 0.84; P = .004) were independently associated with failure by revision surgery. Young age remains a significant risk factor for surgical failure after Bankart repair. Patients who underwent arthroscopic Bankart repair had a significantly lower surgical failure rate (4.5%) than patients who underwent open anterior stabilization (7.7%). Despite advances in surgical technique, 1 in 20 military service members required revision surgery after failed primary stabilization in this study. Level IV, therapeutic case series.

Iliac crest allograft glenoid reconstruction for recurrent anterior shoulder instability in athletes: Surgical technique and results.

Performing a labral repair alone in patients with recurrent anterior instability and a large glenoid defect has led to poor outcomes. We present a technique involving the use of the iliac crest allograft inserted into the glenoid defect in athletes with recurrent anterior shoulder instability and large bony defects of the glenoid (>25% of glenoid diameter). All athletes with recurrent anterior shoulder instability and a large glenoid defect that underwent open anterior shoulder stabilization and glenoid reconstruction with the iliac crest allograft were followed over a 4-year period. Preoperatively, a detailed history and physical exam were obtained along with standard radiographs and magnetic resonance imaging of the affected shoulder. All patients also completed the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) evaluation forms preoperatively. A computed tomography scan was obtained postoperatively to assess osseous union of the graft and the patient again went through a physical exam in addition to completing the SST, ASES, and Western Ontario Shoulder Instability Index (WOSI) forms. 10 patients (9 males, 1 female) were followed for an average of 16 months (4–36 months) and had a mean age of 24.4 years. All patients exhibited a negative apprehension/relocation test and full shoulder strength at final follow-up. Eight of 10 patients had achieved osseous union at 6 months (80.0%). ASES scores improved from 64.3 to 97.8, and SST scores improved from 66.7 to 100. Average postoperative WOSI scores were 93.8%. The use of the iliac crest allograft provides a safe and clinically useful alternative compared to previously described procedures for recurrent shoulder instability in the face of glenoid deficiency.

Arthroscopic Subscapularis Bankart Technique as a Salvage Procedure for Failed Anterior Shoulder Stabilization

Shoulder instability is a relatively common problem. Even with contemporary surgical techniques, instability can recur following both open and arthroscopic fixation. Surgical management of capsular insufficiency in anterior shoulder stabilization represents a significant challenge, particularly in young, active patients. There are a limited number of surgical treatment options. The Laterjet technique can present with a number of intraoperative challenges and postoperative complication. We report an arthroscopic subscapularis tenodesis technique as a salvage procedure for challenging glenohumeral instability cases. Sutures are passed through the subscapularis tendon and capsule before they are tied as one in the subdeltoid psace. The rotator interval is closed with superior and medial advancement of anterior and inferior tissue. This technical note carefully describes this procedure with useful technical tips, illustrations, and diagrams. Two clinical cases are described involving patients with recurrent instability following failed surgery who were successfully managed with this procedure. Both cases described resulted in improved shoulder stability, range of motion, and function following management with this surgical technique. This arthroscopic subscapularis tenodesis procedure is proposed as a useful alternative repair technique for cases of recurrent instability after failed surgery with isolated capsular insufficiency. It is believed that this arthroscopic subscapularis tenodesis technique can potentially provide similar outcomes to open bone block stabilization procedures, while reducing the risks associated with those procedures.

How Does External Rotation Bracing Influence Motion and Functional Scores After Arthroscopic Shoulder Stabilization?

After arthroscopic shoulder stabilization, the loss of motion or delayed recovery of motion remains a clinical problem and may lead to poor patient satisfaction. There remains no consensus regarding the optimal position for postoperative immobilization and it is not known whether the position for shoulder immobilization has an effect on motion and functional recovery. We asked: (1) Do patients treated with external rotation (ER) bracing after arthroscopic anterior shoulder stabilization reliably regain ROM and shoulder function? And (2) what is the frequency of recurrent instability and brace-related complications associated with the use of ER bracing? Forty consecutive patients with a primary diagnosis of anterior shoulder instability underwent arthroscopic stabilization and received postoperative ER bracing; 33 patients (83%; mean age, 23 years; range, 13-44 years) were followed for at least 1 year postoperatively and seven patients were lost to followup. Shoulder ROM and functional scores were recorded preoperatively and at 2 weeks, 12 weeks, 6 months, and greater than 1 year (mean, 16 months) after surgery. All patients recovered their preoperative ROM and most patients achieved normal ROM by 3 months after surgery. Significant improvements in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Shoulder Instability (WOSI) scores were observed at each postoperative time point. The mean (± SD) final scores were 95 ± 9 for the ASES and 87% ± 17% for the WOSI (p < 0.001 compared to preoperative scores). One patient (3%) developed recurrent instability. No patients underwent reoperation for the injured shoulder for any reason during the followup period. ER bracing after arthroscopic shoulder stabilization is associated with a predictable recovery of ROM and functional score improvement. Future studies comparing ER bracing to traditional sling use should be conducted to determine the optimal method of postoperative immobilization. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Revision Surgery of Failed Open Bankart Repair: Case Reports

The clinical outcome of revision surgery for the failed Bankart repair is not well known. The purpose of this case study is to report the success rates achieved in two cases using arthroscopic techniques to revise failed open Bankart repairs. Both patients showed significant improvements in terms of shoulder stability and function at post-arthroscopic revision with no recurrences on follow-up. Their overall function and stability were evidenced by the improvements in shoulder scores and subjective scoring. In conclusion, arthroscopic revision of failed open anterior shoulder stabilisation using suture anchors is a reliable procedure in relation to the recurrence rate, range of motion and shoulder function in carefully selected patients, and with a proper workup. J Med Cases. 2013;4(8):564-568 doi: http://dx.doi.org/10.4021/jmc1354w

Revision Arthroscopic Bankart Repair

Failed anterior shoulder stabilization procedures have traditionally been treated with open procedures. Recent advances in arthroscopic techniques have allowed for certain failed stabilization procedures to be treated by arthroscopic surgery. The aim of this systematic review was to determine the outcomes of revision arthroscopic Bankart repair. We searched Medline, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) for articles on revision arthroscopic Bankart repairs. Key words included shoulder dislocation, anterior shoulder instability, revision surgery, and arthroscopic Bankart repair. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. We included 16 studies comprising 349 patients. All studies were retrospective (1Level II study and 15 Level IV studies). The mean incidence of recurrent instability after revision arthroscopic Bankart repair was 12.7%, and the mean follow-up period was 35.4 months. The most common cause for failure of the primary surgeries was a traumatic injury (62.1%), and 85.1% of patients returned to playing sports. The reasons for failure of revision cases included glenohumeral bone loss, hyperlaxity, and return to contact sports. With proper patient selection, the outcomes of revision arthroscopic Bankart repair appear similar to those of revision open Bankart repair. Prospective, randomized clinical trials are required to confirm these findings. Level IV, systematic review of Level II and Level IV studies.

Is Generalized Ligamentous Laxity a Risk Factor for Poorer Outcome After Arthroscopic Anterior Shoulder Stabilization? A Prospective Evaluation

Generalized ligamentous laxity has been proposed as a significant risk factor for failure after arthroscopic anterior shoulder stabilization. However, this has yet to be proven in a prospective study using a validated scoring system for generalized ligamentous laxity. The purpose of this study was to prospectively measure ligamentous laxity in patients undergoing arthroscopic anterior shoulder stabilization for unidirectional anterior shoulder instability, and determine whether laxity is a risk factor for poorer outcome.

The “Bony Bankart Bridge” Technique for Restoration of Anterior Shoulder Stability

Background: Bony deficiency of the anteroinferior glenoid rim can cause recurrent glenohumeral instability. To address this problem, bony reconstruction is recommended in patients with glenoid bone loss more than 20% to 25%. Recent advances in shoulder surgery techniques allow for the arthroscopic reconstruction of glenoid bone defects to restore stability. Hypothesis: The all-arthroscopic “bony Bankart bridge” (BBB) technique for bony anterior glenohumeral instability can restore shoulder stability and provide good shoulder function as well as improve patient satisfaction for these difficult-to-treat cases. Study Design: Case series; Level of evidence, 4. Methods: A consecutive series of 15 patients with bony anterior shoulder instability were treated using the arthroscopic BBB technique. All patients were assessed with the Disabilities of the Arm, Shoulder and Hand–short version (QuickDASH), American Shoulder and Elbow Surgeons (ASES) score, and Short Form-12 (SF-12) preoperatively and at final evaluation. In addition, a specific questionnaire evaluated patient satisfaction and possible complications. Results: Two women and 13 men were included in the study, with an average age of 44 years (range, 24-70 years). The average glenoid bone loss was 29% (range, 17%-49%). The mean duration of follow-up was 2.7 years (range, 2.0-4.4 years). At that time, the mean ASES score had improved from 81 (range, 50-98) to 98 (range, 88-100) (P = .133). Although this change was not statistically significant because of low patient numbers, the amount of improvement was almost 3 times the minimal clinically important difference of 6.4 points as reported in previous studies. The mean SF-12 (physical component) improved from 46.8 to 56.2 at final follow-up (P = .015). The mean QuickDASH score at final follow-up was 2.8 (range, 0-15.9), and the mean Single Assessment Numeric Evaluation score was 99 (range, 95-100). There were 14 (93%) stable shoulders and 1 (7%) failure with redislocation from a fall. Median patient satisfaction at final follow-up was 10 (range, 7-10) out of 10. Conclusion: The arthroscopic BBB technique for anterior instability with glenoid rim fracture successfully restores shoulder stability with a high median patient satisfaction (10/10) and a very low complication rate.

Arthroscopic Revision Surgery of Failed Open Bankart Repair: Case Reports

The clinical outcome of revision surgery for the failed Bankart repair is not well known. The purpose of this case study is to report the success rates achieved in two cases using arthroscopic techniques to revise failed open Bankart repairs. Both patients showed significant improvements in terms of shoulder stability and function at post-arthroscopic revision with no recurrences on follow-up. Their overall function and stability were evidenced by the improvements in shoulder scores and subjective scoring. In conclusion, arthroscopic revision of failed open anterior shoulder stabilisation using suture anchors is a reliable procedure in relation to the recurrence rate, range of motion and shoulder function in carefully selected patients, and with a proper workup. J Med Cases. 2013;4(8):564-568 doi: http://dx.doi.org/10.4021/jmc1354w

Return to Sport Following Arthroscopic Anterior Shoulder Stabilization

Objectives:The purpose of this study was to determine the capacity to return to sport and other patient-rated outcomes following arthroscopic shoulder stabilization in a case series comparing upper extremity/contact (UE) and lower extremity (LE) athletes.Methods:Patients who underwent arthroscopic anterior shoulder stabilization by the senior author between November 2006 and November 2010 were contacted for follow up on their return to play and outcomes assessment. Outcomes included a questionnaire that had the Single Assessment Numeric Evaluation (SANE), ASES Shoulder Score, Marx Shoulder Activity Scale, and Western Ontario Shoulder Instability Index (WOSI).Results:The cohort consisted of 48 patients involved in active sports. They identified themselves as participating in a sport around the time of their injury that primarily involved either the upper extremity (n = 35) or lower extremity (n = 13). Contact athletes were grouped with the upper extremity athletes. Upper extremity and contact sports included football, basketball, ice hockey, rock climbing, baseball, volleyball, and weightlifting. Lower extremity sports included running, skiing, snowboarding, mountain biking, and soccer. Average time to follow-up was 37 months (range, 19-79 months) in the UE group and 41 months (range, 18-76 months) in the LE group (p = 0.57). Average age at the time of surgery was 26 years (range, 16-42 years) in the UE group and 29 years (range, 18-45 years) in the LE group (p = 0.33). Twenty-three patients (23/35, 66%) in the UE group and 10 patients (10/13, 77%) in the LE group were able to return to their sport by the time of follow-up (p = 0.39). Average time to return to sport was 6.2 months (range, 3-12 months) in the UE/C group and 7.9 months (range, 3-18 months) in the LE group (p = 0.28). Of those patients able to return to their sport, 16 patients (16/23, 70%) in the UE group and 5 patients (5/10, 50%) in the LE group were able to return to their pre-injury activity level (p = 0.18). The average Marx Activity Scale was 11.9 and 11.5 in the UE and LE groups, respectively (p = 0.72), while the average SANE score was 85 and 87 in the UE and LE groups, respectively (p = 0.53). The average ASES score was 89 in the UE group and 94 in the LE group (p = 0.12). The WOSI score was 23% versus 26% in the UE and LE groups, respectively (p = 0.62). Patients were able to indicate reasons for their inability to return, many had more than one: eight patients did not return secondary to loss of strength, six due to pain, five had a fear of reinjury, 3 cited loss of speed as a reason, and 3 felt a sense of instability. Six patients did not return due to a loss of interest in their sport, or development of a new sport interest.Conclusion:There is no significant difference between upper and lower extremity athletes in terms of return to sport, time to return to sport, or other functional outcomes in this cohort. There may be a trend towards greater return to pre-injury activity level in upper extremity athletes, however further evaluation on a larger sample size is necessary to determine this. Despite high scores on the shoulder outcome measures, the athlete’s rate of return to their sport was only moderate.