Arthroscopic Posterior Capsulolabral Repair Research Articles

Outcomes of Arthroscopic Posterior Capsulolabral Repair in Patients with Traumatic Recurrent Posterior Instability of Shoulder

Outcomes of Arthroscopic Posterior Capsulolabral Repair in Patients with Traumatic Recurrent Posterior Instability of Shoulder

Arthroscopic posterior capsulolabral repair grants adequate outcomes in shoulders with posterior instability without glenoid cartilage lesions.

Posterior capsulolabral repair (posterior Bankart) is effective to restore shoulder stability and relieve pain, though a recent meta-analysis reported recurrent instability in 9.5% of patients, and that only 62.7% were able to resume sports. The purpose of this study was to assess the outcomes of arthroscopic posterior capsulolabral repair in a population of unselected patients, in terms of recurrence of instability, clinical scores, and return to sports. The authors retrospectively studied a consecutive series of 22 patients that underwent posterior capsulolabral repair between 2009 and 2019. Patients were assessed before posterior capsulolabral repair and at a minimum follow-up of 24months, in terms of subjective shoulder value (SSV), Western Ontario Shoulder Instability Index (WOSI), as well as level of sport. Following surgery, all complications, reoperations or episodes of instability were noted. The cohort comprised 21 men (95%) and 1 woman (5%), aged 38.8 ± 12.5years (range 17-61) at index surgery. Of the 20 patients that performed sports, only 2 (10%) stopped sports after surgery, while 18 resumed their main sport (90%). At a follow-up of 65.4 ± 34.8months (range 25-146), the SSV was 85.1 ± 14.7, pain on VAS was 1.9 ± 2.1, and the Constant-Murley score was 71.6 ± 17.9. Five patients had subjective instability without dislocation (23%). Nine patients (41%) had no pain (0 points), 6 patients (27%) had mild pain (1-2 points), 4 patients (18%) had moderate pain (3 points), while 3 patients (14%) had severe pain (5-8 points). Arthroscopic posterior capsulolabral repair prevented recurrent dislocation in patients with posterior shoulder instability at a minimum follow-up of 2years, despite persistent pain in 32%, and subjective instability in 23%. These complications were mainly observed in patients with work-related accidents and glenoid cartilage lesions. III, case series.

Outcomes After Revision Posterior Shoulder Capsulolabral Repair in Adolescent Athletes.

Few studies have evaluated the outcomes of posterior arthroscopic capsulolabral repair in adolescents, especially with regard to outcomes after revision repair. Adolescent athletes who undergo revision arthroscopic posterior unidirectional capsulolabral repair will have similar outcomes and return to play when compared with adolescent athletes who underwent primary arthroscopic posterior unidirectional capsulolabral repair. Cohort study; Level of evidence, 3. Data were reviewed from patients who underwent posterior shoulder stabilization between 2000 and 2019 and had a minimum follow-up of 2 years. Patients <11 and >19 years of age and those with multidirectional instability were excluded. Revision surgery was defined as repeat arthroscopic posterior capsular repair. The ability to return to sport (and level of sport), clinical outcomes scores (American Shoulder and Elbow Surgeons [ASES] and visual analog scale for pain), and patient-reported perception of range of motion, strength, and satisfaction were recorded. Comparisons between the primary and revision cohorts were made using the chi-square or the Mann-Whitney U test. Included were 180 adolescent patients (182 shoulders) who underwent a primary unidirectional posterior stabilization, with an average follow-up of 6.1 years. Of these patients, 17 patients required revision surgery (9.3% revision rate). At the final follow-up, patients who underwent revision surgery returned to sport at similar rates to those who did not (70.6% vs 85.9%; P = .095) and were similarly likely to return to their presurgery level of play (41.1% vs 23.7%; P = .10). The no-revision patients had higher ASES scores (76.1 vs 87.1; P = .007) as well as less pain and improved subjective range of motion scores. However, both groups had similar subjective strength scores, and both reported that surgical repair was satisfactory (no revision, 93.2% vs revision, 88.2%; P = .45). Adolescent athletes had a low risk of revision surgery and frequently returned to play after arthroscopic posterior capsulolabral repair, often at a lower level of play. Those who required revision surgery had poorer outcome scores but still reported a high rate of satisfaction.

The influence of posterior acromial morphology on outcomes and return to pushups in young patients undergoing arthroscopic posterior capsulolabral repair

Prior evidence has identified specific posterior acromial morphology as significantly associated with unidirectional posterior shoulder instability. The purpose of this study is to determine the influence of posterior acromial morphology on the outcomes of arthroscopic posterior capsulolabral repair (APCLR) for unidirectional posterior shoulder instability. Additionally, we sought to determine the influence of posterior acromial morphology on the rate and time to return to pushups following APCLR. We performed a retrospective review of prospectively collected data. The study included consecutive patients undergoing APCLR. Data collected included demographics, radiographic measurements including posterior acromial height (PAH) and posterior acromial tilt on preoperative scapular-Y radiographs, and patient-reported outcome measures at the preoperative and postoperative visits. In addition, starting at 6 months postoperative, patients were asked if they could perform pushups defined as at least 10 repetitions. At the final follow-up, we collected the number of pushups patients were able to perform. Thirty-two consecutive patients underwent APCLR with a mean follow-up of 26 months (range, 12-41). Significant improvement from preoperative to 2 years postoperative was demonstrated in Subjective Shoulder Value (50-85), VAS (6-2.5), American Shoulder and Elbow Surgeons (48 to 83), and Western Ontario Shoulder Instability (WOSI) (1437-777), P=.001. The recurrent instability rate was 3/32 (9%). Patients with PAH>23 (N=17) had a recurrent instability rate of 18% (3/17) versus PAH ≤ 23 (N=15) 0% (0/15), worse WOSI scores (P=.41), and a lower number of pushups (P=.48). The percentage of patients reporting the ability to perform pushups was (6 months/1 year/2 years) (50%/78%/95%). The mean number of pushups reported at the final follow-up was 33 (range, 1-60). Following APCLR, approximately 50% of patients resume pushups at 6 months postoperatively, and 80% return at 1 year. Patients reported performing a mean of 33 pushups following APCLR at the final follow-up. Patients with a PAH greater than 23 on preoperative scapular-Y radiographs had a higher rate of recurrent posterior instability, worse WOSI scores, and lower return to pushups; however, the results did not meet statistical significance. Therefore, future larger studies are needed to determine if posterior acromial morphology is independently associated with worse outcomes and increased recurrent instability rates following APCLR.

Outcomes of Revision Arthroscopic Posterior Labral Repair and Capsulorrhaphy: A Systematic Review.

Failure rates up to 14% have been reported after arthroscopic posterior capsulolabral repair. It is unknown if revision arthroscopic posterior capsulolabral stabilization has inferior restoration of stability and return to sport when compared with primary repair. Optimal management of failed posterior capsulolabral stabilization is unknown. To report outcomes of revision posterior capsulolabral repair and factors that contribute to failure and to determine optimal management of failed posterior stabilization procedures. Systematic review; Level of evidence, 4. A computerized search of the PubMed, EMBASE, and Web of Science databases and manual screening of selected article reference lists were performed in January 2022. Randomized controlled trial, cohort, case-control, and case series studies reporting clinical outcomes of revision arthroscopic posterior capsulolabral repair were eligible. Patient characteristics, indications for revision, intraoperative findings, surgical techniques, and patient-reported outcomes were recorded. Owing to heterogeneity of reported outcomes, data were summarized and presented without pooled statistics. Only 3 of the 990 identified studies met inclusion criteria. The included studies encompassed 26 revision arthroscopic posterior capsulolabral repairs, with follow-up ranging from 2.3 to 5.3 years. The failed index procedure was arthroscopic capsulolabral repair with suture anchors (n = 22) or posterior thermal capsulorrhaphy (n = 4). The primary indications for revision were recurrent instability and pain. Six patients experienced recurrent instability after revision. Patient satisfaction ranged from 15% to 25%. This systematic review of 3 studies demonstrated that the incidence of persistent pain and recurrent instability after revision arthroscopic posterior shoulder stabilization is common, and despite slight improvement in patient-reported outcomes, many patients are dissatisfied with their clinical outcomes. Revision arthroscopic posterior shoulder stabilization appears to have a significant failure rate, and there is need for additional prospective studies to help determine the best intervention for these patients.

Arthroscopic Posterior Capsulolabral Repair With Suture-First Versus Anchor-First Technique in Patients With Posterior Shoulder Instability (Type B2): Clinical Midterm Follow-up.

Isolated soft tissue injuries of the posterior capsulolabral complex can be addressed arthroscopically, with various anchor systems available for repair. To evaluate clinical and patient-reported outcomes after arthroscopic capsulolabral repair in patients with posterior shoulder instability (PSI) and to compare differences in outcomes between patients treated with a suture-first technique (PushLock anchor) and an anchor-first technique (FiberTak all-suture anchor). Cohort study; Level of evidence, 3. Included were 32 patients with dynamic structural PSI (type B2 according to the ABC classification) treated with an arthroscopic posterior capsulolabral repair. After a mean follow-up time of 4.8 ± 3.4 years (range, 2-11) patients were evaluated clinically, and standardized outcome scores were obtained for the Subjective Shoulder Value (SSV), the Western Ontario Shoulder Instability Index (WOSI), Rowe, Kerlan-Jobe Orthopaedic Clinic (KJOC), patient satisfaction (0-5 [best]), and pain on a visual analog scale (VAS; 0-10 [worst]). The overall satisfaction level with the outcome of the surgery was 4.6 ± 0.5 (range, 4-5). No patient suffered from instability events. The mean VAS level for pain was 0.4 ± 0.9 (range, 0-4) at rest and 1.9 ± 2.0 (range, 0-6) during motion. The mean SSV was 80 ± 17 (range, 30-100), the mean postoperative WOSI score 75% ± 19% (range, 18-98), the mean Rowe score 78 ± 20 (range, 10-100), and the mean KJOC score was 81 ± 18 (range, 40-100) for the entire cohort. There was no significant difference between the techniques with regard to range of motion, strength, or clinical outcome scores. Arthroscopic posterior capsulolabral repair was a satisfactory method to treat structural PSI type B2 with regard to stability, pain relief, and functional restoration. The majority of patients had good outcomes. No differences in outcomes were observed between the anchor-first and suture-first techniques.

Poster 160: Outcomes of Revision Posterior Shoulder Capsulolabral Repair in Adolescents

Objectives:Posterior arthroscopic capsulolabral repair has been shown to be successful in the athletic population. Adolescents provide a unique set of challenges to the surgeon due to their young age and potential length of time remaining in competitive athletics. Small studies have identified risk factors for failure, but there a paucity of literature evaluating adolescent specifically. The purpose of this study was to determine failure rates of adolescents who underwent arthroscopic posterior capsulolabral repair and to compare clinical outcomes and return to play between adolescents who required revision versus those who did not. It was hypothesized that adolescent athletes who require revision arthroscopic posterior unidirectional capsulolabral repair will have poorer outcomes and return to play and will undergo revision surgery at a higher rate than adults.Methods:A total of 718 patients who underwent posterior shoulder stabilization between 2000-19 with a minimum of 2-year follow-up were reviewed. Patients <11 years and >19 years of age and those with multidirectional instability were excluded. Revision surgery was defined as repeat arthroscopic posterior capsular repair. The ability to return to play, clinical outcomes scores (American Shoulder and Elbow Surgeons scoring system (ASES) and Visual Analog Scale (VAS)), and patient reported perception of range of motion, strength, and whether the surgery was worthwhile were recorded. Comparisons were made using the Chi-square or the Mann-Whitney U tests with P <0.05.Results:184 patients met inclusion criteria, with an average follow-up of 6.1 years. Nineteen patients required revision surgery, for an overall revision rate of 10.3%. At final follow-up, patients who underwent revision surgery returned to sport less frequently (86.7% vs 68.4%, p=0.04) and less likely to return to their pre-surgery level of play (Table 1). Non-revision patient had higher ASES score, as well as greater strength and range of motion. However, both groups had similar pain scores and reported that surgical repair was worthwhile (93.2% vs. 89.5%, p=0.55).Conclusions:Adolescent patients underwent revision posterior capsulolabral repair at a slightly higher rate (10.3%) when compared with athletes of all ages. Patients requiring revision had poorer outcomes scores when compared to those who did not undergo revision surgery but were able to return to sport at a high level and had a high level of satisfaction. Adolescent athletes return to play at high levels following arthroscopic posterior capsulolabral repair with a low rate of revision; however, those that require revision have poorer outcomes but high satisfaction.Table 1.Comparison of postoperative outcomes between non-revision and revision posterior shoulder arthroscopic capsulolabral repair

Poster 175: Beach Chair Versus Lateral Decubitus Positioning for Primary Arthroscopic Posterior Shoulder Stabilization

Objectives:There are no studies that directly compare beach chair (BC) versus lateral decubitus (LD) position for arthroscopic treatment of posterior instability. In the few systematic reviews evaluating BC vs. LD, no difference had been demonstrated in regard to recurrence and revision rates. Additionally, bone loss was not accounted for in the recurrence rate. The purpose of this study is to identify predictors of shoulder instability recurrence and revision after posterior shoulder stabilization surgery in a young, high demand population and evaluate surgical position and glenoid bone loss as independent predictors of the outcomes of interest, recurrence and revision at short- and mid- term follow-up.Methods:A consecutive series of 147 arthroscopic posterior stabilization procedures were performed by sports medicine certified and fellowship trained orthopaedic surgeons from 2005-2019 in either the BC or LD position. Patients were included if they underwent an isolated primary arthroscopic posterior capsulolabral repair. Patients were excluded if concomitant anterior labral repair was performed at the time of surgery. Shoulders were additionally excluded if magnetic resonance imaging (MRI) was not available at the time of preoperative evaluation, or the patient was lost to follow up. All shoulders were evaluated for glenohumeral bone loss using the best-fit circle technique on the sagittal enface MRI. The primary outcomes of interest were recurrent instability and revision stabilization. Recurrent instability was defined as the presence of a recurrent pain limiting activities with physical exam consistent with recurrent posterior instability per clinical notes in the electronic medical record. Rates of recurrence and revision were calculated among the full cohort among patients with available 1-year or 5-year follow up. Patient and procedure characteristics were compared by BC or LD group using two sample t-tests or Chi-square tests.Results:A total of 147 shoulders with a mean age of 22.6 years (4.82 SD) underwent isolated arthroscopic repair and were followed for a mean 6.93 (3.29 SD) years. The overall recurrent instability and revisions rates were 16% (23/147) and 12% (18/147), respectively. With respect to surgical position, there was no significant difference in recurrence or revision (p-value >0.05). With respect to patient age, anchor number, and bone loss there was no significant difference in recurrence or revision with respect to patient age (p-value >0.05).Conclusions:Among fellowship-trained orthopaedic surgeons, there was no difference in rates of recurrent instability and revision surgery after performing arthroscopic stabilization for isolated posterior shoulder instability in a high demand population in either the BC or LD position.

Risk Factors for Revision of Posterior Shoulder Stabilization in Throwing Athletes

Revision posterior shoulder stabilization has been shown to have inferior outcomes when compared to primary surgery. However, risk factors for revision surgery and patient reported outcomes in throwing athletes have not been reported. The purpose of this study was to evaluate the risk factors and patient reported outcomes in throwing athletes undergoing revision posterior stabilization for unidirectional posterior shoulder instability. One hundred throwing athletes (112 shoulders) who underwent arthroscopic posterior labral repair were reviewed at 2-year minimum follow-up. Patients who failed surgical intervention and underwent revision posterior labral surgery were compared to a control group of patients who did not undergo revision. Demographics including age, gender, contact sport participation, level of sport, length of follow-up, and return to sport were compared. American Shoulder and Elbow Surgeons (ASES) and Kerlan Jobe Orthopaedic Clinic (KJOC) Overhead Athlete scores were collected via online surveys and were available for 70 patients. Subjective stability, pain, strength, range of motion (ROM), and perceived effectiveness of surgery were also collected. MRI parameters of glenoid bone version, cartilage version, labrum version, bone width, labrum width, glenoid labrum version and width weight as well as rotator cuff status were also compared. Nine throwers failed primary surgery and required revision posterior stabilization (8.2%) at an average of 2.8 years postoperatively (range 6 – 55 months). Average follow-up was 65 months in the revision group and 38 months in the non-revision group. There was a significantly higher proportion of females in the revision group (44.5% vs 20.8%, p = 0.04). There was no significant difference between the revision and non-revision group in terms of average age (20.1 years vs 19.1 years, p = 0.27), proportion of contact athletes (22.2% vs 43.6%, p = 0.11), or presence of a rotator cuff tear (0% vs 5.9%, p = 0.24). In the revision group, 83% of patients were high school and 17% were college athletes, whereas in the non-revision group, level of participation was 78% high school, 13.5% college, and 2.7% professional, and 5.4% recreational. No statistical difference was seen in MRI measurements of glenoid bone version (9 degrees vs 8.1 degrees, p = 0.31), cartilage version (9.5 degrees vs 8.2 degrees, p = 0.23), labrum version (10.9 degrees vs 10.1 degrees, p = 0.35), labrum version weight (0.26 vs 2.29, p = 0.33), bone width (24.3 mm vs 25.2 mm, p = 0.16), labrum width (29.9 mm vs 28.9 mm, p = 0.27), or labrum width weight (0.19 vs 0.19, p = 0.47). Patients in the revision group had similar preoperative (37.2 vs 47.2, p = 0.15) and postoperative (73.3 vs 81.6, p = 0.45) and difference in (36.3 vs 33.1, p = 0.86) in ASES scores compared to the non-revision group. No significant difference was found in preoperative (32.9 vs 31.9, p = 0.93), postoperative (53.7 vs 50.6, p = 0.87), or change (16.8 vs 20.9, p = 0.74) in KJOC scores between the revision and non-revision groups. There was also no significant difference in subjective postoperative stability (5.2 vs 5, p = 0.92). Pain scores (out of 10) were not significantly different preoperatively (7.7 vs 7.0, p = 0.26), postoperatively (2.6 vs 3.4, p = 0.64), or the change in pain scores (5.2 vs 4.6, p = 0.78). The proportion of patients with perceived full strength (17% vs 46%, p = 0.21), full ROM (17% vs 36%, p = 0.65), and who believed the surgery was worthwhile (85% vs 87.5%, p = 1) were also similar. A smaller percentage of patients in the revision group were able to return to sport compared to the non-revision (33% vs 80.6%, p = 0.03), though the percentage able to return to the same level of participation was not significantly different (17% vs 27.4%, p = 1) (Table 1). Revision rate of arthroscopic posterior shoulder stabilization in throwing athletes was 8.2% at average 2.8 years post-operatively. Females were at a higher risk for revision surgery. Patients in the revision group also had a lower rate of return to sport compared to the control group. Age, rotator cuff injury, glenoid version, nor glenoid width were risk factors for revision. This data is useful to counsel throwers undergoing arthroscopic posterior capsulolabral repair. Throwers may be more likely to require revision surgery than other athletes, and those who undergo revision surgery may have worse outcomes compared to primary surgery.

Risk Factors for Revision Posterior Shoulder Stabilization in Throwing Athletes.

Background:Revision posterior shoulder capsulolabral repair has inferior outcomes compared with primary surgery. Risk factors for revision in throwing athletes are unknown.Purpose/Hypothesis:The purpose of this study was to characterize the revision rate and risk factors for revision surgery in throwing athletes. It was hypothesized that female athletes and those with smaller glenoid bone width would be at higher risk for revision surgery.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 105 throwing athletes who underwent arthroscopic posterior capsulolabral repair of their throwing shoulder were reviewed at a minimum of 2-year follow-up, and patients who required a revision were compared with those who did not. Collected data compared between the revision and no-revision groups included age, sex, contact sport participation, and return to sport (RTS). American Shoulder and Elbow Surgeons (ASES) score, Kerlan-Jobe Orthopaedic Clinic (KJOC) score, stability, pain, strength, range of motion (ROM), and patient satisfaction. Radiographic parameters including glenoid bone version, cartilage version, labral version, bone width, labral width, glenoid labral version and width weight were also compared between both groups.Results:Nine throwers required revision (8.6%) at an average of 2.8 years postoperatively. There were more female athletes in the revision than no-revision group (55.5% vs 23.4%; P = .03). There was no significant difference in age, proportion of contact athletes, rotator cuff tears, glenoid bone version, cartilage version, labral version, labral version weight, bone width, labral width, or labral width weight. Both groups had similar preoperative, postoperative, and change in ASES, KJOC, pain, strength, stability, and ROM scores. The proportion of patients with full strength and with full ROM, as well as patients who were satisfied with outcomes was similar between groups. Fewer patients in the revision group returned to sports compared with those in the no-revision group (14.3% vs 83.6%; P < .001), although return to sports at same level was not significantly different between groups (14.3% vs 37.2%; P = .41).Conclusion:The revision rate of arthroscopic posterior shoulder stabilization in throwers was 8.6%. Female athletes were at higher risk for revision, and return to sports was lower in patients who underwent revision surgery.

Posterior Glenohumeral Instability: Diagnosis and Management

Posterior glenohumeral instability can manifest as posterior shoulder pain and dysfunction, particularly among athletes. Repetitive, posteriorly-directed axial loads, as commonly encountered by contact athletes (American football linemen, rugby players), result in microtrauma that can induce posteroinferior labral tears. Alternatively, SLAP tears commonly seen in throwing athletes may propagate in a posteroinferior direction (i.e., a type VIII SLAP tear), owing to a complex pathologic cascade involving glenohumeral capsular contracture and imbalances among the dynamic stabilizing muscles of both the glenohumeral joint and shoulder girdle. The diagnosis of posterior glenohumeral instability is elucidated by a thorough history and physical examination. Posterior shoulder pain is oftentimes insidious in onset. The throwing athlete with posterior glenohumeral instability may complain of diminished control, accuracy, and generalized shoulder discomfort. A number of provocative physical examination maneuvers have been described (Kim test, Jerk test), which load the humeral head against the labral lesion and recreate patients’ symptoms. Magnetic resonance imaging and magnetic resonance arthrography can be of value in demonstrating avulsions of the labrum from the posteroinferior glenoid, and computed tomography is useful for quantifying the location and amount of attritional glenoid bone loss, although in contradistinction to anterior glenohumeral instability, clearly defined thresholds that would otherwise guide treatment have not been established. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported. However, high rates of return to play at the previous level of participation, particularly among throwing athletes, have been less consistently observed. Risk factors for the need for revision stabilization include surgery on the dominant extremity, female sex, and capsulolabral repairs involving either anchorless techniques or the use of less than 4 anchors.

Revision Arthroscopic Posterior Shoulder Capsulolabral Repair in Contact Athletes: Risk Factors and Outcomes

To determine risk factors and outcomes of revision arthroscopic posterior capsulolabral repair in contact athletes. Contact athletes with unidirectional posterior instability who underwent arthroscopic posterior capsulolabral repair from 2000 to 2014 with minimum 4-year follow-up were reviewed. Revision rate was determined and those who required revision surgery were compared with those who did not. Age, gender, labral and/or capsular injury, level of sport, and return to sport were compared. Pre- and postoperative American Shoulder and Elbow Surgeons, pain, function, stability, range of motion, strength, and satisfaction were also compared. Magnetic resonance imaging measurements of glenoid bone width, glenoid version, labral width, labral version, and cartilage version were also compared. A total of 149 contact athletes' shoulders met inclusion criteria. Eight shoulders required revision surgery (5.4%) at 13.0-year follow-up with 2.6 years between primary surgery and revision. Preoperative stability was significantly worse in those that required revision (0.008). Postoperative American Shoulder and Elbow Surgeons score was significantly worse in the revision group (75.1 vs 87.8, P= .03). The only significant risk factor for requiring revision surgery was decreased glenoid bone width (26.4 mm vs 29.1 mm, P= .005). Cartilage version, labral version, and bone version were not significantly different, nor was labral width. Sex, labral injury, capsule injury, both capsule and labrum injury, and level of sport were not risk factors. Both return to sport at the same level (revision= 16.7% vs nonrevision= 72.1%, P < .001) and overall return to sport (revision= 50.0% vs nonrevision=93.7%, P < .001) were significantly worse in the revision group. Contact athletes underwent revision arthroscopic posterior capsulolabral repair at an incidence of 5.4% at minimum 4-year and average 13.0-year follow-up. The only significant risk factors for requiring revision surgery was smaller glenoid bone width and higher preoperative instability. Return to play after their subsequent surgery was significantly worse. Level III, comparative study.

Risk Factors and Outcomes of Revision Arthroscopic Posterior Shoulder Capsulolabral Repair in Contact Athletes

Risk factors and outcomes of revision arthroscopic posterior capsulolabral repair are currently not well defined in contact athletes.

Risk Factors and Outcomes of Revision Arthroscopic Posterior Shoulder Capsulolabral Repair in Contact Athletes

Objectives: Risk factors and outcomes of revision arthroscopic posterior capsulolabral repairare currently not well defined in contact athletes.Evaluation of risk factors for contact athletes who require revision arthroscopic posterior unidirectional capsulolabral repair is needed. Methods: A total of 186 contact athletes’ shoulders that underwent arthroscopic posterior capsulolabral repair at minimum 2 year follow-up were reviewed. Those who required revision surgery were compared with those who did not. Parameters assessed included age, gender, labral and/or capsular injury, level of sport, and return to sport. Glenoid bone width, bone version, labral width, and labral version were also compared. Results: Eleven shoulders required revision surgery (5.9%) at mean 12.0 year follow-up. The only significant risk factor was glenoid bone width (revision=26.4 mm vs. non-revision=29.1 mm, p=0.005). Cartilage version (p=0.676), labral version (p=0.539), and bone version (p=0.791) were not significantly different between groups, nor was labral width (p=0.751). Gender (p=0.326), labral injury (p=0.349), capsule injury (p=0.683), and level of sport (p=0.381) were not significant factors for requiring revision surgery. Both return to sport at the same level (revision=16.7% vs. non-revision=72.1%, p&lt;0.001) and overall return to sport (revision=50% vs. non-revision=93.7%, p&lt;0.001) was significantly worse in the revision group. Of those who had revision surgery, 33.3% stated their original surgery was not worthwhile, which was significantly higher than the 4.5% in the non-revision group (p=0.041). Conclusion: Contact athletes underwent revision arthroscopic posterior capsulolabral repair at an incidence of 5.9% at 12 year follow-up. The only significant risk factor for requiring revision surgery was smaller glenoid bone width. Return to play was significantly worse in those who required revision surgery. This data is essential for patient selection, optimal treatment techniques, and patient education as posterior shoulder capsulolabral repair in contact athletes that require revision has not previously been evaluated.

Risk Factors and Outcomes of Revision Arthroscopic Posterior Shoulder Capsulolabral Repair

Background: Risk factors and outcomes of revision arthroscopic posterior capsulolabral repair of the shoulder are currently not well defined. Hypothesis: Athletes who require revision arthroscopic posterior unidirectional capsulolabral repair will have poorer outcomes and return to play when compared with those undergoing primary procedures, with risk factors including younger age, injury size, bone loss, and anchor number. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 297 shoulders that underwent arthroscopic posterior capsulolabral repair at minimum 2-year follow-up were reviewed. In addition to surgical data, the American Shoulder and Elbow Surgeons scoring system with subjective stability, range of motion, strength, and pain scores as well as return to sport were compared pre- and postoperatively between those who did and did not require revision surgery. Magnetic resonance arthrogram measurements of glenoid labral, chondral, and bone version and labral and bone width were also compared. Results: Nineteen shoulders required revision surgery (6.4%) at 8.9-year follow-up. Significant risk factors included female sex (P = .001), dominant shoulder (P = .005), and concomitant rotator cuff injury (P = .029). Patients with ≤3 anchors were more likely to require revision (odds ratio = 3.48). Smaller glenoid bone width was a risk factor for requiring future revision surgery (P < .001), but glenoid labral, chondral, and bone version and labral width were not risk factors. All patients had significant improvements in American Shoulder and Elbow Surgeons, pain, range of motion, and strength scores after the original surgery; however, those who required revision surgery had less improvement (P < .05). Stability improved significantly for nonrevisions (P < .001) but did not for revisions (P = .662). In the nonrevision group, 64.3% returned to sport at the same level, which was significantly higher than the 15.4% of the revision group (P = .004). Overall, 78.6% of the nonrevision group and 61.6% of the revision group returned to sport at some level (P = .280). Conclusion: Athletes underwent revision arthroscopic posterior capsulolabral repair at an incidence of 6.4%. Revision patients had significantly poorer outcome scores and return to play when compared with those who did not undergo revision surgery with risk factors being dominant shoulder surgery, female sex, concomitant rotator cuff injury, the use of 3 or fewer anchors, and smaller glenoid bone width. These data are essential for patient selection, optimal treatment techniques, and patient education as posterior shoulder instability failure requiring revision has not previously been evaluated.

Incidence and Risk Factors for Failure of Arthroscopic Posterior Capsulolabral Reconstruction

Objectives:Risk factors and outcomes of revision arthroscopic posterior capsulolabral repair is not well defined. It is hypothesized that athletes who require revision arthroscopic posterior unidirectional capsulolabral repair will have poorer outcomes and return to play with risk factors including younger age, injury size, bone loss, anchor number, and anchor type.Methods:A review of 161 shoulders who underwent arthroscopic posterior capsulolabral repair using modern techniques at minimum 2 year follow up was completed. In addition to surgical data, ASES, stability, ROM, strength, and pain scores were compared pre- and post-operatively as well as return to sport. Those who required revision surgery were identified and compared to those not undergoing revision.Results:Twenty shoulders required revision surgery (12.4%) at 5.3 year follow-up. Significant risk factors included female gender (p = 0.001), dominant shoulder (p = 0.005), and concomitant rotator cuff injury (p = 0.029). Patients with 3 or fewer anchors were more likely to require revision (OR = 3.48). There was no difference after normalization to tear size and location (p > 0.05). Return to sport at the same level was significantly lower if revision surgery was required (15.4% vs. 64.3%) (p = 0.004). All patients had significant improvements in ASES, pain, ROM, and strength after the original surgery, however, those who required revision surgery had less improvement (p < 0.05). Stability improved significantly in non-revision athletes (p < 0.001), but did not in revision patients (p = 0.662).Conclusion:Athletes required revision arthroscopic posterior capsulolabral repair at an incidence of 12.4% and had poorer outcome scores and return to play with risk factors being dominant shoulder surgery, female gender, concomitant rotator cuff injury, and the use of 3 or fewer anchors. This data is essential for patient selection, optimal treatment techniques, and patient education as posterior shoulder instability failure requiring revision has not previously been evaluated.Risk Factors for Revision SurgeryRisk factorp valueodds ratioDominant shoulder0.0059.9Female gender0.0014.47Total anchor number*0.0053.48Rotator cuff injury0.0294.07*Normalized anchor number was not significant

In Throwers With Posterior Instability, Rotator Cuff Tears Are Common but Do Not Affect Surgical Outcomes.

In a previous study, compared with throwing athletes with superior labral anterior posterior (SLAP) tears, those with concomitant SLAP tears and rotator cuff tears (RCTs) had significantly poorer outcome scores and return to play. Posterior shoulder instability also occurs in throwing athletes, but no studies currently exist regarding outcomes of these patients with concomitant RCTs. The authors hypothesized that throwing athletes treated with arthroscopic capsulolabral repair for posterior shoulder instability with coexistent rotator cuff pathology would have poorer outcome scores and return to play. Fifty-six consecutive throwing athletes with unidirectional posterior shoulder instability underwent arthroscopic capsulolabral repair. Preoperative and postoperative patient-centered outcomes of pain, stability, function, range of motion, strength, and American Shoulder and Elbow Surgeons Shoulder (ASES) scores, as well as return to play, were evaluated. Patients with and without rotator cuff pathology were compared. Forty-three percent (24/56) of throwing athletes had rotator cuff pathology in addition to posterior capsulolabral pathology. All RCTs were débrided. At a mean of 3 years, there were no differences in preoperative and postoperative patient-centered outcomes between those with and without RCTs. Return-to-play rates showed no between-group differences; 92% (22/24) of athletes with concomitant RCTs returned to sport (P = .414), and 67% (16/24) returned to the same level (P = .430). Arthroscopic capsulolabral reconstruction is successful in throwing athletes with RCTs treated with arthroscopic débridement. Unlike the previous study evaluating throwers outcomes after surgical treatment for concomitant SLAP tears and RCTs, the authors found no difference in patient-reported outcome measures or return to play for throwing athletes with concomitant posterior shoulder instability and RCTs. In throwing athletes with concomitant posterior instability and RCTs, arthroscopic posterior capsulolabral repair with rotator cuff débridement is successful.

Concomitant Rotator Cuff Tears in Throwing Athletes with Posterior Instability Are Common but Do Not Effect Surgical Outcomes

One previous study found that throwing athletes with SLAP and concomitant rotator cuff tears had significantly poorer outcome scores and return to play compared with those with SLAP tears only. Posterior shoulder instability is also common in throwing athletes, however, no studies exist reporting outcomes of these patients with concomitant rotator cuff tears. We hypothesize that throwers treated with arthroscopic capsulolabral repair for posterior shoulder instability with coexistent rotator cuff pathology will have poorer outcome scores and return to play. Fifty-six male over-head throwing athletes with unidirectional posterior shoulder instability who were reviewed. Pre- and post-operative patient centered outcomes of pain, stability, function, ROM, strength, and ASES scores as well as return-to-play were evaluated. Patients with and without rotator cuff pathology were compared. All athletes with rotator cuff pathology were treated with arthroscopic debridement. Twenty-four throwers of 56 were found to have rotator cuff pathology in addition to posterior capsulolabral pathology at average 3-year follow-up. There were no differences between those with and without rotator cuff tears in regards to pre- and post-operative patient centered outcomes including pain, stability, function, ROM, strength, and ASES scores. Return to play rates were no different, and 92% with concomitant rotator cuff tears returned to sport while 67% returned to the same level. Unlike a previous study evaluating throwing athletes’ outcomes after a SLAP tear with rotator cuff tears, throwers with posterior shoulder instability and concomitant rotator cuff tears showed no difference with respect to patient-reported outcome measures or return to play. This suggests arthroscopic posterior capsulolabral repair with rotator cuff debridement is a successful technique to manage posterior shoulder instability with concomitant rotator cuff tears.

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.

Arthroscopic Stabilization of Posterior Shoulder Instability Is Successful in American Football Players

To evaluate subjective and objective clinical outcomes of arthroscopic posterior capsulolabral repair for the treatment of symptomatic unidirectional posterior shoulder instability in American football players. Fifty-six consecutive American football players with unidirectional posterior shoulder instability underwent an arthroscopic posterior capsulolabral repair with or without suture anchors. Patients were evaluated, with return to play as the primary outcome measure supplemented with the American Shoulder and Elbow Surgeons (ASES) scoring system. Stability, range of motion, strength, pain, and function were also assessed with subjective scales. At a mean follow-up of 44.7 months postoperatively, 93% returned to sport and 79% returned to sport at the same level. Significant improvements (P < .01) were seen between preoperative and postoperative evaluations in ASESscore and subjective scores of stability, range of motion, strength, pain, and function. Excellent or good results (ASES score > 60; stability < 6) were achieved in 96.5% of athletes, and 96% were satisfied with their operations. Arthroscopic capsulolabral repair for unidirectional posterior shoulder instability is effective in American football players because it improves stability, pain, and joint function, which optimizes the likelihood of successful return to play. Case series; Level of evidence, IV.