Arthroscopic Shoulder Stabilization Research Articles

Rehabilitation guidelines following arthroscopic shoulder stabilisation surgery for traumatic instability – a Delphi consensus

BackgroundThere is no consistent approach to rehabilitation following arthroscopic shoulder stabilisation surgery (ASSS) in the UK. The aim of this study was to agree a set of post-operative guidelines for clinical practice. MethodExpert stakeholders (surgeons, physiotherapists and patients) were identified via professional networks and patient involvement and engagements groups. A three-stage online Delphi study was undertaken. Consensus was defined by the OMERACT threshold of 70% agreement. Results11 surgeons, 22 physiotherapists and 4 patients participated. It was agreed patients should be routinely immobilised in a sling for up to 3 weeks but can discard earlier if able. During the immobilisation period, patients should move only within a defined “safe zone.” Permitted functional activities include using cutlery, lifting a drink, slicing bread, using kitchen utensils, wiping a table, light dusting, pulling up clothing, washing/drying dishes. Closing car doors or draining saucepans should be avoided. Through range movements can commence after 4 weeks, resisted movements at 6 weeks. Patients can resume light work as they feel able and return to manual work after 12 weeks.Return to non-contact sports when functional markers for return to play are met was agreed. Return to contact sport is based on function & confidence after a minimum of 12 weeks. Additional factors to consider when determining rehabilitation progression: functional/physical milestones, patient’s confidence and presence of kinesiophobia. The preferred outcome measure is the Oxford Instability Shoulder Score. ConclusionThis consensus provides expert recommendations for the development of rehabilitation guidelines following ASSS. Contribution of the paper•This paper is the first to provide expert recommendations for patients undergoing rehabilitation following arthroscopic shoulder stabilisation surgery.•This paper provides clinicians and patients with expert guidance on appropriate expectations regarding functional restriction and progression following arthroscopic shoulder stabilisation surgery.•In the absence of national clinical guidelines for this patient group, these recommendations will reduce variation and improve quality of care.•The knowledge acquired from this study will also lay the foundation for clinical guidelines to be developed.•The results of this study also demonstrate the need for further, empirical work to be carried out in this area.

Arthroscopic Shoulder Stabilization in High School Football Players.

Destabilizing shoulder injuries are common in high school American football players; however, the rate of recurrent glenohumeral instability and return to play after arthroscopic labral stabilization surgery remains unknown. The purpose of this study was to determine the rate of recurrent instability on return to competitive high school football after arthroscopic shoulder labral stabilization and capsulorrhaphy procedures. It was hypothesized that the instability rate would be greater in players with more years of eligibility remaining (YER) to play at the high school level. Case series; Level of evidence, 4. Consecutive male high school football players with at least 1 YER who sustained at least 1 anterior traumatic inseason shoulder instability episode and underwent arthroscopic stabilization between 2012 and 2017 were identified. Patients and/or families were contacted by phone to discuss (1) recurrent instability episodes and (2) return to competitive sport and/or recreational athletic activity. Statistical analysis was conducted using chi-square tests to compare recurrent shoulder instability with return to play and YER. A total of 45 football players aged 14 to 17 years were included, with a mean follow-up of 4.1 years. Most patients (60%) chose not to return to competitive football, due mainly to fear of recurrent injury. Overall, the recurrent instability rate was 15.6% (7/45). The instability rate in players who returned to football was 16.7%, with 66.7% requiring revision surgery. The instability rate in patients who did not return to football was 14.8%, with no revision procedures required. In players who returned to football, the instability rate in YER group 4 was significantly higher than that in YER groups 1 to 3 (42% vs 10.5%, respectively, P = .03), with each year of play conferring an additional 10% risk of reinjury. There was a significant difference in the type of recurrent instability in players who returned to any sport versus those who did not (P = .029). High school football players who returned to competitive play after arthroscopic shoulder stabilization surgery experienced a higher rate of recurrent instability that was dependent on their YER. Over half of the players chose not to return to football, with fear of reinjury being the most common reason.

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.

Risk Factors for Glenoid Bone Loss in the Setting of Posterior Glenohumeral Instability.

Posterior instability has been reported to account for up to 24% of cases of shoulder instability in certain active populations. However, there is a paucity of data available regarding the risk factors associated with posterior glenoid bone loss. To characterize the epidemiology of, and risk factors associated with, glenoid bone loss within a cohort of patients who underwent primary arthroscopic shoulder stabilization for isolated posterior-type glenohumeral instability. Cross-sectional study; Level of evidence, 3. This was a retrospective analysis of patients who underwent primary arthroscopic shoulder stabilization for posterior-type instability between January 2011 and December 2019. Preoperative magnetic resonance arthrograms were used to calculate posterior glenoid bone loss using a perfect circle technique. Patient characteristics and revision rates were obtained. Bone loss (both in millimeters and as a percentage) was compared between patients based on sex, age, arm dominance, sports participation, time to surgery, glenoid version, history of trauma, and number of anchors used for labral repair. Included were 112 patients with a mean age of 28.66 ± 10.07 years; 91 patients (81.25%) were found to have measurable bone loss. The mean bone loss was 2.46 ± 1.68 mm (8.98% ± 6.12%). Significantly greater bone loss was found in athletes versus nonathletes (10.09% ± 6.86 vs 7.44% ± 4.56; P = .0232), female versus male patients (11.17% ± 6.53 vs 8.17% ± 5.80; P = .0212), and patients dominant arm involvement versus nondominant arm involvement (10.26% ± 5.63 vs 7.07% ± 6.38; P = .0064). Multivariate regression analysis identified dominant arm involvement as an independent risk factor for bone loss (P = .0033), and dominant arm involvement (P = .0024) and athlete status (P = .0133) as risk factors for bone loss >13.5%. At the conclusion of the study period, 7 patients had experienced recurrent instability (6.25%). The findings of this study are in alignment with existing data suggesting that posterior glenoid bone loss is highly prevalent in patients undergoing primary arthroscopic stabilization for posterior-type shoulder instability. Our results suggest that patients with dominant arm involvement are at risk for greater posterior glenoid bone loss. Athlete status and dominant arm involvement were identified as independent risk factors for bone loss >13.5%.

Comparison of 1- and 3-Week Immobilization Following Arthroscopic Shoulder Stabilization: Results of a Prospective Study

Purpose: We investigated the effects of 1- and 3-week of absolute immobilization duration on pain, range of motion (ROM), shoulder function, and recurrence rate on shoulder arthroscopic anterior capsulolabral repair (AACR) patients. Method: Fifty shoulder AACR patients’ pain intensity, shoulder ROM, and function were evaluated 4, 8, and 12 weeks after surgery (1-week group: 26; 3-week group: 24 patients). Function was assessed with American Shoulder and Elbow Surgeons (ASES) score at postoperative 12 weeks and final follow-up (average of postoperative 30 months). Whether there was a re-dislocation after surgery was also questioned at final follow-up. Results: Similar ROM were observed on both groups at the postoperative 4, 8, and 12 weeks ( p &gt; 0.05). Pain intensities at rest ( p = 0.40), night ( p = 0.22), and during the activity ( p = 0.49) were also similar on both groups. Also, no difference was observed for function between the two groups ( p = 0.99). Only one re-dislocation was in the 3-week immobilization group. Conclusion: Both 1- and 3-week of absolute immobilization demonstrated similar results in terms of shoulder ROM, pain, function, and recurrence rate after the shoulder AACR. Furthermore, earlier mobilization led to higher shoulder flexion at 4 weeks postoperatively. Either of the rehabilitation approaches can be adopted based on the patient's situation.

Mid- to Long-Term Outcomes of Arthroscopic Shoulder Stabilization in Athletes: A Systematic Review.

There exists a considerable amount of evidence regarding short-term outcomes of shoulder arthroscopy in athletes; however, mid- to long-term data are limited. Therefore, the purpose of this review is to evaluate studies assessing mid- to long-term outcomes and rates of return to sport in athletes undergoing primary shoulder arthroscopy. A search for the systematic review was performed in PubMed, Scopus, and Embase on 14 March 2023. Study parameters, as well as their respective outcomes, were described in detail and compiled into diagrams. Five studies were included, which contained data on a total of 307 shoulders in patients with mean ages ranging from 20.3 to 26.9 years and mean follow-up times ranging from 6.3 to 14 years. The arthroscopic Bankart repair was the primary surgical intervention performed in all five studies. The overall rate of return to sport was 84% (range, 70-100%) across the studies. The rate of return to sport at pre-injury level was 65.2% (range, 40-82.6%) across four studies. The overall rate of recurrent instability was 17.3%, with redislocation specifically occurring in 13.7% of patients across all studies. The overall rate of revision surgery was 11.1%. Athletes who underwent primary shoulder arthroscopy demonstrated favorable outcomes and a high rate of RTS at a minimum follow-up of 5 years. However, rates of recurrent instability, redislocation, and revision surgery occurred at less than favorable numbers, which emphasizes the importance of proper patient selection when considering candidates for arthroscopic versus open repairs.

Poster 175: ALPSA Lesions Associated with High Rate of Early Repair Failure

Objectives: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions occur in patients with recurrent shoulder instability and are associated with higher rates of failure after capsulolabral repair surgery compared to typical Bankart lesions. Despite recognition that these lesions can portend poor outcomes, there is relatively limited data to understand the associated injuries and postoperative course in a young, active population. The purpose of this study is to evaluate ALPSA lesions for associated pathology and outcomes. Methods: Methods: We reviewed the records of 312 patients who underwent arthroscopic shoulder stabilization by one of two fellowship trained sports surgeons at a single facility between 1 January 2010 and 31 December 2015. Inclusion criteria were a minimum follow-up of five years after index surgical repair and presence of an ALPSA lesion as identified on arthroscopic exam, leaving 46 patients available for review. Our primary outcome measures were failure and operative revision surgery. We considered failure as any recurrent shoulder instability events including subjective subluxation and dislocation, recurrence of pain consistent with instability, or functionally limiting apprehension. We performed survival analysis and a multivariate logistic regression analysis to identify factors associated with failure. Results: Results: In total, 46 patients with average age 21.2 years met inclusion and underwent surgery a median of 7.1 months after initial recalled injury event. 11/46 had concomitant posterior pathology in addition to anterior labral lesion. Six patients were found to have SLAP lesions. All patients experienced subjective instability, and 44/46 endorsed pain prior to surgery. 38/46 reported having experienced complete dislocation. The median number of dislocations before surgery was 3. Repairs were performed with average 3.7 anchors. Eight patients failed surgery at median 15.1 months post-index procedure, with 75% of failures occurring before two years with the remaining 25% occurring later in follow-up. Three of these failed revision repair. Conclusions: Conclusions: ALPSA lesions frequently occur in the presence of other intra-articular shoulder lesions and portend a high rate of recurrent shoulder instability despite repair. Notably, while failure occurs at a high rate, most repair failure for these lesions tends to occur early.

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.

Injury Risk in Collegiate Football Players With Generalized Joint Hypermobility: A Prospective Cohort Study Over 2 Years.

Generalized joint hypermobility (GJH) has been identified as a risk factor for injury in various athletic patient populations. To evaluate GJH as a predisposing risk factor for injury in a population of National Collegiate Athletic Association (NCAA) Division I football players. Cohort study; Level of evidence, 2. The Beighton score was collected for 73 athletes during their preseason physical examinations in 2019. GJH was defined as a Beighton score ≥4. Athlete descriptive characteristics, including age, height, weight, and playing position, were recorded. The cohort was evaluated prospectively for 2 years, and the number of musculoskeletal issues, injuries, treatment episodes, days unavailable, and surgical procedures for each athlete during this period were recorded. These measures were compared between the GJH and no-GJH groups. The mean Beighton score was 1.4 ± 1.5 for the 73 players; 7 players (9.6%) had a Beighton score indicating GJH. During the 2-year evaluation, there were 438 musculoskeletal issues, including 289 injuries. The mean number of treatment episodes per athlete was 77 ± 71 (range, 0-340), and the mean number of days unavailable was 67 ± 92 days (range, 0-432 days). There were 23 athletes who required 25 operations, the most common procedure being arthroscopic shoulder stabilization (n = 6). The number of injuries per athlete was not significantly different between the GJH and no-GJH groups (3.0 ± 2.1 vs 4.1 ± 3.0; P = .13), nor were there any between-group differences in the number of treatments received (74.6 ± 81.9 vs 77.2 ± 71.5; P = .47), days unavailable (79.6 ± 124.5 vs 65.3 ± 89.3; P = .61), or rates of surgery (43% vs 30%; P = .67). A preseason diagnosis of GJH did not place NCAA football players at a greater risk for injury during the 2-year study period. Based on the findings of this study, no specific preparticipation risk counseling or intervention is warranted for football players who are diagnosed with GJH as defined by the Beighton score.

Effects of increased body mass index on one year outcomes following soft tissue arthroscopic shoulder instability repair

The purpose of this study was to investigate the impact of high body mass index on the 1-year minimal outcome following arthroscopic shoulder stabilization. Patients who underwent arthroscopic Bankart repair (ABR) between 2017 and 2021 were identified and assigned to 1 of 3 cohorts based on their preoperative body mass index: normal (18-25), overweight (25-30), and obese (>30). The primary outcomes assessed were postoperative shoulder instability and revision rates. The 3 groups were compared using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, pain intensity, Clinical Global Impression scores, visual analog scale pain scores, and shoulder range of motion at 1 year postoperatively. During the study period, 142 patients underwent ABR and had an average age of 35±10 years. Obese patients had a higher percentage of partial rotator cuff tears (60% vs. 27%, odds ratio: 3.2 [1.1, 9.2]; P=.009), longer mean operative time (99.8±40.0 vs. 75.7±28.5 minutes; P<.001), and shorter time to complication (0.5±0 vs. 7.0±0 months; P=.038). After controlling for confounding factors, obesity was associated with a lesser improvement in upper extremity function scores (obese vs. normal:-4.9 [-9.4,-0.5]; P=.029); although this difference exists, found future studies are needed to determine the clinical significance. There were no differences in patient reported outcome measures, recurrence rate, or revision surgery rates between cohorts at any time point (P>.05). Obesity is an independent risk factor for longer operative times but does not confer a higher risk of recurrent instability, revision surgery, or lower outcome scores 1 year following ABR.

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

Background: Arthroscopic capsulolabral repair for posterior shoulder instability has been shown to improve patient-reported outcomes and return to sport at short-term and midterm follow-up, but long-term outcomes are unknown. Purpose: To determine the objective and subjective clinical outcomes of shoulder function after arthroscopic posterior shoulder stabilization at a minimum 10-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: A total of 53 patients (55 shoulders) with unidirectional recurrent posterior shoulder instability who underwent arthroscopic capsulolabral repair were evaluated at a mean follow-up of 15.4 years. Outcomes such as the American Shoulder and Elbow Surgeons (ASES) shoulder score, Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score, and subjective strength, stability, range of motion, and pain were evaluated preoperatively and postoperatively at a minimum 10-year follow-up. Outcomes from the same patient cohort were previously collected at 3.0-year follow-up and were evaluated for longitudinal analysis. Subgroup analyses for sport type (contact vs noncontact), position (thrower vs nonthrower), and revision versus nonrevision were performed. Risk factors for revision surgery based on magnetic resonance imaging findings, patient characteristics, and surgical findings were investigated. Results: Arthroscopic capsulolabral repair for posterior shoulder instability led to a statistically significant improvement on all outcome measures, with similar values at short-term (3.0-year) and long-term (15.4-year) follow-up. Across the total population, patients with 19 of 55 shoulders (35%) returned to sport at the same preinjury level, and patients with 33 of 55 shoulders (60%) returned to sport at some level. At long-term follow-up, patients with only 22% of shoulders were involved in the primary sport in which the injury was sustained, with patients with 28% of shoulders discontinuing sporting participation because of ongoing shoulder issues. Throwers trended toward lower Kerlan-Jobe Orthopaedic Clinic scores than nonthrowers both preoperatively (36.5 ± 22.8 vs 48.7 ± 22.9, respectively; P = .10) and postoperatively (57.4 ± 27.0 vs 73.5 ± 26.8, respectively; P = .09) but had similar improvements. Contact and noncontact athletes had similar preoperative and postoperative values, with equal improvements after surgery. With failure defined as revision surgery, an ASES score <60, or a stability value >5, 19 of 55 shoulders (35%) met failure criteria at final follow-up. Overall, 7 of 55 shoulders (13%) underwent revision surgery. At long-term follow-up, patients who underwent revision surgery had worse outcomes than those who did not undergo revision (ASES score: 53.1 ± 25.9 vs 81.8 ± 19.4, respectively; P < .001). An acute injury in the postoperative period (P < .001) and a smaller glenoid bone width on magnetic resonance imaging (P = .02) were the only identified risk factors for revision surgery. Conclusion: Arthroscopic capsulolabral repair for posterior shoulder instability was a durable treatment option that improved long-term shoulder pain and function and facilitated return to sport in the majority of patients at a mean follow-up of 15.4 years, although a notable proportion of patients met various criteria for failure.

Shoulder instability in military personnel: diagnosis and outcomes of arthroscopic stabilisation

IntroductionShoulder instability is a common problem for military personnel due to the highly physical demands of work and training. This study assessed the pattern of glenoid labrum tears suffered by...

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]

Rehabilitation following shoulder arthroscopic stabilisation surgery: A survey of UK practice.

Optimal rehabilitation following arthroscopic shoulder stabilisation for traumatic anterior instability is unknown. The purpose of this study was to establish current UK practice for this patient group. A self-administered online questionnaire was developed and distributed to UK surgeons and physiotherapists. 138 responses were received. Routine immobilisation was reported in 79.7% of responses with a cross-body sling being the preferred position (63.4%). Duration of immobilisation and timescales to initiate movement were highly variable. Return to light work was advised when patients felt able (25.4%) or after 6 weeks (26.1%). 58.7% recommended waiting for 12 weeks to return to manual work. 56% recommended non-contact sport could be resumed after 12 weeks. For contact sport, recommendations varied from 6 weeks (3.8%) to 6 months (5.8%). Psychological readiness was the most frequently cited criteria for return to play (58.6%). Factors such as hyperlaxity (40.6%), age (32.6%) and kinesiophobia (28.3%) were not considered as relevant as reported quality of surgical fixation (50%). There is no clear consensus regarding optimal post-operative rehabilitation following arthroscopic shoulder stabilisation. Further work is required to establish high value, personalised pathways for this patient group.

Ex vivo evaluation of arthroscopically assisted shoulder stabilization in dogs using an intra-articular aiming device.

To evaluate the use of an intra-articular aiming device (IAD) for medial shoulder stabilization with a suture-toggle repair or an interference screw repair using bone anchors in dogs. Ex-vivo Study METHODS: Specimens were randomly divided into 2 groups (anchor and suture-toggle) with 10 shoulders each. Abduction angles were measured by goniometry prior to and following medial glenerohumeral ligament transection and after receiving arthroscopically assisted stabilization with either bone anchors or suture-toggle constructs. Bone stock and insertion angles were measured with computed tomography scans. All specimens were inspected by dissection. Abduction angles increased post-transection in both groups, and were restored to normal in the anchor group, but 2° smaller than normal in the suture-toggle group following stabilization. Median magnitude of bone stock surrounding all tunnels ranged between 5.9 and 12.9 mm in the anchor group and 8.8 and 15.6 mm in the suture-toggle group (p=.002). Median insertion angles at the cranial glenoid, caudal glenoid, and humerus were 17.3°, 36.8 ° and 43.4° in the anchor group, respectively, and median insertion angles at the glenoid and humerus were 38.2° and 35.6° in the suture-toggle group, respectively (p=.91). Placement of anchors were not feasible in 3 specimens in the anchor group, and mild violations of the articular surfaces were detected in 3 specimens overall. Arthroscopically assisted shoulder stabilization with an IAD was feasible in canine cadavers. An IAD may facilitate arthroscopic shoulder stabilization in dogs. Further studies are warranted to evaluate safety and efficacy in a clinical setting.

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.

Risk for recurrent instability and reoperation following arthroscopic and open shoulder stabilization in a large cross-sectional population

BackgroundRecurrent shoulder instability is an orthopedic problem with potentially long-term functional ramifications. Although arthroscopic stabilization has become increasingly utilized over open stabilization, optimal surgical intervention to minimize recurrent instability remains controversial.MethodsThe PearlDiver Mariner database was queried for all cases of open and arthroscopic shoulder stabilization from 2010 to 2019. Utilization trends were aggregated after identifying cohorts of 107,210 and 13,217 patients who respectively underwent arthroscopic or open stabilization using Current Procedural Terminology codes. Subsets from those cohorts with laterality-specific International Classification of Diseases, Tenth Revision codes for shoulder instability were used to evaluate 2-year rates of recurrent instability (presence of shoulder dislocation or revision open or arthroscopic stabilization). Linear regression and chi-squared analysis were used to analyze utilization trends and to compare recurrent instability.ResultsArthroscopic stabilization comprised 90% of all stabilization procedures with annual utilization continuing to increase into 2019. Latarjet utilization increased from 15% to 42% of all open stabilization procedures while open Bankart repair utilization decreased from 56% to 35%. The rate of recurrent instability was 10.2% after arthroscopic stabilization and 12.3% after open stabilization (P = .01). Rates of redislocation (4.0% vs. 2.6%, P < .01), conversion to shoulder arthroplasty (1.2% vs. 0.4%, P < .01), and revision open stabilization (6.8% vs. 2.3%, P < .01) after index open stabilization were significantly higher than after index arthroscopic stabilization. There was no difference in revision stabilization or dislocation rates between open procedures.ConclusionDespite increasing utilization of coracoid transfer, arthroscopic stabilization is still the dominant modality used for surgical treatment of shoulder instability and in our analysis, showed lower 2-year rates of dislocation, revision open stabilization, and conversion to shoulder arthroplasty.

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.

Poster 176: International Expert Consensus on Return to Sport Criteria Following Shoulder Stabilization Surgery: A Delphi Study

Objectives:A comprehensive approach to standardize the criteria of return to sport (RTS) following common shoulder procedure in athletes is required to safely return the physically active population to sport postoperatively. There is lack of studies validating the RTS criteria following arthroscopic and/or open shoulder stabilization surgery. We developed a list of widely accepted criteria of RTS following shoulder stabilization surgery using Delphi consensus methods with international experts.Methods:A working group developed a list of approximately 50 criteria. Experts included 27 world renowned shoulder surgeons from various countries who have been recognized as international experts in the field and were invited speakers to international sports medicine meetings rated their agreement to each of the listed criteria. Experts were surveyed on 3 occasions to establish consensus on the inclusion of each RTS criterion in the final list of accepted criteria of RTS after shoulder stabilization surgery. For each round, a 70% agreement was used as a cutoff for consensus. Statements without this level of agreement were excluded in subsequent rounds. Descriptive statistics were used for analysis. Predefined criteria were used to refine item lists after each survey. Final list of criteria of RTS following shoulder stabilization surgery was complied by the working group and included those that received > 75% agreement on all 3 rounds of rating by experts.Results:We initially identified 50 RTS criteria following shoulder stabilization surgery from the literature that the experts were asked to rate their agreement. Twenty-seven international experts completed the rating in all 3 rounds. The RTS criteria were divided consisted of 5 subgroups including current evidence, ideal characteristics of the RTS criteria, general considerations for RTS criteria, specific considerations for RTS criteria, and dissemination of RTS criteria following shoulder stabilization. For Round 1, the response rate was 100% and 10 (20%) of 47 criteria were eliminated leaving 37 statements for evaluation in Round 2. Round 2 had a 100% response rate, and 1 (2.5%) statement was eliminated leaving 36 criteria for the final round. Round 3 had a 96% response rate, and no statements were eliminated. Respondents agreed on a total 36 statements to define the RTS criteria following shoulder stabilization in athletes. Table 1 provides the final list of accepted criteria and the percentage of agreement for each individual criterion.Conclusions:The final list of statements agreed upon by international experts provide insight into a standardized return to sport criteria following shoulder stabilization surgery in physically active patients. This agreed upon criteria can aid those providing care to athletes in their decision making when determining optimal timing for return to sport.Table 1.Statements that reached an expert consensus above 70% in 3 rounds.