Arthroscopic Stabilization Research Articles

Acromioclavicular joint Stabilization: Our experience with the lockdown technique

BackgroundAcromioclavicular joint (AC joint) disruption is a common injury with considerable variation with regards to surgical management. The Lockdown™ procedure (previously known as Surgilig™), Modified Weaver-Dunn procedure, Arthroscopic AC joint stabilization and Ligament Augmentation and Reconstruction system (LARS) procedure have all been described for treatment of this injury with varying outcomes. PurposeTo measure the functional and radiological outcomes following all cases of AC joint reconstruction using the Lockdown™ technique over the last 10 years at Medway Maritime Hospital. MethodsData on a total of 53 patients who underwent AC joint reconstruction between 2012 and 2021 were collected. Electronic records were used to extract data regarding patient characteristics, surgery details, and duration of follow-up. Telephonic interviews of patients were conducted to collect data on hand dominance, surgical complications, and responses to Oxford shoulder score (OSS) and QuickDASH score questionnaires. Hospital PACS data were reviewed to record preoperative injury severity and postoperative acromioclavicular joint reduction. ResultsResults for 42 patients were available and analysed as 10 could not be contacted and 1 patient sadly passed away. Of the patients reviewed, 92.9% were males with a mean age of 42.2 years (Range 16–67 years) and mean follow up of 68 months (12–119.1 months). The injury involved the dominant arm in 59.5%cases. Majority of the cases were Rockwood type V injuries (71.43%) while the rest were either type III(19.05%) or type IV(9.52%).The mean preoperative OSS was 21.3/48 which improved to 44.3/48 in the postoperative period. Similarly, the mean QuickDASH score was 50.6 preoperatively, that improved to 9.1 postoperatively.The most common patient reported complication was prominent metalwork seen in 5 cases (11.6%) followed by stiffness seen in 3 cases (7%) and superficial infection seen in 1 case (2.3%). The AC joint remained reduced radiologically in 81% of cases, while a resubluxation between 50 and 100% was seen in the rest of the cases. Patients with radiological resubluxation did not report this as a complication in 87.5% of the cases. Overall, 38 patients reported their outcome as excellent, 2 patients rated it good while 1 patient reported it as fair and 1 as poor. ConclusionThe Lockdown™ technique for stabilization of AC joint has excellent or good patient satisfaction in 95.2% of cases in long term follow up of more than 5.7 years. Prominent metalwork and stiffness are the commonest clinical complications. Radiological resubluxation can be seen in a fifth of the cases but does not directly lead to patient dissatisfaction. Level of evidenceLevel IV Retrospective case series.

The incidence of subclinical infection in patients undergoing revision shoulder stabilization surgery: a retrospective chart review

Shoulder instability continues to be a common problem that is difficult to treat. Part of this difficulty can be attributed to the numerous postoperative complications that can impact the clinical course. Our study aims to primarily identify the incidence of subclinical infection in patients undergoing revision shoulder stabilization surgery and secondarily identify any risk factors for developing a subclinical infection. From January 2012 to December 2022, 94 charts of patients who underwent revision surgery by the senior author after a previous arthroscopic or open stabilization surgery for shoulder instability were reviewed. All patients of any age who underwent either bony or soft tissue revision surgery, regardless of the number of previous surgeries or corticosteroid injections, were included. Patients were excluded if they had a previous infection in the shoulder, if there was no record of the procedures performed in the previous surgery, or if cultures were not available for review. For each patient, demographic information (age, sex, race, smoking status, previous corticosteroid injections, malnutrition, renal failure, liver failure, diabetes mellitus, immunocompromised status, and intravenous drug use), surgical information (procedures performed, type of surgery, and date of surgery), and culture results were recorded. Overall, 107 patients were included in our study. Twenty-nine patients (27.1%) had positive cultures (60 cultures in total). Twenty-six patients had positive Cutibacterium acnes (C. acnes) cultures. On average, C. acnes cultures took 10.65 days to turn positive, whereas 24 of 27 patients had cultures that were positive within 14 days of the culture being obtained. There was no difference in infection incidence rates between soft tissue and bony stabilization procedures (P=.86) or arthroscopic and open procedures (P=.59). Males were more than 5 times more likely than females to be culture positive in our cohort (93.1% vs. 73.1%, relative risk [RR]=1.27, P=.03). Finally, 10 control cultures were taken from the operating room air environment (8 distinct surgeries had 1 control culture taken, whereas 1 surgery had 2), 2 of which were positive for C. acnes (both taken from the same patient operation). This patient had their shoulder cultures positive for C. acnes as well. More than a quarter of patients requiring revision surgery after shoulder stabilization procedures have a subclinical shoulder infection, with males being at a higher risk of developing an infection than females. Surgeons should always consider infection as a reason for the lack of clinical improvement and possibly needing revision surgery after shoulder stabilization. The prompt diagnosis and treatment of these infections could be vital in improving results after these surgeries.

Surgical Intervention Following a First Traumatic Anterior Shoulder Dislocation Is Worthy of Consideration

Up to 60% of patients experience recurrence after a first traumatic anterior shoulder dislocation (FTASD), which is often defined as having experienced either dislocation or subluxation. Thus surgical intervention after FTASD is worthy of consideration and is guided by the number of patients who need to receive surgical intervention to prevent 1 redislocation (i.e., number needed to treat), (subjective) health benefit, complication risk, and costs. Operative intervention through arthroscopic stabilization can be successful in reducing recurrence risk in FTASD, as has been shown in multiple randomized controlled trials. Nevertheless, there is a large “gray area” for the indication of arthroscopic stabilization, and it is therefore heavily debated which patients should receive operative treatment. Previous trials showed widely varying redislocation rates in both the intervention and control group, meta-analysis shows 2% to 19% after operative and 20% to 75% after nonoperative treatment, and redislocation rates may not correlate with patient-reported outcomes. The literature is quite heterogeneous, and a major confounder is time to follow-up. Furthermore, there is insufficient standardization of reporting of outcomes and no consensus on definition of risk factors. As a result, surgery is a reasonable intervention for FTASD patients, but in which patients it best prevents redislocation requires additional refinement.

Outcomes of total shoulder arthroplasty in patients with prior anterior shoulder instability: minimum 5-year follow-up

Patients with a history of anterior shoulder instability (ASI) commonly progress to glenohumeral arthritis or even "dislocation arthropathy" and often require total shoulder arthroplasty (TSA). The purposes of this study were to 1) report patient reported outcomes (PROs) after TSA in patients with a history of ASI, 2) compare TSA outcomes of those whose ASI was managed operatively versus those managed nonoperatively, and 3) report PROs of TSA in patients who previously underwent arthroscopic versus open ASI management. Patients were included if they had a history of ASI and were at least 5 years out from TSA performed by a single surgeon between 10/2005 and 01/2017. Exclusion criteria included prior rotator cuff repair, hemi-arthroplasty, or glenohumeral joint infection prior to index TSA. Patients were separated into two groups, those with previous operatively managed ASI and those whose ASI was treated nonoperatively. Prospectively collected demographic, surgical, and subjective data were retrospectively reviewed. PROs utilized were the ASES score, SANE, QuickDASH, SF-12 PCS. Failure was defined as revision TSA surgery, conversion to reverse TSA, or prosthetic joint infection. Kaplan-Meier survivorship analysis was performed. 36 patients (27 male, 9 female) with a mean age of 56.4 years (range, 18.8-72.2) were included. Patients in the operative ASI group were younger than those in the nonoperative ASI group (50.6 vs 64.0 years, p<.001). Operative ASI patients underwent 10 open and 11 arthroscopic anterior stabilization surgeries prior to their TSA (mean, 2; range, 1-4). 6 of 21 (28.6%) TSAs failed in patients with operative ASI while there were no failures in the nonoperative ASI group (p=0.03). Follow-up was obtained in 28 of 30 (93%) eligible patients at an average of 7.45 years (range, 5.0-13.6). In the collective cohort, ASES, SANE, QuickDASH, and SF-12 PCS scores significantly improved with no differences in the postoperative PROs between the two groups. No significant differences were found when comparing PROs between prior open and prior arthroscopic ASI procedures or when comparing the number of prior ASI procedures. Kaplan-Meier analysis demonstrated 79% 5-year survivorship in patients with prior ASI surgery and 100% survivorship in nonoperatively managed ASI patients (p=.030). At mid-term follow-up, patients with a history of prior ASI undergoing TSA can expect continued improvement in function compared to preoperative values. However, TSA survivorship is decreased in patients with a history of ASI surgery compared to those without prior surgery.

A High Rate of Return to Running Is Seen After Both Arthroscopic and Open Shoulder Surgery

To determine the percentage of patients who report the ability to run 1 mile at various time points after arthroscopic and open shoulder surgery. We performed a retrospective review of prospectively collected data for all active-duty military patients aged 18 to 45 years who underwent shoulder surgery at a single institution over a 2-year period. The rehabilitation protocol discouraged running before 3 months, but all patients were able to return to unrestricted running at 3 months postoperatively. Patients were excluded if they lacked 1-year follow-up data. Parameters collected included demographic information and validated patient-reported outcome measures at the preoperative and short-term postoperative visits, as well as patients' ability to run at least 1 mile postoperatively. A total of 126patients were identified who underwent shoulder surgery with return-to-running data. Compared with baseline, significant improvements in patient-reported outcomes were shown at 1 and 2 years postoperatively (P= .001). The percentage of patients reporting the ability to run 1 mile postoperatively was 59% at 3 months, 74% at 4.5 months, 79% at 6 months, 83% at 12 months, and 91% at 24 months. There was no significant difference in patients undergoing shoulder surgery for instability versus non-instability diagnoses or in patients undergoing open versus arthroscopic anterior stabilization. All 11 patients unable to return to running at final follow-up had chronic lower-extremity diagnoses limiting their running ability. Young military athletes undergoing arthroscopic and open shoulder surgery have a high rate of early return to running. Approximately 60% of patients report the ability to run 1 mile at 3 months postoperatively, and three-quarters of patients do so at 4.5 months. Age, sex, military occupation, underlying diagnosis or type of surgery did not influence the rate of return to running after shoulder surgery. Level IV, therapeutic case series.

Arthroscopic Labral Repair and Pancapsular Shift With Knotless All-Suture Anchors in the Setting of Multidirectional Instability of the Shoulder

In the management of multidirectional type of shoulder instability (MDI), arthroscopic surgical stabilization is a preferred treatment option after failed conservative therapy regimens because of the ability to easily access all aspects of the capsule with one surgical procedure. As arthroscopic techniques have evolved, factors critical to postoperative success have been elucidated. Currently, optimal arthroscopic treatment of MDI involves circumferentially restoring labral integrity, a tailored, patient-specific surgical reduction of capsular volume, and adequately managing potential lesions of the biceps anchor. The purpose of this article and accompanying video is to present our technique for arthroscopic circumferential labral repair and pancapsular shift using knotless all-suture anchors in the setting of MDI with a concurrent type II SLAP lesion.

Poster 184: Demographics and Outcomes of Shoulder Instability in Individuals with Elevated Body Mass Index

Objectives: Traumatic shoulder dislocations in the adolescent, active adult, and elderly have been well studied. However, to our knowledge, no specific study has investigated the characteristics and outcomes of anterior shoulder dislocations in morbidly obese individuals. The objective of this study is to describe shoulder dislocations in patients with body mass index (BMI) greater than 40. Methods: A retrospective chart review was performed to identify patients 18 years of age and older with a BMI greater than or equal to 40 who presented with a shoulder dislocation within a single institution from 2000-2020 were included in this study. Patients who had a BMI of less than 40, sustained a periprosthetic shoulder dislocation, and patients who were pregnant were excluded from this study. Dislocation pattern, associated injuries, treatment modalities, and associated complications were recorded. Complications were defined to include recurrent instability as demonstrated by a single recurrent dislocation event, infection, arthrofibrosis, and associated neurovascular injury. Results: Seventy-seven patients were included in our study. Fifty-two patients (67.5%) were female. Average age was 47.95 ± 2.06 (range 18-81), with average BMI of 45.01 ± 5.67 (range 40-78). Mean follow up for our patient cohort was 411.5 days (1.13 years). Sixty-five dislocations (84%) were due to a ground level fall whereas 8 (10%) were due to assault and 4 (5%) were due to a motor vehicle collision (MVC) (p&lt;0.01). There was a significant increase in the number of patients with BMI greater than 40 presenting per year (r2 = - 0.831, p &lt; 0.01) over the past 20 years. In addition, there was also a significant increase in the average BMI per year in this population (r2 = 0.504, p=0.028). Fifteen patients (19.5%) experienced at least one recurrent dislocation episode, with average time to recurrent dislocation of 449 days (1.23 years). Hill-Sachs lesions were the most common associated injury (p=0.03). Bankart lesions were the only associated injury that were found to be associated with an elevated BMI (p = 0.04), Nine patients (11.7%) sustained an associated neurologic injury which was found to have no association with BMI. There were 56 patients (72.7%) who were managed non-operatively and 21 patients (27.3%) who underwent surgical intervention. One patient failed nonoperative management and arthroscopic stabilization, going on to require shoulder arthrodesis and biceps tenodesis. They subsequently developed a post-operative infection necessitating revision arthrodesis. Conclusions: Over time, there has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations. These injuries most commonly happen due to low energy mechanisms and can be associated with Bankart lesions and associated neurologic injuries. There was a recurrent dislocation rate of 19.5%, which is consistent with this age cohort. As the current trend continues it will become increasingly important to better understand these injuries. Morbidly obese patients may incur higher health care costs and resource expenditure to treat such injuries. In addition, appropriate patient education and outcome expectations for nonoperative and operative treatment should be provided given the high risk of recurrent dislocations in this patient population.

Open treatment of posterior glenoid bone loss and bipolar bone loss.

Posterior glenohumeral instability is an increasingly common and challenging orthopaedic problem. While an arthroscopic soft tissue stabilization procedure (i.e., reverse Bankart repair) is effective in treating most cases of posterior instability, this procedure may be inadequate in shoulders with critical posterior glenoid bone loss (GBL), or in cases of an engaging reverse Hill-Sachs lesion. Thus, the purpose of the present manuscript was to report contemporary surgical approaches, techniques, and outcomes for the open treatment of glenoid or humeral head bone loss in posterior instability to help guide clinical decision making. Open osteoarticular augmentation procedures have emerged as a popular option to treat posterior bone loss, with bony auto- and allografts utilized from a variety of donor sites including iliac crest, scapular spine, acromion, distal clavicle, and distal tibia. The combination of glenoid retroversion and bone loss can be addressed with a posterior glenoid opening wedge osteotomy. Bipolar bone loss may be treated with a combination of the aforementioned techniques, in addition to a reverse remplissage, a modified McLaughlin procedure, or various arthroplasty-related options. Although short and mid-term outcomes are dependable, studies reporting long-term outcomes are sparse. Moreover, there is no current consensus regarding the most effective treatment of posterior shoulder instability in the setting of bone loss, and open surgical techniques continue to evolve. Further research is necessary to determine long-term effectiveness of these surgical options.

Poster 189: The Latarjet Procedure: 6-Year Outcomes in Female Patients

Objectives: Despite nearly 30% of first-time anterior shoulder dislocations occurring in females, little has been reported on the outcomes of female patients with recurrent instability and bone loss. Stabilization surgery via the Latarjet procedure can reduce the risk of recurrent dislocation and improve patient quality of life. Prior studies have focused on high-risk subgroups, such as young males who play contact sports, and there thus remains a paucity of data regarding female-specific outcomes. The limited data on shoulder stabilization surgery in female patients has demonstrated low post-operative return to sport and shoulder scores, suggesting that current strategies are not adequately meeting the demands of this demographic. The objective of this study was to investigate and retrospectively report on the outcomes of female patients undergoing the Latarjet procedure. Methods: A query of the administrative database at a single surgical center based on the CPT code 23462 was used to identify all patients from January 2010 to October 2021 who underwent the Latarjet procedure. All female patients undergoing the Latarjet procedure with minimum 24-month follow-up were considered for inclusion in the study. We retrospectively reviewed clinical and operative notes of all eligible patients. Patients were contacted via telephone or email and interviewed to obtain Numeric Pain Rating Scale (NPRS), Single Assessment Numeric Evaluation (SANE), and Return to Sport (RTS) data. Results: After applying inclusion and exclusion criteria, a total of 30 patients were eligible for participation in the study. Of these, one (3.3%) declined to participate and 10 (33.3%) were unable to be contacted, leaving 19 (63.3%) patients available for analysis. The median age at the time of surgery was 29.0 years (IQR, 23.5-41.0), median BMI 24.5 kg/m2 (IQR, 21.8-30.6), and average follow up 76.5 months (range, 24.6-144.3). Eleven patients (57.9%) had undergone prior arthroscopic soft-tissue stabilization. Concomitant procedures occurred in 10 (52.6%) patients including open capsular shift in seven (36.8%), arthroscopic plication in three (15.8%), and arthroscopic debridement in three (15.8%). All surgical procedures were performed using an open approach. The subscapularis was managed with tenotomy in 6 patients (31.6%) and a split in 12 (63.2%). The approach was not detailed in one patient (5.3%) (Table 1). Median post-operative NPRS and SANE scores were 1 (IQR, 0-4) and 70 (IQR, 63-85), respectively. Patient reported sporting activities included: cheerleading (1), softball (2), yoga (1), track and field (2), and soccer (1) (Table 2). Twelve patients (63.2%) denied involvement in athletic activity prior to surgery. Of the seven patients who reported playing a sport in the three years prior to surgery, 3 (42.9%) had a successful RTS at a median of 12.0 months (range, 8.0-36.0). Among these three patients, the level of play upon return was variable (1 worse, 1 same, 1 better). In the four patients who did not RTS, two (50%) cited a shoulder specific reason (Table 3). Four patients (21.1%) required reoperation at a median of 15.3 months (IQR, 11.3-43.0) (Table 4). The indication for all reoperations included persistent pain and lack of range of motion. One patient (5.3%) went on to require reverse total shoulder arthroplasty due to persistent pain and poor function, and one (5.3%) required total shoulder arthroplasty due to recurrent instability after involvement in a motor vehicle accident. Conclusions: At mid-term follow-up female patients reported acceptable pain levels despite overall low shoulder function and RTS in comparison to published data. The role of patient sex should be explored further as a variable to be taken into consideration when determining appropriate treatment options for shoulder instability. [Table: see text][Table: see text][Table: see text][Table: see text]

Poster 185: Arthroscopic Inferior to Superior Capsular Shift Results in Superior Clinical Outcomes Compared to Arthroscopic Bankart Repair For the Treatment of Anterior Capsulolabral Tears After Shoulder Dislocation

Objectives: In the setting of anterior shoulder instability, both boney and soft tissue structures are at risk of injury. Often, there is an injury to the anterior capsulolabral complex. This pathology is most often treated with a traditional arthroscopic Bankart repair. The open Bankart is regaining popularity as some surgeons report a lower re-dislocation rate as compared to its arthroscopic counterpart. Some believe that a better capsular shift is achieved with open surgery. We recently developed a technique for performing this capsular shift arthroscopically. The purpose of this study is to analyze and compare clinical outcomes of patients with traumatic anterior shoulder instability treated with two different arthroscopic techniques, arthroscopic capsular shift and arthroscopic Bankart repair (Figure 1). The primary objective of this study is to analyze and compare clinical outcomes, Western Ontario Shoulder Instability (WOSI) scores, complication, and re-dislocation rates. We hypothesize that patients treated with arthroscopic capsular shift will have similar clinical outcomes and a lower failure rate at one year compared with the other surgical cohort. Methods: This study included patients who underwent arthroscopic soft-tissue stabilization surgery for shoulder instability between 2012-2021. Patients were included if they had an isolated primary soft- tissue repair performed arthroscopically with one of the above-mentioned surgical techniques. Patients were excluded if they had concomitant glenoid fractures, less than one year of clinical follow-up, posterior instability, multidirectional instability, and presence of HAGL lesions Demographic information, WOSI scores, pre-operative glenoid and humeral head dimensions, and new dislocation events were recorded. Results: Sixty-three patients met the inclusion and exclusion criteria. There were 27 patients in the Bankart repair group and 36 in the capsular shift group. The two groups had similar demographics and baseline characteristics, except for the length of clinical follow-up (which is due to the capsular shift technique being developed more recently) (p&lt;0.001) (Table 1). Both groups had similar pre-operative glenoid AP and Hill-Sachs depth measurements (p=0.358 and 0.329, respectively) (Table 1). Patient- reported outcomes were similar at baseline (p=0.602) and post-operatively (p=0.621). Both groups showed improvements in WOSI post-operatively (p&lt;0.001), however more patients met MCID in the capsular shift group as compared to the Bankart repair group (93% vs 75%, respectively). In terms of clinical outcomes, patients who received a capsular shift had a lower rate of re-dislocation as compared to the Bankart group (6% vs 22%). Conclusions: The arthroscopic capsular shift technique results in better post-operative clinical outcomes as compared to arthroscopic Bankart repair with a lower recurrence rate, lower rate of post-operative apprehension, and an increased proportion of patients who meet MCID for WOSI. This technique could be a better alternative for Bankart repair in patients with soft-tissue pathologies following anterior shoulder dislocations, however longer-term studies are necessary to determine the longevity of these outcomes. [Table: see text]

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.

Dynamic Anterior Stabilization of the Shoulder: Onlay Biceps Transfer to the Anterior Glenoid Using the Double Double-Pulley Technique

The treatment of anterior glenohumeral instability includes several surgical options, ranging from soft tissue to bony procedures—open or arthroscopic. In arthroscopic dynamic anterior stabilization (DAS) of the shoulder, the long head of the biceps is transferred to the anterior glenoid through a subscapularis tendon split. The biceps may be fixed either in an inlay or in an onlay position. Inlay DAS theoretically increases anterior glenohumeral stability through 3 different effects: the hammock effect, sling effect, and the tensioning effect. Onlay DAS may additionally increase stability through a labroplasty effect, produced by the onlay positioning of the biceps on the anterior glenoid rim. The current technical note presents tips and tricks, and pearls and pitfalls, to reproducibly perform onlay DAS using all-suture anchors and the double double-pulley technique.

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.

Simultaneous Arthroscopic Glenohumeral Stabilization and Glenoid Microfracture in Young, Active-Duty Military Patients at Minimum Five-Years Follow-Up: A Reasonable Solution for a Painful Pathology

Simultaneous Arthroscopic Glenohumeral Stabilization and Glenoid Microfracture in Young, Active-Duty Military Patients at Minimum Five-Years Follow-Up: A Reasonable Solution for a Painful Pathology

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.

Lateral Decubitus Positioning For Shoulder Arthroscopy

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

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.

Evaluation of Technical Differences in Arthroscopic Lateral Ligament Stabilization for Chronic Ankle Instability: A Review

Evaluation of Technical Differences in Arthroscopic Lateral Ligament Stabilization for Chronic Ankle Instability: A Review

Use of Computed Tomography in the Evaluation of Anterior Shoulder Instability: Possible Effect on Surgical Management

Background: Glenoid bone loss is a critical factor in the management of anterior shoulder instability (ASI). Computed tomography (CT) is often considered the gold standard to evaluate glenoid bone loss, but it is associated with negative factors such as radiation. Thus, interest exists as to when orthopaedic surgeons need a CT scan to guide decision-making when treating ASI. Purpose: To determine whether information gained from a shoulder CT scan alters orthopaedic surgeons’ management plan for ASI and, secondarily, to determine whether surgeon- and patient-specific factors affect whether a CT scan changes treatment and which clinical factors are most important in surgical decision-making. Study Design: Cross-sectional study. Methods: A questionnaire composed of 24 ASI vignettes was administered to Herodicus Society members, American Shoulder and Elbow Surgeons Neer Circle members, and sports medicine fellowship–trained orthopaedic surgeons. Participants chose their recommended surgical treatment from the options of arthroscopic Bankart repair, open Bankart repair, bony reconstruction procedure, or other based on patient history, radiographs, and magnetic resonance imaging. Participants were then shown CT images and asked whether their treatment plan changed and, if not, whether the CT scan was not necessary or had reinforced their decision. Generalized linear mixed-effects logistic regression modeling was performed to assess the influence of vignette and respondent characteristics on treatment decisions. Results: A total of 74 orthopaedic surgeons completed the survey; 96% were fellowship trained (sports medicine, 50%; shoulder and elbow surgery, 41%), and 66% practiced in academic settings. CT imaging did not change the selected treatment strategy in 75.6% of responses. In cases when management did not change, surgeons reported that the CT scan reinforced their decision in 53.4% of responses and was not necessary for decision-making in 22.2% of responses. Decision-making was more likely to be changed after CT in male patients and those with off-track lesions. Conclusion: Information gained from a CT scan did not alter treatment decision-making in three-quarters of vignettes among surgeons experienced in the management of ASI. The finding that CT scans did alter the treatment plan in nearly a quarter of cases is not insignificant, and it appears that in patients with borderline glenoid track status and few other risk factors for recurrence after arthroscopic stabilization, CT imaging is more likely to change management.