Arthroscopic Stabilization Procedures Research Articles

Nonoperative Treatment of Isolated Posterior Glenohumeral Instability in an Active Military Population: Effect of Glenoid and Acromial Morphology

Background: Nonoperative management of posterior shoulder instability is common. However, limited data are available to assess the pathomorphologic factors associated with its failure. Purpose/Hypothesis: The purpose of this study was 2-fold: (1) to determine glenohumeral pathomorphologic features predictive of nonoperative management failure of posterior instability; and (2) to determine the relationship between nonoperative management failure and posterior glenoid bone loss (pGBL) progression. It was hypothesized that greater posterior acromial height (PAH) would adversely affect nonoperative survivorship and that shoulders treated nonoperatively would have pGBL progression compared with those undergoing surgical stabilization. Study Design: Case-control study; Level of evidence, 3. Methods: This was a retrospective review of a consecutive series of patients with isolated posterior shoulder instability, defined as isolated posterior labral tear on magnetic resonance imaging (MRI) with corresponding physical examination findings, who underwent nonoperative management for 6 months and had no previous related surgical history. The primary outcome of interest was the failure of nonoperative management, defined as the inability to return to full military duty or requiring surgical intervention. The morphologic features assessed for association with nonoperative management failure included pGBL, glenoid version, acromial morphology, and posterior humeral head subluxation. We secondarily sought to determine the progression of pGBL on serial MRI scans. Cox proportional hazard analysis was used to evaluate risk factors for failure. Results: In this study, 42 of 90 (46.7%) patients had failed nonoperative management and went on to receive an arthroscopic stabilization procedure. The group with failed treatment demonstrated a greater humeral head subluxation ratio than those with successful nonoperative management (0.65 ± 0.2 vs 0.62 ± 0.2; P = .038). Cox proportional hazard analysis identified pGBL, greater PAH, less posterior acromial coverage, and posterior humeral subluxation as significant risk factors for failure. Of those with failed nonoperative management, 17 had repeat MRI scans at a mean of 488.2 ± 87 days after index MRI for comparison, demonstrating a statistically significant progression of pGBL (index MRI, 2.68% ± 1.71%) versus after nonoperative treatment failure (6.54% ± 1.59%; P = .003). Conclusion: Failure occurred 47% of the time in patients who underwent nonoperative management for isolated posterior glenohumeral instability for a minimum of 6 months, and it was associated with a greater posterior humeral head subluxation, less posterior acromial coverage, greater PAH, and greater amounts of glenoid retroversion on index MRI. Additionally, those who had repeat MRI approximately 1 year after the index MRI demonstrated greater pGBL compared with the index MRI.

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.

Shoulder Stabilization Technique Using the Medial Glenohumeral Ligament in Patients With the Buford Complex

The Buford complex is an anatomic variation defined as the association of a cordlike middle glenohumeral ligament (MGHL) and an absent anterosuperior labrum. It can be challenging to properly identify on preoperative imaging and remains mostly an arthroscopic finding. It may, however, lead to problematic situations when encountered during an arthroscopic soft-tissue stabilization procedure, as the treatment of choice in such cases is a bone block. Moreover, reattaching the MGHL to the anterior border of the glenoid rim has traditionally not been recommended because it theoretically leads to severe restriction in external rotation. This technical note describes arthroscopic stabilization for anterior traumatic glenohumeral instability associated with the Buford complex. The cordlike MGHL is used to reconstruct a neo-labrum, associated with an anteroinferior glenohumeral ligament plication. Glenohumeral stabilization using the cordlike MGHL of the Buford complex may be an efficient alternative to a bone block procedure.

Correlation of Glenoid Concavity With Surgical Failure After Arthroscopic Stabilization for Recurrent Anterior Shoulder Instability

Background: Glenoid concavity compression by rotator cuff muscle contraction is one of the key mechanisms in the stability of the glenohumeral joint. Purpose/Hypothesis: The purpose of this study was to evaluate the effects of glenoid concavity, as represented by the bony shoulder stability ratio (BSSR) and other factors, including glenoid bone defect size, on the surgical failure of arthroscopic stabilization procedures for recurrent anterior shoulder instability. The authors also aimed to determine the critical value of BSSR. It was hypothesized that both glenoid concavity and glenoid bone defect size would be correlated with surgical failure, with glenoid concavity having a stronger correlation. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 120 patients who underwent arthroscopic stabilization procedures for recurrent anterior shoulder instability were included. Patients with bony Bankart lesions were excluded to eliminate the postoperative effects of bony fragment restoration on the glenoid concavity. For each patient, variable factors including BSSR, glenoid bone defect size, presence of off-track Hill-Sachs lesions, and age at first dislocation were recorded. Chi-square analysis and Student t test were performed to analyze the effect of each variable on surgical failure. Multivariate logistic regression analysis was used to determine the combined effect of >2 variables on surgical failure. The critical value of BSSR was analyzed using a receiver operating characteristic curve. Results: Nine patients (7.5%) had recurrent instability requiring revision surgery. BSSR (patients with recurrence, 18.6% ± 19.4%; patients without recurrence, 41.8% ± 10.5%; P = .01), glenoid bone defect size (17.5% ± 3.6% vs 11.7% ± 7.0%; P = .02), age at the time of first dislocation (18.8 ± 3.9 years vs 22.0 ± 6.5 years; P = .04), and number of suture anchors used (4.1 ± 0.3 vs 5.8 ± 1.6; P < .001) showed significant differences between patients with and without surgical failure. Multivariate logistic regression analysis revealed surgical failure to be correlated with BSSR (odds ratio, 0.849; P = .02) and the number of suture anchors used (odds ratio, 0.070; P = .03). The critical value of BSSR was 29.3% (area under the curve, 0.84; 95% CI, 0.67-1.00; P < .001; sensitivity, 78%; specificity, 93%). Conclusion: Glenoid concavity is strongly correlated with surgical failure after arthroscopic stabilization procedures for anterior shoulder instability. The value of BSSR reflects shoulder instability caused by glenoid bone morphology more accurately than glenoid bone defect size.

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.

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

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

Paper 73: Patient Factors Associated with Humeral Avulsion of Glenohumeral Ligament (HAGL) Lesions: An Analysis of the MOON Shoulder Instability Cohort

Objectives:We sought to identify pre-operative physical exam findings, imaging findings, and surgical management trends associated with humeral avulsion of the glenohumeral ligament (HAGL) lesions by utilizing a large, multicenter orthopedic outcomes database.Methods:Patients with anterior shoulder instability who underwent surgical management from 2012 to 2020 at 11 orthopedic centers were prospectively enrolled. Patients with a HAGL lesion identified intra-operatively were compared to patients without a HAGL lesion; patients with isolated posterior HAGL lesions were excluded from data analysis. Pre-operative patient demographics, physical examination, and imaging findings were collected; intra-operative findings and surgical procedures performed were also recorded. Student’s T-test, Fisher Exact test and Chi Square test were used to compare groups and determine risk factors. Logistic regression analysis was performed to determine independent risk factors associated with need for an open stabilization procedure, and odds ratio (OR) and 95% confidence interval (95% CI) were calculated. Significance was set at p<0.05.Results:From 2012 to 2020, 22 HAGL lesions were identified in 1002 patients (2.2%). Baseline demographics, including age, gender, BMI, and number of lifetime shoulder dislocations, were similar between the HAGL and non-HAGL groups. As compared to non-HAGL patients, HAGL patients were less likely to have a Hill Sachs lesion (51.8% vs. 27.3%, p=0.02) or an anterior labral tear (81.7% vs. 63.6%, p=0.03) on pre-operative MRI. On pre-operative physical examination, HAGL patients demonstrated increased external rotation when their affected arm was positioned in 90° of abduction as compared to non-HAGL patients (90° vs. 85°, p=0.01). The most common procedure performed amongst all patients was an arthroscopic Bankart repair (45.5% of the HAGL patients and 78.9% of the non-HAGL group); however, HAGL patients were more likely than non-HAGL patients to undergo an open stabilization procedure (68.2% vs. 10.7%, p<0.001) and less likely to undergo an arthroscopic stabilization procedure (72.7% vs. 94.7%, p<0.001). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization procedure (OR 31.3, 95% CI 11.0 – 88.9, p<0.001).Conclusions:Patients with anterior shoulder instability and a HAGL lesion are less likely to exhibit classic pre-operative imaging findings associated with anterior shoulder instability, such as Hill Sachs lesions or anterior labral pathology. Increased external rotation at 90° of shoulder abduction on pre-operative physical exam may suggest presence of a HAGL lesion. Other demographic factors, including age, gender, BMI, and number of lifetime shoulder dislocations, do not differ significantly between patients with and without HAGL lesions. Patients with HAGL lesions undergo open stabilization procedures more frequently than patients without HAGL lesions.

Paper 06: The Natural History of Nonoperative Treatment of Posterior Instability in a High Demand Population

Objectives:Nonoperative management of posterior shoulder instability is common, however there is limited data available to assess the pathomorphology of nonoperative management. The purpose of this study is to evaluate glenohumeral pathomorphology in shoulders with posterior glenohumeral instability treated nonoperatively.Methods:We conducted a retrospective review of a consecutive series of patient with isolated posterior shoulder instability defined as an isolated posterior labral tear with a corresponding positive Jerk or Kim test. Patients were excluded if they had prior shoulder surgery or absence of a Jerk or Kim test. Non-operative management was defined as a trial of formal physical therapy pursuit of nonsurgical modalities for a minimum 6 months. Patients who underwent non-operative management and subsequently had a repeat MRI of the initially injured shoulder were identified, and the two studies were compared to evaluate for changes in glenoid bone loss, glenoid morphology, cartilage injuries, and the presence of concurrent pathology. Our primary outcome was glenoid changes associated with failure of non-operative management, which was defined as reoperation and/or medical separation from the military due to the injured shoulder. Secondary outcomes included evaluation of potential risk factors for failure of non-operative management including glenoid bone loss, glenoid version, and posterior humeral head subluxation. Continuous variables were compared with student’s t-test or Fisher exact test when appropriate. Categorical variables were analyzed using Chi-squared. Multivariable regression analysis was used to evaluate risk factors for failure.Results:42/90 (46.7%) patients failed a 6-month trial of nonoperative management after being diagnosed with posterior glenohumeral instability and went onto receive an arthroscopic stabilization procedure. The failure group demonstrated a significantly greater humeral head subluxation ratio than the cohort of patients who survived nonoperative management (0.65 ± 0.2 vs 0.62 ± 0.2; p = 0.0375). Of those who failed nonoperative management only 17 had repeat MRI’s for comparison with initial MRI’s, which revealed a significantly greater increase in glenoid bone loss (6.54 ± 1.59 vs 2.68 ±1.71; p = 0.00274). The mean time from index MRI and repeat MRI was 488 days (95% CI 317 to 658).Conclusions:In patients that underwent 6-months of nonoperative management for isolated posterior glenohumeral instability, failure occurred approximately 47% of the time and was associated with a greater posterior humeral head subluxation ratio on index MRI than those who did not fail. Additionally, those who had repeat MRI on average 1.3 years later demonstrated greater glenoid bone loss when compared to the index MRI.

High Incidence of Combined and Posterior Labral Tears in Military Patients With Operative Shoulder Instability

Background: Anterior shoulder instability is the pattern most commonly reported in the civilian population, but military servicemembers may represent a unique population. At 1.7 per 1000 person-years, servicemembers not only have a higher incidence of instability events compared with civilians (reported rate of 0.2-0.8), but the distribution of labral tears in the military may differ significantly as well. Hypothesis: The incidence of combined and posterior labral tears in the military population will be greater than numbers previously reported. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The Wounded, Ill, and Injured Registry, a Department of Defense patient reported outcomes data collection platform that includes all military branches, was queried retrospectively for all patients who had undergone a primary arthroscopic or open shoulder stabilization procedure (Current Procedural Terminology codes 29806, 23455, 23462) between October 2016 and January 2019. Demographic information was obtained through intake forms completed by patients at the time of enrollment into the Military Orthopaedics Tracking Injuries and Outcomes Network. Tear location was determined arthroscopically and labeled as anterior, inferior, posterior, superior, or any combination thereof. Chi-square analysis was used to compare the percentage of patients with isolated anterior, isolated posterior, isolated inferior, or combined labral tears in the current study cohort with those in a previously reported cohort of patients with operative shoulder instability at a single military treatment facility. Results: A total of 311 patients were included who had undergone primary shoulder stabilization during the study period. Of these patients, 94 (30.2%) had isolated anterior tears, 76 (24.4%) had isolated posterior tears, and 136 (43.7%) had combined tears. We observed a higher percentage of combined tears in our data set than in a data set from a single military treatment facility (χ2(2) = 48.2; P < .00001). Chi-square analysis demonstrated that significantly more female patients had an isolated anterior labral tear (51.2%) compared with male patients (27.1%; χ2(2) = 9.4; P = .009). Conclusion: The incidence of combined and posterior labral tears in the military population is greater than numbers previously reported in both military and civilian populations.

Clinical Outcomes in Patients With Humeral Avulsion Glenohumeral Ligament Lesions in the Setting of Anterior Shoulder Instability: A Retrospective Comparative Study

Background: Humeral avulsion glenohumeral ligament (HAGL) lesions are often underreported but have been shown to occur in up to 10% of cases of anterior shoulder instability. Purpose: To compare clinical outcomes and recurrence rates of patients with HAGL lesions undergoing open stabilization for anterior shoulder instability versus a pair-matched control. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of all patients who underwent both arthroscopic and open stabilization procedures with a minimum 24-month follow-up was performed. Patients with HAGL lesions were pair-matched in a 1:6 ratio for age, sex, sport, level of preoperative play, and follow-up length with those without HAGL lesions who underwent arthroscopic Bankart repair alone. Return to play (RTP), the level of return, and the timing of return were assessed. In addition, recurrence, visual analog scale for pain (VAS), Subjective Shoulder Value (SSV), Rowe score, satisfaction, and whether they would undergo the same surgery again were compared. Results: A total of 15 patients with HAGL lesions who underwent shoulder stabilization procedures were included, with a mean age of 21.5 ± 4.1 years and mean follow-up of 53.5 ± 17.4 months, and were pair-matched to 90 patients without HAGL lesions. Overall, there was no significant difference in any of the clinical outcome scores (VAS, Rowe, SSV, satisfaction) used between the 2 groups (1.6 vs 1.7, P = .86; 83.4 vs 88.0, P = .06; 85.7 vs 87.2, P = .76; and 86.7% vs 94.5%, P = .26, respectively). In addition, there were no significant differences in terms of overall rates, levels, and timing of RTP between the 2 groups (93.3% vs 90.0%, P > .99; 80.0% vs 78.9%, P > .99; and 5.3 ± 2.2 vs 5.9 ± 2.9 months, P = .45, respectively). There was no significant difference in the rates of apprehension, subluxation, and recurrent instability between the HAGL and pair-matched control groups (26.7% vs 26.7%, P > .99; 6.7% vs 3.3%, P = .47; and 13.3% vs 6.7% months, P = .32, respectively). Conclusion: Patients with anterior shoulder instability undergoing surgical stabilization with open HAGL repair demonstrate excellent functional outcomes and high rates of RTP, with low rates of recurrence in the medium term compared with a control group without HAGL lesions who underwent arthroscopic Bankart repair alone.

The arthroscopic Bankart operation: a 10-year follow-up study.

Traumatic shoulder instability most frequently occurs in young people often during sports events. Currently, the arthroscopic Bankart repair is the therapy of choice in the absence of extensive glenoid bone loss and has proved to be a safe and effective procedure. Nevertheless, we see recurrence of instability-especially if new trauma happens-and further data are needed to guide the right decision-making for these often young patients. The purpose of this study was to determine the long-term outcome 10years after arthroscopic Bankart operation in terms of satisfaction of the patient, functional result, complications, recurrent instability, and development of osteoarthritis, and to look after possible risk factors for recurrence of instability and statistical proof of these. Thirty-nine out of 49 patients underwent physical examination of both shoulders. We could perform a postoperative shoulder a-p X-ray in 28 patients. According to Samilson, [24] the extent of osteoarthritis was measured. The Constant score and the postoperative ROWE score were determined for both shoulders as well as the WOSI Score. In 25 cases, we calculated the ISIS Score. We could reach out to 89.6% of patients and 79.6% could be physically examined. The vast majority of 95.5% are either very satisfied or satisfied with the result at the time we ended the follow-up. The mean Constant score of 95.5 reflects this result. In contrast to this, we found at the same time in 15.3% ongoing clinical signs of instability of the concerning shoulder, even though 9.1% had to be re-operated for recurrent instability in between the follow-up timeline and we found in the X-rays (57.1% of all patients) in 35.7% at least moderate and in 10.7% severe signs of osteoarthritis. The Constant score but not the ROWE score differed significantly in patients with no or mild compared to those with moderate-to-severe osteoarthritis. The arthroscopic Bankart stabilization procedure showed after 10years to be a very safe operation and to be able to produce a satisfying and functional very good long-term result-reflected by the Constant score. We assume that the extent of osteoarthritis seems to be the determining factor of the very good functional result, even though ongoing instability was present in 15.3% of the patients.

Arthroscopic Biceps Transfer to the Glenoid With Bankart Repair Grants Satisfactory 2-Year Results for Recurrent Anteroinferior Glenohumeral Instability in Subcritical Bone Loss

To evaluate the short-term outcomes of the arthroscopic dynamic anterior stabilization (DAS), which is a transfer of the intra-articular portion of the long head biceps through the subscapularis split and fixation on the anterior glenoid, combined with a Bankart repair. A retrospective evaluation was performed of DAS and a minimum of 2-year follow-up. Inclusion criteria were the presence of anteroinferior instability, a positive apprehension test at 90° of abduction and external rotation, and subcritical glenoid bone loss (less than 20%). Exclusion criteria were severe (≥20%) glenoid bone loss, presence of biceps lesions or rupture (spontaneous or biceps tenotomy), pre-existing glenohumeral osteoarthritis, multidirectional or voluntary instability, previous arthroscopic stabilization procedure, and epilepsy. Outcomes included the Rowe score, range of motion (ROM), and recurrence. Twenty-three patients were treated with DAS and arthroscopic Bankart repair during the study period. One person was lost to follow-up, leaving 22 patients available at last follow-up. Those 22 patients had an average age of 31.9 ± 12.3 years (range, 18-68) and were evaluated at an average follow-up of 3.2 ± 0.7 years (range, 1.2-4.2). The Rowe score increased from 36.1 ± 16.2 (range, 10-70) preoperatively to 89.8 ± 20.1 (range, 30-100) postoperatively (P < .001) with almost all patients (90.9%) improving their score beyond the minimal clinically important difference of 9.7 points. Postoperatively, ROM was maintained. Three patients (13.6%) analyzed at final follow-up demonstrated recurrence, one was successfully treated conservatively, but two revised with a Latarjet. No postoperative Popeye deformity, biceps cramping, or other complication were reported. The DAS procedure may be an option for augmentation of a Bankart repair in patients with anterior shoulder instability and subcritical bone loss. ROM is maintained without evidence of postoperative Popeye deformity or biceps cramping. Level IV, retrospective study.

Postoperative Stiffness and Pain After Arthroscopic Labral Stabilization: Consider Anchor Arthropathy

To describe the key clinical, imaging, and arthroscopic characteristics of anchor arthropathy after arthroscopic shoulder stabilization procedures and, secondarily, to define risk factors for the development of anchor-induced arthropathy. A total of 23 patients who underwent revision arthroscopic shoulder surgery and were diagnosed with glenohumeral arthropathy were retrospectively identified from prospectively collected data registries between January 2000 and May 2018. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, and examination findings before revision surgery. Pre-revision imaging was used to assess presence of glenohumeral osteoarthritis and chondromalacia, anchors/sutures, loose bodies, and labral pathology. The same parameters were recorded intraoperatively during revision surgery. Descriptive statistics were performed for demographic data and means with standard deviations were calculated for continuous data. A McNemar-Bowker test was used to analyze marginal homogeneity between preoperative imaging and intraoperative findings. Mean age at presentation was 33.4 ± 11.7 years (range 16-59, 17 male patients; 6 female patients). More than one half (13/23) developed symptoms within 10 months after index arthroscopic procedure (mean 32.2 ± 59.9 months, range <1 to 165.2 months) with 87% presenting with pain and 100% presenting with loss of motion on examination. Plain radiographs demonstrated humeral osteoarthritis in 57% (13/23) of patients, magnetic resonance imaging (MRI) revealed recurrent labral pathology in 19 of 23 (83%) patients, potential proud implants in 12 of 23 (52%), and loose bodies in 12 of 23 (52%). Intraoperatively, all had evidence of osteoarthritis; 22 of 23 (96%) had prominent implants. Humeral head chondromalacia was present in 21 of 23 patients (91%), the majority of which was linear stripe wear, and 6 of 23 (26%) had severe global glenohumeral osteoarthritis. Statistical analysis revealed a 54.5% (95% confidence interval 0.327-0.749) sensitivity of MRI identification of proud implants with a specificity of 100% (95% confidence interval 0.055-1). The ability of MRI to accurately assess chondromalacia of the humeral head (P= .342) or glenoid (P= .685) was not statistically significant. Anchor arthropathy is characterized by symptoms of pain and stiffness on examination and in many cases develops early after stabilization surgery (<10 months). Implants were implicated in the majority of cases of humeral head chondromalacia. MRI scans may produce false-negative identification of proud implants and can be a poor predictor of the severity of chondromalacia and intra-articular pathology; thus, a high index of clinical suspicion is necessary in patients with motion loss and pain postoperatively. Level IV, case series.

Latarjet After Failed Arthroscopic Bankart Repair Results in Twice the Rate of Recurrent Instability Compared With Primary Latarjet

To assess recurrent instability of the shoulder following open Latarjet performed as the primary stabilization procedure or as a salvage procedure. A retrospective, comparative cohort study was performed for a consecutive series of patients in the Military Health System who underwent open Latarjet from January 1, 2010, to December 31, 2018. All patients were diagnosed with recurrent anterior shoulder instability and had a minimum of 2 years of postoperative follow-up. Patients were categorized as either having a primary Latarjet (PL; no prior shoulder stabilization procedure) or salvage Latarjet (SL; ≥1 previous arthroscopic surgical stabilization procedures). A total of 234 Latarjet procedures were performed in 234 patients. The overall recurrent instability rate was 15.8% (37/234), the overall reoperation rate was 16.7% (36/234), and the overall complication rate was 14.2% (33/234) over a mean 5.0 years of follow-up. There were 99 PL procedures and 135 SL procedures. The SL group had significantly more recurrent instability than the PL group (SL 28/135, 20.7%; PL 9/99, 9.1%; P= .0158). There was no difference in overall reoperation rates (SL 26/135, 19.3%; PL 13/99, 13.1%; P= .2140) or complication rates (SL 20/135, 14.8%; PL 13/99, 13.3%; P= .9101). The rate of recurrent instability following the Latarjet procedure in an active, high-risk population is 15.8%. Primary Latarjet was found to have lower rates of recurrence compared with salvage Latarjet procedures (9.1% versus 20.7%). III.

Open Capsulorrhaphy for Recurrent Multidirectional Instability of the Shoulder

Background: The management of multidirectional instability (MDI) of the shoulder remains challenging, especially in athletes who participate in sports and may require multiple surgical procedures to achieve shoulder stabilization. Open or arthroscopic procedures can be performed to address shoulder MDI. Indications: Open capsulorrhaphy is preferred in patients with underlying tissue hyperlaxity and who had 1 or more, previously failed, arthroscopic shoulder stabilization procedures. Technique Description: With the patient in the beach-chair position (45°), tissue dissection is performed to the level of subscapularis tendon via the deltopectoral approach. The subscapularis tenotomy is performed in an L-shaped fashion, and the subscapularis tendon is tagged with multiple sutures and mobilized. Careful separation of the subscapularis tendon from the underlying capsular tissue is critical. Capsulotomy is performed, consisting of a vertical limb and an inferior limb that extends to the 5 o’clock position on the humeral neck (right shoulder). After evaluating the integrity of the labrum, the capsule is shifted superiorly and laterally, and repaired using 4 to 5 suture anchors. The redundant capsule is excised, and the subscapularis tendon is repaired in a side-to-side fashion, augmented by transosseous equivalent repair using the capsular sutures. Results: Adequate shoulder stabilization was achieved following open capsulorrhaphy in a young female athlete with tissue hyperlaxity and history of a previously failed arthroscopic soft tissue stabilization surgery of the shoulder. The athlete returned to sport at 6 months postoperatively and did not experience recurrent shoulder instability episodes at midterm follow-up. Discussion/Conclusion: Based on the existing literature, 82% to 97% of patients who underwent open capsulorrhaphy for MDI had no recurrent shoulder instability episodes at midterm follow-up. One study reported 64% return-to-sport rate following open capsulorrhaphy in 15 adolescent athletes with Ehlers-Danlos syndrome, but more research is necessary to better define the indications and outcomes of this procedure in physically active patients.

Effects of Glenoid and Humeral Bone Defects on Recurrent Anterior Instability of the Shoulder.

For proper treatment of recurrent anterior instability of the shoulder with a bone defect, the defect size should be assessed preoperatively with three-dimensional computed tomography or magnetic resonance imaging. In general, the risk of postoperative recurrence of instability is estimated on the basis of preoperative imaging of bipolar bone defects: more than 20%–25% glenoid bone loss and off-track Hill-Sachs lesions have been considered risk factors for recurrence. In patients with a glenoid bone defect more than 20%–25%, a bone graft procedure, such as the Latarjet procedure, is preferred regardless of the glenoid track concept, because compared with arthroscopic stabilization procedure, it provides greater postoperative stability. For patients with a borderline glenoid bone defect (around 20%), surgeons should discuss surgical options with the patients, considering their demand and physical activity level. In addition, the surgeon should take care to prevent postoperative instability and long-term complications. Arthroscopic soft-tissue reconstruction including labral repair and capsular plication combined with the additional remplissage procedure is an anatomical procedure and could be considered as one of the primary treatment methods for patients with glenoid bone defects around 20%. Therefore, treatment strategies for recurrent anterior shoulder instability combined with bone defects should be determined more flexibly on the basis of the patient's individual condition.

Preoperative Diagnostic Rates and Clinical Outcomes After Arthroscopic Stabilization Procedures for Panlabral Tear of the Glenohumeral Joint

To evaluate preoperative diagnostic rates for panlabral tear using imaging studies or physical examinations and to evaluate clinical outcomes after arthroscopic stabilization procedures with 2 different patient surgical positions. Patients who underwent arthroscopic stabilization for recurrent anterior shoulder instability with panlabral tear and were followed up for at least 2 years were included. A panlabral tear was defined as labral tear involving at least 270° of the glenoid surface on arthroscopic examination. All patients underwent preoperative magnetic resonance (MR) imaging or MR arthrography and physical examinations including anterior apprehension, posterior jerk, and compressive rotation tests. The clinical outcomes were assessed by the American Shoulder and Elbow Surgeons, Rowe, and visual analog scale for pain scores, and recurrence rate. According to patient position during surgery, patients were divided into group I (beach chair position) and group II (lateral decubitus position). Forty-eight patients (24 in group I and 24 in group II) were enrolled. Preoperative MR imaging or MR arthrography detected only 18.8% of panlabral tears. No patient had positive findings on all 3 physical examination tests for panlabral tear. Clinical outcomes were significantly improved after operation (American Shoulder and Elbow Surgeons score: 58.4 ± 6.2 preoperatively, 85.2 ± 6.4 at the final, P < .001; Rowe score: 49.0 ± 12.2 preoperatively, 86.8 ± 9.1 at the final, P < .001) and postoperative recurrence was occurred in 1patient (2%). No differences were found in clinical outcomes and recurrence rate (4% vs 0%) according to patient positioning, despite the larger number of suture anchors used in group II (6.2 ± 1.5 in group I, 7.6 ± 1.1 in group II, P < .001). It remained difficult to preoperatively diagnose panlabral tear using standard physical examinations and imaging studies. Nevertheless, arthroscopic stabilization procedures for patients with panlabral tear provided satisfactory clinical outcomes with a low recurrence rate. Patient position during surgery did not alter clinical outcomes and recurrence rate, despite the use of different numbers of suture anchors. Level III, Retrospective comparative therapeutic trial.

Factors Related to Patient Dissatisfaction Versus Objective Failure After Arthroscopic Shoulder Stabilization for Instability.

After arthroscopic stabilization procedures for recurrent anterior shoulder instability, patients are not always satisfied with their shoulder, even when the operation successfully restored stability. The aim of this study was to evaluate the factors associated with subjective patient dissatisfaction after arthroscopic stabilization procedures for recurrent anterior shoulder instability and to compare these factors with those associated with objective surgical failure. A total of 195 patients who underwent an arthroscopic stabilization procedure for recurrent anterior shoulder instability were included in this study. At the 2-year postoperative visit, subjective patient dissatisfaction was assessed with a 15-point scale. Objective surgical failure was defined as postoperative dislocation or subluxation events requiring revision surgery. Several factors, including age at the first dislocation, age at the time of the operation, presence of an off-track Hill-Sachs lesion, width of the Hill-Sachs lesion, size of the glenoid bone defect, and number of instability events, were recorded. Multivariable linear regression analysis and multivariable logistic regression analysis were performed using a backward stepwise procedure as the variable selection method. Fifteen patients (7.7%) had recurrent instability requiring revision surgery. In the group of 180 patients without surgical failure, the width of the Hill-Sachs lesion (regression coefficient: 0.052, p = 0.011) and number of instability events (regression coefficient: 0.103, p = 0.029) were positively correlated with subjective patient dissatisfaction, whereas concomitant repair of a SLAP (superior labrum anterior-posterior) lesion showed negative correlation (regression coefficient: -0.926, p = 0.004). In the total cohort of patients, objective surgical failure was correlated with the age at the time of the operation (odds ratio [OR]: 0.851, p = 0.042), size of the glenoid bone defect (OR: 1.172, p < 0.001), and number of instability events (OR: 1.147, p = 0.048). Other variables, including an off-track Hill-Sachs lesion or a concomitant remplissage procedure, were not correlated with subjective patient dissatisfaction or objective surgical failure. Factors related to subjective patient dissatisfaction differed from those related to objective surgical failure. For a better understanding of the clinical outcomes after surgery, surgeons should assess the factors that correlate with subjective patient dissatisfaction and objective surgical failure. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Failure of Arthroscopic Revision Anterior Shoulder Stabilization

Recurrent anterior instability following a failed Bankart repair in the shoulder represents a challenging clinical scenario. Few studies have examined the role of arthroscopic revision anterior stabilization as a treatment option in these cases. The purpose of this study was to evaluate the outcomes of arthroscopic revision anterior stabilization for patients with recurrent instability after a failed index procedure. Ninety-two patients underwent arthroscopic revision anterior stabilization after a failed index (open or arthroscopic) stabilization procedure. Sixty-five patients with a minimum of 2 years of follow-up were included in this study. The mean age at the time of revision surgery was 26 years (range, 15 to 57 years). The rate of recurrent instability and risk factors for failure were evaluated; the mean duration of follow-up was 4.7 years (range, 2 to 10.8 years). Glenoid and humeral bone loss were quantitatively assessed using preoperative T1-weighted magnetic resonance arthrograms to determine if the lesions were on-track or off-track. Twenty-seven (42%) of the patients experienced recurrent instability at a mean of 2.3 years after arthroscopic revision anterior stabilization. On multivariate analysis, the presence of an off-track lesion, an age of <22 years, and ligamentous laxity were independent predictors of recurrence (p = 0.022, 0.028, and 0.031, respectively). Among a cohort with these risk factors excluded, the failure rate was 19%. Arthroscopic revision anterior stabilization is associated with a high rate of recurrent instability, and patient selection is of critical importance in order to minimize recurrence. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.