Bankart Research Articles

Indications, management, and outcomes of humeral avulsions of the glenohumeral ligament: a systematic review.

To provide an updated overview of recent literature regarding the clinical indications, management, and outcomes of humeral avulsions of the glenohumeral ligament (HAGL) lesion. Medline, Cochrane and Embase were systematically searched using keywords "humeral avulsion of the glenohumeral ligament" and others to identify studies reporting on management of HAGL lesions. Studies were double-screened and reviewed by two blinded authors according to selection criteria. Data was systematically extracted on the following topics: demographics, mechanism of injury, indication for treatment, treatment, post-operative complications, associated injuries, and outcomes including clinical outcome scores, clinical evaluations, and return to activity. There were 14 studies included that evaluated a total of 119 patients with HAGL lesions. In these studies, 69% of patients were male with a mean age of 24 years. Sports (23.5%) and fitness training (41.2%) were the most common injury mechanisms. Instability was the most common indication for treatment, followed by pain and recurrent dislocations. 85 associated lesions were reported, with non-descript labral tears (34.5%) and Bankart lesions (22.4%) being the most common. Out of patients treated, 117 of 119 patients were treated operatively, with 60 open and 57 arthroscopic procedures. A variety of clinical outcome scores showed postoperative functional shoulder improvement and 97% of patients were able to return to some level of activity. HAGL lesions commonly present with associated injuries, necessitating a high clinical awareness of their presentation and management options to prevent undiagnosed lesions that can lead to persistent instability and pain. Surgical management yields good clinical outcomes.

THICKNESS OF THE CORACOHUMERAL LIGAMENT IN CASES OF RECURRENT SHOULDER DISLOCATION

Enhancement of the joint capsule, fibrovascular tissue, and synovial membrane in the rotator cuff interval using MRI can aid the identification of adhesive capsulitis following intravenous gadolinium injection. This study assesses the thickness of the coracohumeral ligament (CHL) in the cases of recurrent shoulder dislocation and identifies the status of the CHL in these cases. A 3T MRI machine was used to perform the imaging. Patients were included with a history of at least two episodes of shoulder dislocation at the radiology department of King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, from January 2017 to May 2020. A total of 177 patients were diagnosed with recurrent shoulder dislocation through its associated symptoms, out of which 107 had a history of shoulder dislocation. A mean CHL thickness was reported in the control group as 1.6 (± 0.49) mm, while in patients with shoulder dislocation it was reported as 2.84 (± 0.91) mm. A statistically significant relationship was observed between CHL thickness and the presence of Hill-Sachs and Bankart lesions. The study concluded that increased CHL thickness is strongly correlated with shoulder dislocation: there is a good predictability of shoulder dislocation based on the presence of thickened CHL.

A Systematic Review of Acute Irreducible Shoulder Dislocations in the 21st Century.

Background:Rarely, closed reduction cannot be achieved in patients with acute shoulder dislocation, necessitating open management. A paucity of literature exists regarding these cases.Purpose:To perform a systematic review on the mechanism, management, and outcome data of acute irreducible shoulder dislocations.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of the literature was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE between 2000 and 2020. Inclusion criteria were as follows: human participants, acute irreducible shoulder dislocation requiring open management, English language, and publication within the past 20 years. We excluded basic science articles, technique articles, reviews, editorials, and studies of chronic shoulder dislocations or dislocations with ipsilateral humeral shaft fractures.Results:Twelve articles fit the inclusion criteria and were considered for review. All studies were single case reports (level 4 evidence). Ten of the 12 studies were of male patients. The direction of dislocation included 7 anterior/anteroinferior, 2 posterior, 1 inferior, 1 bilateral inferior, and 1 superolateral. Most dislocations were irreducible owing to a mechanical block to reduction. The most common type of block was an incarcerated long head of the biceps tendon, followed by interposition of 1 of the rotator cuff tendons. The axillary and musculocutaneous nerves, displaced fracture fragments, and Hill-Sachs and bony Bankart lesions were other causes of blocks to reduction. Eleven patients were treated with open surgery, while 1 patient was treated arthroscopically. Procedures performed were dependent on concurrent pathology. Final follow-up ranged from 6 weeks to 2 years, with no repeat dislocation episodes reported. Complications after open reduction included 1 case of brachial plexopathy (posterior cord) and 1 case of musculocutaneous nerve palsy.Conclusion:There is a paucity of literature on the management of irreducible acute shoulder dislocations. The most common irreducible dislocation found in this systematic review was anterior with a mechanical block attributed to interposition of the long head of the biceps tendon. When patients were treated with an open or arthroscopic procedure, recurrence was low, with none reporting recurrent dislocation in limited follow-up.

Suspension fixation of iliac bone grafts under arthroscopy is an effective method for the treatment of unstable bony Bankart disease of the shoulder joint in patients with joint relaxation

PurposeTo evaluate the results of arthroscopic autologous iliac bone graft suspension fixation combined with the Remplissage procedure in the treatment of recurrent shoulder dislocation with bony Bankart lesions and joint hyperlaxity.MethodsFrom 2018 to 2020, 22 patients with joint laxity underwent arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure due to recurrent shoulder dislocation. Clinical assessment included range of motion (forward flexion, abduction, 90° external rotation, conventional external rotation, adduction, and internal rotation), visual analog scale (VAS) score, Rowe score, University of California Los Angeles (UCLA) score, and Western Ontario Shoulder Instability Index (WOSI) score. Post-operatively, the healing of the bone graft was evaluated with computed tomography (CT) scanning.ResultsAll 22 patients were followed up for a mean of 19.3 ± 4.1 months. CT imaging showed that the healing time of the bone graft was 6–8 weeks. The patient satisfaction rate was 100%, there were no cases of redislocation, all patients returned to their preinjury training state, and the fear test was negative. At the final follow-up, the UCLA, VAS, Rowe, and WOSI scores were 29.8 ± 2.1, 2.2 ± 0.8, 89.4 ± 4.2, and 482.3 ± 46.2, respectively (p < 0.001).ConclusionArthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure are effective in preventing recurrent instability with joint hyperlaxity. Furthermore, no patient had redislocation.Level of evidenceIV.

Combined Bankart and SLAP repair: patient-reported outcome measurements after a minimum 5-year follow-up.

Anterior shoulder instability is typically characterized by detachment of the anteroinferior labrum (Bankart lesion). Some patients also sustain a superior labrum anterior-to-posterior (SLAP) injury. The purpose of this study was to compare the medium-term clinical results of isolated anterior Bankart repairs (ABR) with those of combined Bankart and SLAP repair (ABR + SLAP). Data on all patients treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected from medical charts. The minimum follow-up was 5years. Patients were interviewed to assess patient-reported outcome measurements (PROM) as determined by the American Shoulder and Elbow Surgeons Score (ASES), the Subjective Shoulder Score (SSV), and the Disabilities of the Arm, Shoulder, and Hand Score (DASH), as well as their quality of life (QOL: SF12 questionnaire). Information on complications, re-operations, and recurrent instability was recorded and evaluated as well. A total of 150 patients (88% males) with a mean age 23.7years (range 15-40) were included. Forty-two patients following ABR + SLAP repair were compared to 108 patients following ABR alone, with a mean follow-up of 7.8years (range 5-10.7). The rate of re-dislocation was similar in both groups (26% for ABR + SLAP vs 20% for ABR, p = .44). There were no significant differences in functional outcome between the ABR + SLAP and the ABR alone groups (SSV 86.7 vs 86.5, p = .93, ASES 89.6 vs 86.5, p = .11, and DASH 4.9 vs 7, p = .17), or in QOL outcome (SF12 physical 95.6 vs 93.3, p = .27, SF12 mental 84.4 vs 85.7, p = .63). Surgical repair for anterior shoulder instability and a coexisting SLAP lesion yields clinical results as good as those of isolated ABR, as evidenced by similar PROM and re-dislocation rates after medium-term follow-up. III.

Type and Diagnosis of Lesions Associated with Traumatic Anterior Shoulder Dislocation

Objective: Anterior dislocations are common large joint dislocations due to the anatomical structure and mobility of the shoulder joint and are seen in 1-2% of the population. The most common form is a traumatic anterior shoulder dislocation, approximately 90-95%. The lesions accompanying traumatic anterior shoulder dislocation are mostly Bankart and Hill-Sachs lesions, rotator cuff tear, tuberculum major fracture, and neurological injury. This study evaluates osseous, neurological, and soft tissue lesions in traumatic anterior shoulder dislocations. Material and Methods: Eighty-four patients (male:62, female:22) who applied to our center due to traumatic shoulder dislocation between January 2014 and January 2021 were evaluated. Demographic data of the patients and accompanying shoulder circumference lesions were detected. The types of lesions were grouped as isolated and combined. The lesions were diagnosed clinically and radiologically (shoulder radiographs and magnetic resonance imaging (MRI)). Results: The mean age of the patients was 33.4 (18-81) years, 62 were male, and 22 were female. Dislocation-related lesions were detected in 61.1% of the patients. The lesions were seen as isolated and combined. While rotator cuff tears were the most common isolated lesions, Bankart + Hill-Sachs lesions were the most common combined lesions. Conclusion: Isolated or combined lesions accompanying traumatic anterior shoulder dislocations are common and cause shoulder instability when not treated. It is detected by clinical examination and MRI after a dislocation to diagnose associated lesions. We recommend performing a shoulder MRI to detect associated lesions after shoulder dislocation.

Anterior mid-portion capsular tear with Bankart lesion in recurrent anterior shoulder dislocation: outcome report and bone defect evaluation.

This study aimed to report the incidence of anterior mid-portion capsular tears identified during arthroscopic Bankart repair (ABR), the clinical outcomes of repairing this combined lesion, and to evaluate the associated bone defects. We retrospectively reviewed the records of patients undergoing ABR between January 2014 and December 2017. Data from patients with capsular tears identified during ABR were included and analyzed. Age, number of dislocations, repair technique, follow-up results, and X-rays were reviewed. The size of the glenoid defect and Hill-Sachs lesion were reviewed via magnetic resonance imaging or magnetic resonance arthrography (MRA). Records of 95 patients undergoing ABR during the study period were reviewed, and nine were included. The overall incidence of capsular tears was 9.5% and the mean age at surgery was 45.3 ± 14.3years. All cases had > 3 dislocations before treatment. All patients had labral lesions, and one had a glenoid defect. Hill-Sachs lesions were observed in eight patients. Seven patients underwent MRA examination, and all seven showed axillary pouch disruption. Over 3.9 ± 1.1years of follow-up, there was no instability recurrence, and Rowe scores improved from 42.2 to 96.7 (p < 0.001). There was no recurrent shoulder instability after combined arthroscopic repair of capsular and Bankart lesions. There were Rowe score improvements over at least three years of follow-up. Although our case number was small, we found that mid-portion capsular tear occurred in patients over 30years with multiple recurrent dislocations, with or without small glenoid bone defects, and with axillary pouch disruption on MRA images.

Arthroscopic Techniques to Stabilize Glenoid Bony Bankart Fragments

A bony Bankart lesion is an avulsion of the labroligamentous complex associated with an anterior glenoid rim fracture. Bony Bankart lesions can be seen in up to 70% of traumatic shoulder dislocations. With such a high prevalence, the development of an optimal repair technique is important. Selection of the most appropriate repair method depends heavily on the individual hard- and soft-tissue characteristics of the presenting lesion, as well as surgeon experience with the various repair options. We describe 3 arthroscopic Bankart fixation techniques (labrum alone, transosseous, and double row) to address a range of presenting Bankart pathologies.

No Difference Between Anchorless and Traditional Suture Anchors in Arthroscopic Bankart Repair: A Clinical Comparison.

BackgroundShoulder instability and recurrent dislocations are common problems encountered by orthopedic surgeons and are frequently associated with a Bankart lesion. These are classically treated with either open or arthroscopic repair utilizing traditional suture anchors, though anchorless fixation techniques have recently been developed as an alternate fixation method that reduces native bone loss and has comparable pull-out strength.MethodsA retrospective review was performed at a single institution for patients who underwent Bankart repair from January 2008 through February 2014. American Shoulder and Elbow Surgeons (ASES) questionnaires were mailed to 35 patients with anchorless fixation and 35 age-, gender-, and surgeon-matched patients with traditional suture anchors. Statistical analysis was performed comparing re-dislocation, additional surgery, and ASES scores with statistical significance set at p < 0.05.ResultsEleven patients in the anchorless implant group and 15 patients in the anchor group completed the questionnaire. The mean follow-up was 4.1 years in the anchorless group and 5.6 years in the anchor group (p=0.04). The number of implants was 4.82 in the anchorless group and 3.87 in the anchor group (p = 0.04). No difference was found in re-dislocation rates (p = 0.80) or additional surgery on the affected shoulder (p = 0.75). ASES scores were found to have no statistical difference (89.89 for the anchorless group versus 85.37 for the anchor group; p = 0.78).ConclusionIn patients undergoing arthroscopic Bankart lesion repair with traditional anchors compared to anchorless fixation, there appears to be no difference in shoulder re-dislocation rates, recurrent ipsilateral shoulder surgery, or ASES scores.

Management of amultifragmentary glenoid fracture : Case report of atwo-stage surgical procedure

This article describes amultifragmentary glenoid fracture in a65-year-old patient after falling from aheight of2m. The accident led to complete Y‑shaped destruction of the glenohumeral joint with alarge posteroinferior fragment and a large anteroinferior glenoid fragment. The treatment consisted of atwo-stage surgical procedure and acombination of open and arthroscopic techniques. First, open surgery of one fragment from the dorsal side was performed using screw osteosynthesis. Arthroscopic refixation of the anterior glenoid fragment (bony Bankart lesion) followed 4 weeks later using aguided Endobutton® technique (Smith & Nephew). Ideberg type6multifragmentary glenoid fractures are rare and should be treated surgically, especially with dislocated fragments, instability in the glenohumeral joint and in younger patients. Given the lack of evidence in the literature, individual surgical strategies are necessary.

Bankart Repair With Remplissage Restores Better Shoulder Stability Than Bankart Repair Alone, and Medial or Two Remplissage Anchors Increase Stability but Decrease Range of Motion: A Finite Element Analysis

To investigate the effects of the number and location of anchors for remplissage on postoperative glenohumeral biomechanics. A biomechanical study was conducted involving finite element model constructed based on data from the intact glenohumeral joint. Seven models were established, including a normal model, a model of Bankart lesion combined with "off-track" Hill-Sachs lesion, a model of Bankart repair alone, and 4 models of Bankart repair with remplissage based on different remplissage anchor numbers and locations. The effects of the number and location of the remplissage anchors on glenohumeral stability were studied through calculation and comparison of (1) the stress and its distribution on the joint capsule, cartilage, labrum and anchors as well as (2) the displacement of the humeral head. Finite element analysis demonstrated that contact stress on the glenohumeral cartilage decreased when medial or 2 anchors were used and was minimized in the combined repair model with 2 medial anchors. The stress on remplissage anchors was greater when the anchors were placed medially. The humeral head displacement was maximized in the combined lesion model. The combined repair models with 2 medially placed anchors showed the largest slope on the force-displacement curve, indicating the largest strain on the humeral head. Based on a finite element analysis, Bankart repair with remplissage restored better shoulder stability compared with Bankart repair alone in the treatment of anterior shoulder instability involving Bankart lesion combined with "off-track" Hill-Sachs lesion. When the anchor for remplissage was medially placed or 2 anchors were used, the stability of the glenohumeral joint increased but with a loss of range of motion. The results of this study will assist in choosing the number and location of anchors for remplissage during shoulder stabilization surgery although with some limitations.

Poster 141: Novel Equation to Accurately Compute the Glenoid Bone Loss with a Bony Bankart

Objectives:The glenohumeral joint is the most frequently injured joint, with anterior dislocations occurring in 98% of cases. There is often an osseous Bankart fragment (OBF) of the glenoid rim that remains in both acute and chronic instability. By calculating the percent bone loss (%BL) of the glenoid surface, the best reconstruction method is selected. Reported values of the critical %BL range from 13.5 to 25%. This study validates a new geometric equation to compute the glenoid %BL for patients undergoing shoulder stabilization surgery and accounting for the decrease in bone loss expected with incorporation of the OBF into the anticipated repair. The goal of the study was to determine if the accuracy of the %BL computed with the novel equation would improve compared to the diameter ratio, as well as if the inclusion of the OBF would indicate a pre-operative selection of more conservative reconstructive management.Methods:This retrospective radiographical validation study reviewed pre-operative CT scans for 36 patients who underwent surgical reconstruction for shoulder dislocations with Bankart lesions, with and without OBFs. Two independent raters measured the dimensions required for the novel equation, the diameter ratio, and the ‘true’ area from pre-operative CT scans three months apart. The %BL for these three methods and the reduction in %BL by including the OBF were compared. As well, the validity of the measurement technique was assessed through inter-and intra-rater analyses.Results:Our findings revealed the novel equation was more accurate in determining the %BL versus the diameter ratio. Without the OBF, the %BL was most similar for the novel equation (23.514% ± 13.613%) and area method (21.223% ± 9.842%), and there was no statistically significant difference between the %BL for these two methods (p-value = 0.423). Instead, the diameter ratio had larger values of %BL (27.774% ± 12.00%) and there was a statistically significant difference compared to the %BL obtained with the area method (p-value = 0.015). Furthermore, by including the OBF in the reconstruction this would have led to a change in pre-operative surgical plan for 50% of patients, favouring more conservative repairs since the %BL would have been below the selected critical cut-off value of 13.5%.Conclusions:By accounting for the area overestimate of the diameter ratio and incorporating the OBF, our novel equation reduced the %BL in general, even below the critical threshold for half of our cohort. Future studies will investigate the clinical implications of our novel equation, and its impact in pre-operative planning through large scale randomized-controlled trials with long term post-operative functional outcomes assessment. This research paves the way for potentially less invasive treatment options, and improvement in post-repair outcomes, such as greater long-term shoulder stability, decreased incidence of re-tearing and faster recovery time.

Poster 137: Do Sex-Based Differences in Native Glenoid Anatomy Predispose to Shoulder Instability? A Radiographic Analysis

Poster 137: Do Sex-Based Differences in Native Glenoid Anatomy Predispose to Shoulder Instability? A Radiographic Analysis

Poster 166: Biomechanical Evaluation of Open Bankart and Soft Tissue Bristow Procedures with 10% Glenoid Bone Loss

Objectives:Chronic anterior shoulder instability can be debilitating for a wide number of individuals from the general populations, high level and recreational athletes, laborers and the members of the military. Glenoid bone loss presents a more difficult problem to treat as it negates the positive results that can be achieved with arthroscopic labral repair alone. The optimal procedure for subcritical bone loss of 10% or less is undetermined. In young competitive contact athletes, there is still a high failure rate with arthroscopic procedures. Therefore, the purpose of this study was to biomechanically characterize the effects of soft tissue Bristow (conjoint tendon transfer) and open Bankart repair in a 10% glenoid defect model.Methods:Eight fresh cadavers were studied using a custom shoulder testing system. The rotator cuff muscles were loaded to simulate physiologic muscle conditions. Range of motion, anterior-inferior translation at 60° of external rotation with 20, 30 and 40N of force were tested in scapular and coronal planes. Stiffness and the force required to dislocate in the anterior-inferior direction were also quantified in the coronal plane. 4 different states were examined including: (1) intact capsule (2) Bankart lesion with 10% bone loss, (3) soft tissue Bristow (conjoint tendon transfer), and (4) open Bankart repair. Repeated measures ANOVA with Bonferroni correction was used for statistical analysis.Results:The bony Bankart (injury model) increased range of motion in both the scapular and coronal planes. The conjoint tendon transfer had little effect on range of motion, and the Bankart repair decreased the range of motion to a similar state with that of the pre-injury model. The injury state showed increased translation which was decreased with both the conjoint tendon transfer and the Bankart repair (Figure 1A). The conjoint tendon transfer shifts the humeral head posteriorly in 0° and 30° of external rotation in the scapular plane. There was no difference in stiffness during dislocation between conjoint tendon transfer and Bankart repair (Figure 1B).Conclusions:Both the soft tissue Bristow and the open Bankart repair were noted to decrease anterior translation in this shoulder instability model. Both open repair models significantly decreased anterior translation and are valid surgical options for the treatment of instability with 10% glenoid bone loss. Surgically, an open Bankart repair is more anatomic and may be the preferred technique.

Study on the functional outcome of arthroscopic Bankart repair in post-traumatic recurrent anterior dislocation of shoulder

Introduction: Shoulder joint is the most common joint to get dislocated with the anteroinferior type being the commonest. Detachment of the glenoid labrum termed as Bankart lesion is the cause of recurrent shoulder dislocation. Arthroscopic repair has gained popularity in recent days.Methods: 33 patients were studied with a follow-up period of 1year after undergoing Arthroscopic Bankart repair by a single experienced orthopaedic (Arthroscopic) surgeon. All the patients included in the study strictly followed rehabilitation protocol. Modified University of California Los Angeles (UCLA) scale was used to evaluate the effectiveness of the surgery.Results: In our study the mean post operative UCLA score was 30.9 with maximum score being 34 and minimum score was 20. 51.5% patients had excellent result whereas 36.4% had good, 9.1% with fair and 3% with poor outcome. Thus, patients with satisfactory score returning to sports activity and job was 87.9%Conclusion: Arthroscopic Bankart repair gives good to excellent functional and clinical outcome in anterior shoulder instability.

Poster 152: Arthroscopic Bankart Repair Following a Second Dislocation Results in Increased Failure Rates Compared to Immediate Repair After Following a Traumatic First Time Dislocation

Objectives:Many surgeons will consider nonoperative treatment following a 1st time dislocation and will consider operative management if a second instability event occurs particularly for the in season athlete. The objective of this study was to compare rates of recurrent dislocation and post-surgical outcomes in patients undergoing arthroscopic bankart repair for anterior shoulder instability immediately following a 1st time traumatic anterior dislocation versus patients who sustained a 2nd dislocation event following initial conservative management. We hypothesized that patients sustaining a 2nd anterior shoulder dislocation would be more at risk for recurrent dislocations after arthroscopic repair and secondarily, would have worse objective and subjective outcomes.Methods:This was a retrospective chart review identifying all patients undergoing primary arthroscopic surgical stabilization for anterior shoulder instability between 2013-2019 at a single academic institution. Demographics, clinical history, physical exam, imaging, operative details, and postoperative course was reviewed. Patients were eligible for inclusion if they underwent arthroscopic Bankart repair without remplissage sustained one or two dislocation events and were clinically followed for a minimum of 12 months postoperatively. Exclusion criteria included posterior instability, multidirectional instability, and previous stabilization surgery, Primary outcome was documentation of recurrent shoulder dislocation during the postoperative period. Secondary clinical outcome measures were assessed including need for revision surgery, need for manipulation under anesthesia (MUA), range of motion, strength, Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), PROMIS mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Brophy shoulder activity scores.Results:A series of 89 patients (mean age 21.3 years ± 7.3 years) met criteria for inclusion. 72 shoulders underwent surgical stabilization after a single shoulder dislocation event and 17 underwent surgery after sustaining two documented shoulder dislocations. No significant difference in demographic and radiographic characteristics, including presence of bony Bankart and off-track Hill Sachs lesions, was present between the groups. The rate of recurrent dislocation was significantly higher in the multiple dislocation group compared to single dislocations (31% vs 12%, p=0.048). There was a trend toward increased rate of revision stabilization in the 2nd dislocation group which did not reach statistical significance (22% vs 58%, p=0.167). No significant difference was present in the need for revision surgery, need for MUA, conversion to Latarjet procedure, range of motion, supraspinatus strength, VAS, PROMIS, ASES, and Brophy scores between the groups.Conclusions:Immediate surgical stabilization following a 1st time dislocation significantly diminishes the risk of recurrent dislocation in comparison to those who undergo surgery following two dislocation events. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and undergo surgical stabilization following just one additional event are at increased risk of failure following surgery. Furthermore, patients who have sustained even one additional dislocation from the primary event may benefit from more aggressive approaches may be necessary including arthroscopic approaches with augmentation or open approaches. Despite differences in recurrence rates, both groups achieved excellent subjective functional outcomes at a minimum of 12 months after surgery.

Poster 182: Beach Chair vs Lateral Decubitus Surgical Positioning for Arthroscopic Anterior Shoulder Stabilization: A Retrospective Comparison of Clinical and Patient-Reported Outcomes

Objectives:Surgical positioning can affect intra- and post-operative complication rates for many reasons, including potential differences in anatomic approaches and proximity to nearby nerves. The beach chair and lateral decubitus positions are the two most common positions for shoulder arthroscopy, and each offers their own unique advantages and disadvantages for surgeons. Beach chair allows for an easier transition to open surgery if necessary, and also has a lower incidence rate of neuropathies, relative to lateral decubitus. However, the lateral decubitus positioning allows for better access to the glenohumeral joint, easier visualization of the labrum, and greater circumferential access to the joint. The surgical position is often selected according to each individual surgeon’s preference, with no clear superiority of one position over the other. This study was conducted to compare clinical and patient-reported outcomes between patients who underwent arthroscopic anterior shoulder stabilization in beach chair vs. lateral decubitus positions.Methods:A list of all patients diagnosed with the CPT codes 29806 and 29807 from 2015-2019 was obtained from the medical records. Patients were only included if anterior instability was confirmed, arthroscopic surgery was performed in response to shoulder instability, and a minimum of 2-year follow-up was available. Data collected for eligible patients includes: pathology present (Hill-Sachs lesion, bony Bankart lesion), number and location of anchors used, surgery duration, intra-operative and post-operative complications, recurrent instability, reoperation, and revision. Patients were also contacted to complete patient-reported outcome surveys including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score, Single Assessment Numeric Evaluation (SANE), and a return to sport (RTS) questionnaire. Demographic, intra-operative data, and post-operative outcomes were compared between patients who underwent surgery in beach chair vs lateral decubitus positioning.Results:294 patients were included in this study, 162 patients who underwent surgery in the lateral decubitus position and 132 in beach chair position with an average follow-up of 3.3 years. There were no significant differences in demographics, concomitant surgeries, prevalence of Hill-Sachs and bony Bankart lesions, surgery duration, or intra-operative complications between groups (all p>0.05). Beach chair was associated with an increased number of anchors used (4.0 vs. 3.3, p=0.01) and a smaller proportion of inferior anchors being placed at the 6 o’clock position (8.3% vs. 25.0%, p=0.022) (Table 1). Rates of post-operative dislocations, recurrent instability, reoperations, all complications, and RTS also did not differ between groups (all p>0.05). Beach chair position had a trend for increase in revision rate but was not significant (beach chair 6.1% vs. lateral decubitus 1.9%, p=0.069). Finally, there was no difference between groups regarding post-operative ASES, SANE, and Oxford Shoulder Scores (all p>0.05).Conclusions:Surgical positioning for arthroscopic anterior shoulder stabilization did not affect post-operative clinical and patient-reported outcomes. Lateral decubitus patient positioning was associated with the use of fewer anchors and an increased proportion of inferior anchors placed at the 6 o’clock position of the labrum.Table 1.Comparison of intra-operative data and post-operative outcomes between patients who underwent shoulder stabilization surgery in the beach chair vs. lateral decubitus position. SLAP=superior labral tear anterior to posterior, RTS=return to sport, ASES=American Shoulder and Elbow Surgeons, SANE=Single Assessment Numeric Evaluation. Categorical data is presented as n (%), and continuous data is presented as mean ± standard deviation. Statistically significant differences are in bold.

Paper 59: Comparison of Knotless versus Knotted Suture Anchors in the Arthroscopic Management of Adolescent Shoulder Instability

Objectives:Shoulder instability among adolescent athletes remains a complex challenge with high recurrence rates. Knotted suture anchors have provided consistently reliable biomechanical and clinical results. In recent years, the advent of the knotless suture anchor technology has come with proposed advantages of minimizing technical difficulty and knot migration, as well as reducing subsequent intra-articular cartilage irritation and damage. While several studies have analyzed the utility of knotless suture anchors in the adult population, to our knowledge, there has not been a direct comparison within this more at risk for surgical failure adolescent population. The purpose of this study was to compare the effect of knotted versus knotless suture anchor use on postoperative outcomes of arthroscopic shoulder instability surgery in the adolescent athlete.Methods:A multicenter comparative cohort was conducted of patients that underwent primary arthroscopic shoulder labral repair with suture anchor implants for shoulder instability between June 2015 and November 2017. Additional inclusion criteria included patient age <20 years and minimum follow up duration of 3.5 years. Data collected included demographics, number and type of suture anchor (knotted or knotless), number of instability events, type of instability, and presence of bony Bankart lesions. All included patients had <20% glenoid bone loss at the time of surgery. Type of instability was also recorded and was classified as either: anterior, posterior, or multidirectional (MDI). The primary outcome measure was surgical failure, which was defined as any recurrent instability event post-surgery. Incidence of secondary surgery (including revision or need for additional procedure), surgical times, and return to sport (RTS) data were also recorded. Patient-reported outcomes were evaluated using the Pediatric and Adolescent Shoulder Survey (PASS), SANE (Single Assessment Numeric Evaluation) scores, and the Quick version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey.Results:Eighty-eight shoulders (54 male, 34 female) from 84 patients met inclusion criteria and were analyzed. 43 received knotless anchors and 45 received knotted anchors. Mean follow-up duration was 4.5 years (range, 3.5-6 years) for the knotless cohort and 4.8 years (range, 3.7-5.8 years) for the knotted cohort. Demographics and type of instability by suture anchor type is shown in Table 1. Surgical failure rate was significantly lower in the knotless cohort (knotless, 16%; knotted, 53%; P<.001). Patients with knotless suture anchors reported significantly higher mean PASS scores (knotless, 90.2; knotted, 81.3; P=.002). There was no difference in both RTS rates (knotless, 86%; knotted, 68%; P=.055) and incidence of repeat surgery between cohorts (knotless, 9%; knotted, 13%; P=.551).Surgical times, SANE scores, and QuickDASH scores were available for approximately three-quarters of shoulders (total, 65; knotless, 36; knotted, 29) in the cohort. Mean surgical time was approximately 18 minutes shorter for knotless anchors (knotless, 84.4 minutes; knotted, 102.7 minutes; P<.001). SANE scores were significantly higher in the knotless group (knotless, 88.8; knotted, 74.3; P=0.004). QuickDASH scores, of which a lower score is considered a better outcome, were not different (knotless, 5.7; knotted, 11.4; P=.063).Conclusions:Our initial intent was to demonstrate that knotless anchors would be just as successful as labral repairs with knotted anchors, but our results indicate several promising advantages, including: better patient reported outcome measures (PASS and SANE scores), reduced surgical times, and lower failure rates at a mean 4.5 years. There were some non-significant differences in the two cohorts regarding the type of instability that likely contributed to the differences in the number of anchors utilized. Future studies with larger sample sizes may serve to confirm our observed benefits associated with knotless anchors. In summary, the utilization of knotless suture anchor constructs for the repair of labral tears in adolescent shoulder instability may be safely considered with potentially improved outcomes over knotted anchors.Table 1.Demographic characteristics of included patients

Poster 144: Minimum 2-year Outcomes after Knotless All-Suture Anchor Bankart Repair

Objectives:Knotless, all suture anchors have significant theoretical and technical advantages such as less bone removal, easier revision, lower profile so less risk for cartilage damage, but clinical results are lacking. The purpose of this study was to report on minimum 2-year outcomes after arthroscopic knotless all-suture Bankart repair in patients with anterior shoulder instabilityMethods:IRB approval was obtained prior to initiation of this study. Data was collected prospectively and retrospectively reviewed. Patients met inclusion criteria if they were a minimum 2 years out from a Bankart repair using all-suture, knotless anchors (FiberTak anchors) for the repairs by a single surgeon from September 2017 to June 2019. Patients were excluded if they had an anterior labroligamentous periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, glenolabral articular disruption lesion, or a rotator cuff repair. Outcome data was collected preoperatively and evaluated at a minimum follow-up of 2 years postoperatively using the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numeric Evaluation Score (SANE), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the Short Form 12 physical component summary (SF-12 PCS), and patient satisfaction to assess surgical outcomes at final follow-up. Also included are several questions regarding shoulder pain, function and sports participation. Patients with re-dislocations and revision surgery were noted along with any surgical complications. Surgical failure was defined as revision instability surgery, re-dislocation requiring reduction with an ASES score less than 70 or a satisfaction score of 6 or less.Results:A total of 32 patients, 8 females and 24 males, with an average age of 28.5 (SD10.7) years at the time of surgery were included. Postoperative shoulder re-dislocations were reported in 5 cases (15.6%) with 2 patients progressing to a Latarjet (6.0%) at 2 & 3 years post-operatively. There were no postage stamp fractures noted. Moreover, the anchors did not interfere with revision surgery in any way. At final follow-up, mean PRO’s significantly improved over preoperative levels. ASES score improved from 58 to 93 (p<0.001), SANE improved from 58-94 (p<0.001), QuickDASH improved from 32.0 to 6.0 (p<0.001) and SF-12 PCS improved from 45.6 to 55.7 (p<0.001). Median postoperative satisfaction was 10/10 (range4-10). Patients reported a significant improvement in shoulder pain during competition (p<.001), and ability to compete in sports (p< .001). There was also significant improvement in painless use of arm for overhead activities (p= .001) and ability to throw a softball 20 yards (p= .001)Conclusions:The arthroscopic treatment of Bankart lesions with knotless all-suture anchors leads to results similar to clinical outcomes to prior studies, with the advantage of ease of revision. Long-term follow-up studies with large patient cohorts will show if the other theoretical advantages of these anchors are born out.

Postoperative imaging of the shoulder

Imaging of the postoperative shoulder joint includes complex, diagnostically challenging changes regarding the anatomical structures. Case-based presentation of common surgical procedures, expected postoperative findings, and typical complications. Interdisciplinary evaluation of (didactically instructive) cases and discussion of pertinent literature and expert opinions. Presentation of normal postoperative findings and complications after subacromial decompression, surgical treatment of rotator cuff lesions, SLAP (superior labral anterior to posterior) lesions/lesions of the long biceps tendon, Bankart lesions as well as instability-related procedures and after shoulder arthroplasty. Discussion of the appropriate use of imaging methods with afocus on magnetic resonance imaging (MRI), which are supplemented by computed tomography (CT), and conventional x‑ray images. The broad spectrum of complex findings as well as the evermore developing and thereby changing surgical procedures result in significant challenges in the radiological evaluation of the postoperative shoulder joint. To differentiate physiological reactions from pathological changes it is necessary to have general knowledge of the common surgical procedures, expected postoperative findings and possible complications. A variety imaging modalities can be used to further advance diagnostic precision.