Incidence Of Recurrent Instability Research Articles

Surgical Treatment of Posterolateral Rotational Instability of the Elbow: a Systematic Review

Posterolateral rotational instability (PLRI) of the elbow joint can occur acutely as a result of dislocation of the bones of the forearm, and also be chronic, for example, after inadequate healing of a previous rupture of the lateral ligamentous complex, in particular the lateral ulnar collateral ligament (LUCL). It is necessary to take into account that, as a result of repeated microtraumas, persistent pain syndrome and recurrence of dislocation develop, which can lead to disability. We conducted a systematic review of the literature according to the protocol outlined in the PRISMA guidelines. From 1,903 publications, 11 studies were selected that met our criteria and assessed the results of treatment of 181 patients. The main reason for the development of PLRI was simple traumatic dislocation of the forearm bones (37.5%). Of the studies that assessed the elbow joint using the MEPS, 86.5% of patients had excellent or good results, with a mean MEBS score of 91 points. Before surgery, pain syndrome was present in 131 patients (87.3%) out of 150, and in the postoperative period it was observed in 55 (36.6%) out of 150 (p=0.01). The incidence of recurrent instability after surgery was observed in 6.6% of patients. A review of the literature on the problem of the elbow joint shows that this problem has not been fully studied, treatment strategies differ and should be performed based on the surgeon’s experience and available data, however, it has been proven that the key to the stability of the elbow joint is the LUCL, which requires its restoration through its refixation or plastic surgery.

Repair of a Reverse HAGL: A 2-Portal Technique

Background: Glenohumeral joint stability is reliant on a combination of static and dynamic constraints. Humeral avulsion of the posterior band of the inferior glenohumeral ligament (HAGL) is an exceedingly rare injury. These injuries can be difficult to diagnose and can lead to continued pain, dysfunction, and recurrent instability. There is a paucity of literature regarding surgical management of reverse HAGL lesions. Indications: Many intrasubstance reverse HAGL lesions can be managed nonoperatively with rehabilitation focused on improving shoulder stability. Although the incidence of recurrent instability in patients with reverse HAGL lesions is unknown, the acute detached humeral lesions in athletes are often treated surgically to restore normal shoulder. Technique Description: The patient was placed in a standard beach chair position, and the standard portals were made for a diagnostic shoulder arthroscopy. The anterior portal was the primary viewing portal. Using the initial posterior skin incision, instruments were introduced through the defect from the retracted posterior band of the inferior glenohumeral ligament. Using a combination of the 30° and 70° arthroscope, the HAGL was mobilized from the infraspinatus musculature. Two knotless suture devices (1.8-mm suture anchor, 2.6-mm suture anchor) were used to reduce the reverse HAGL lesion to an anatomical position, and the posterior capsule was closed thereafter. Results: Only case studies and a single case series have been published pertaining to reverse HAGL repair techniques and related outcomes. When diagnosed and treated appropriately, arthroscopic repairs yield promising results with a high percentage of patients returning to prior level of activity or returning to prior participation level in sport. However, outcome data are limited given the rare occurrence of this injury pattern. Discussion/Conclusion: Reverse HAGL pathology can be treated effectively with arthroscopic surgical repair to restore the normal capsular anatomy and prevent recurrent instability and persistent posterior shoulder pain. Using a 2-portal approach with posterior capsular closure is a minimally invasive operation that allows for appropriate management of these rare injuries. 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.

Criteria-based return-to-sport testing helps identify functional deficits in young athletes following posterior labral repair but may not reduce recurrence or increase return to play

The purpose of this study was to compare recurrent instability and return to play (RTP) in young athletes who underwent clearance to full activity based on a validated return-to-sport (RTS) test to those who underwent time-based clearance following primary posterior labral repair. This was a retrospective review of athletes with posterior shoulder instability who underwent primary arthroscopic posterior labral repair from 2012 to 2021 with minimum 1-year follow-up. Patients who underwent RTS testing at a minimum of 5 months postoperatively were compared to a historic control cohort of patients who underwent time-based clearance. There were 30 patients in the RTS cohort and 67 patients in the control cohort (mean follow-up 32.1 and 38.6 months, respectively). Of the 30 patients who underwent RTS testing, 11 passed without failing any sections, 10 passed while failing 1 section, and 9 failed the RTS test by failing 2+ sections. No differences were found between the RTS and control cohort in the incidence of recurrent instability (6.7% vs. 9.0%), overall RTP (94.7% vs. 94.3%), RTP at the same level as before injury (84.2% vs. 80.0%), recurrent pain/weakness (23.3% vs. 25.4%), or revision surgery (0% vs. 3.0%), respectively. While RTS testing in young athletes after posterior labral repair did not reduce recurrence or improve return to play compared to time-based clearance, two-thirds of athletes who underwent testing failed at least 1 section, indicating some functional deficit. Thus, RTS testing may help guide postoperative rehabilitation following posterior stabilization.

Paper 50: Isolated Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Regardless of Tibial Tubercle - Trochlear Groove Distance and Patellar Height: Minimum 5-Year Outcomes

Objectives:It remains unclear which subset of patients with recurrent patellofemoral instability would benefit from a concomitant bony realignment procedure in addition to a medial patellofemoral ligament (MPFL) reconstruction. The purpose of this study is to provide midterm results on previously reported patient reported outcomes (PRO), return to sport (RTS) and imaging measurements collected for patients who underwent an isolated MPFL reconstruction as part of an ongoing prospective trial. This includes minimum 5-year outcomes data on a cohort of 55 patients as well as 2-year outcomes data on an expanded cohort of 121 patients.Methods:Patients with recurrent patellar instability who did not meet exclusion criteria were prospectively enrolled in an institutional registry beginning in March 2014. Exclusion criteria included patients with a prior history of a patellar stabilization procedure, an off-loadable (inferior/lateral) Outerbridge Grade IV chondral defect, obligatory dislocators (patients who require patellar dislocation in order to achieve full knee extension) or patients with a “Jumping J” sign and patients who reported anterior knee pain as more than 50% of their chief complaint.All patients who were not excluded by the above criteria underwent primary, unilateral, isolated MPFL reconstruction regardless of their bony anatomy (tibial tubercle - trochlear groove (TT-TG), trochlear morphology, trochlear depth, or patellar height) for treatment of recurrent patellar instability. Patient data including PROs, episodes of recurrent instability or dislocation, and ability to return to sport (RTS) was obtained annually. Radiographic MRI measurements including TT-TG, Caton-Deschamps Index (CDI), Patellar Trochlear Index (PTI), Trochlear Depth Index (TDI), Patellar Tendon to Lateral Trochlear Ridge (PT-LTR) and Tibial Tubercle to Lateral Trochlear Ridge (TT-LTR) were obtained at baseline.Results:138 patients (72% female; mean age 20.1 ± 6.1 years) underwent isolated MPFL reconstruction between March 2014 and December 2019. 55 patients reached the ≥5-year postoperative time point, of which 40 (72%) completed follow-up PROs. 121 patients reached the ≥2-year postoperative time point, of which 89 (74%) completed follow-up PROs.99% (n=136) of patients at 2 years and 96% (n=132) of patients at ≥ 5 years had no self-reported post-operative patellofemoral instability: 6 patients (4%) reported recurrent instability at a mean of 3.0 ± 0.7 years postoperatively. Activities during which failure occurred included jumping on a trampoline, dancing, and playing lacrosse.Preoperatively, 100 (72%) patients participated in sports or physical activity, of which 87 reported return to sport (87%). All patients that returned to sport did so within 24 months postoperatively with a mean RTS of 9.3 months. KOOS-Qol, Pedi-Fabs, IKDC, KOOS-PS and Kujala PROS are reported in Table 1.The mean TT-TG was 15.1 ± 4.9 mm (1.90 to 27.2 mm), mean CDI was 1.14 ± 0.16 (0.72 to 1.65), mean PTI was 46.9 ± 15.1% (13 to 100%) and mean trochlear depth was 2.5 ± 1.2 mm (-1.55 to 5.15 mm). Trochlear dysplasia, defined as a TDI < 3 mm, was present in 77 (56%) of patients. The mean measure of extensor mechanism containment, TT-LTR, was -8.4 ± 5.7 mm (-24.0 to 3.20 mm) and the rate of TT-LTR within 1 mm, found to be predictive of recurrent instability, was 8% (n=11). The mean PT-LTR, a measurement of lateral patellar tracking, was 5.7 ± 6.2 mm (-5.70 to 21.1 mm).The six patients who experienced recurrent instability after an isolated MPFL reconstruction had a mean CDI of 1.19 and a mean TT-TG of 18.75. Individual imaging data for these six patients can be seen in Table 2.Conclusions:Midterm outcomes for patients who underwent isolated MPFL reconstruction (within strict exclusion criteria parameters) are shown to be favorable and maintained at 5 years. Additionally, the outcomes for the expanded cohort of patients with a minimum of 2-year follow up supports the previously published results. Most athletes were able to return to sport. Completion of this study enrollment with long term follow up will allow for more robust assessment of long-term outcomes and incidence of recurrent instability after isolated MPFL reconstruction. The ultimate goal of this work is the creation of a predictive model utilizing the bony and clinical characteristics of those patients who sustain recurrent instability in order to better predict who might benefit from additional bony realignment procedures at the time of their index procedure.Table 1.Patient Reported Outcomes at Baseline, 2 years and ≥ 5 yearsTable 2.Radiographic Measurements for Patients with Recurrent Patellar Instability after Isolated MPFL Reconstruction

The Incidence of Recurrent Instability After Medial Retinacular Repair, Quadriceps Tendon Femoral Ligament Reconstruction, and the Roux Goldthwait Patellar Tendon Transfer for Patellar Instability

Background:For skeletally immature patients with recurrent patellofemoral instability, numerous soft tissue procedures have been described to stabilize the patella while protecting the physis, with varied success rates and no clear superiority of a given procedure. Cases characterized by habitual instability or severe patellofemoral dysmorphology often warrant multiple simultaneous procedures to correct both proximal and distal malalignment.Hypothesis/Purpose:To determine the incidence of recurrent instability and post-operative complications in a series of patients treated with (1) quadriceps tendon femoral ligament reconstruction (QTFLR) and medial retinacular repair (MRR), or (2) QTFLR and Roux-Goldthwait patellar tendon transfer (RG) with or without MMR; and to compare these outcomes to those for isolated MRR.Methods:Eligible participants were retrospectively identified from surgeon records based on diagnosis of patellar instability, surgical treatment with MRR, QTFLR, RG, or a combination of these procedures, and minimum follow-up of 6 months. The medical records of included participants were reviewed to collect demographic data and document post-operative complications and recurrent instability. The presence of skeletal immaturity, patella alta, trochlear dysplasia, and elevated TT-TG were determined from radiographs and MRI. Statistical analysis included independent t-tests, rank sum procedure, and Chi-square analysis for univariate analysis, and stepwise binary logistic regression analysis to determine predictors of recurrent instability and complications.Results:Seventy patients (41 females, 29 males) were included with a mean age of 16.4 years and mean follow-up of 3.5 years. The QTFLR + MRR group (n=11) had 36.3% incidence of recurrent instability (dislocation in 3, subluxation in 1) and 9.1% incidence of complications. The QTFLR + RG ± MRR group (n=13) had 23.1% incidence of recurrent instability (no dislocations, subluxation in 3) and 7.7% incidence of complications. The isolated MRR group (n=46) had a 23.9% incidence of recurrent instability (dislocation in 7, subluxation in 4) and 15.2% incidence of complications. There was a significantly higher presence of trochlear dysplasia (p<0.001) and elevated TT-TG (p=0.004) in the combination procedure group compared to the isolated MRR group. Elevated TT-TG and skeletal immaturity were significantly associated with post-operative subluxation in the isolated MRR group. No other factors were predictive of recurrent instability or post-operative complications for any groups.Conclusion:The incidence of recurrent instability after combined soft tissue procedures for patellar instability ranged from 23-36%, similar to the incidence of recurrent instability of 24% for isolated MRR despite the combined procedure group having a higher presence of trochlear dysplasia and elevated TT-TG distance.

Chapter 6: Attritional Glenoid Bone Loss in the Shoulder: Operative Considerations.

Patients with recurrent anterior shoulder instability often have glenoid bone loss present in addition to soft tissue pathologies. It is known that patients with significant glenoid bone loss are best treated with a boney augmentation procedure as opposed to a soft tissue Bankart repair because of the high rate of recurrent instability that results from a Bankart repair. Although the Latarjet technique has been the gold-standard treatment for patients with glenoid bone loss because of the low incidence of recurrent instability, it has a high complication rate and a steep learning curve. Herein, the authors present the technique and outcomes for arthroscopic anatomic glenoid reconstruction that has a similar complication rate to the Bankart repair but with a low recurrence rate similar to the Latarjet. This procedure is safe, has a short learning curve, low recurrence rate, and positive patient-reported outcomes.

Recurrence of Patellar Instability in Adolescents Undergoing Surgery for Osteochondral Defects Without Concomitant Ligament Reconstruction

Background: First-time patellar dislocation with an associated chondral or osteochondral loose body is typically treated operatively to address the loose fragment. The incidence of recurrent instability in this patient population if the medial patellofemoral ligament (MPFL) is not reconstructed is unknown. Purpose: To determine the recurrent instability rate in patients undergoing surgery for patellar instability with chondral or osteochondral loose bodies, as well as to identify and stratify risk factors for recurrent instability. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective analysis of adolescent patients treated operatively for acute patellar dislocation with associated chondral or osteochondral loose bodies between 2010 and 2016 at a single pediatric level I trauma center with minimum 2-year follow-up. Potential demographic, injury-related, radiographic, and surgical risk factors were recorded. The primary outcome variable was recurrent subluxation and/or dislocation. Secondary outcome variables included need for additional procedures, Kujala score, Single Assessment Numerical Evaluation (SANE) score, and patient satisfaction. Results: Forty-one patients were included. In total, 61% experienced recurrent instability at a mean follow-up of 4.1 years and 39% required subsequent MPFL reconstruction. Tibial tubercle-trochlear groove (TT-TG) distance greater than 15 mm was a risk factor for recurrent instability (P = .03). Patients with TT-TG distance greater than 15 mm and greater than 20 mm had recurrent instability rates of 75% and 86%, respectively. MPFL repair did not reduce the rate of recurrent instability (P = .87). Recurrent instability was associated with significantly worse mean Kujala (93.9 vs 83.0; P = .01), SANE (88.9 vs 73.1; P = .01), and patient satisfaction scores (9.4 vs 7.3; P = .002). Conclusion: If the MPFL is not reconstructed during index loose body treatment, children have a 61% recurrent instability rate. Patients with TT-TG distance greater than 15 mm, and particularly greater than 20 mm, are at highest risk for recurrent instability.

Ligamentous integrity in Spinal Cord Injury without Radiographic Abnormality (SCIWORA): a case series

PURPOSE OF STUDY: Prolonged bracing following injury in patients with Spinal Cord Injury without Radiographic Abnormality (SCIWORA) remains controversial. Some authors claim that there is occult instability and a risk of recurrent injury whereas others propose that the spinal column will deform elastically, but will return to its baseline stability by elastic recoil. We aim to assess the presence of ligamentous injury on MRI and the incidence of recurrent instability following SCIWORA in order to determine the need for prolonged bracing. METHODS: A retrospective chart review was performed for a series of 12 patients with documented SCIWORA that presented to Red Cross Children's Hospital over the past 8 years. Details regarding mode of injury, age at presentation, neurological deficit at presentation, MRI findings and long-term prognosis were documented. RESULTS: There were nine males and three females. The median age was 4.35 years. All patients were victims of high energy motor vehicle accidents. In two patients there was disruption of the ligamentum flavum at the level of the injury. There were no episodes of recurrent instability or neurological compromise in those patients that had recovered. None of our patients had rigid bracing following the diagnosis of SCIWORA. CONCLUSION: Infrequently observed disruption of isolated stabilising structures in SCIWORA did not lead to early or delayed instability in our patients. We did not find evidence to support the practice of prolonged rigid bracing to prevent recurrence following SCIWORA. LEVEL OF EVIDENCE: Prognostic case study, level IV.

Arthroscopic Implant-Free Bone Grafting for Shoulder Instability With Glenoid Bone Loss

Background: Posttraumatic anteroinferior shoulder dislocations with concomitant glenoid bone loss show high recurrence rates. The open J-bone graft technique for implant-less anatomic restoration of bony glenoid structure has previously been described, whereas results of arthroscopic techniques are currently not available. Purpose: To evaluate clinical and radiological outcome after arthroscopic anatomic reconstruction of the glenoid for recurrent anteroinferior glenohumeral instability. Study Design: Case series; Level of evidence, 4. Methods: Fifteen shoulders of 14 patients with recurrent anteroinferior shoulder instability were prospectively followed after glenoid reconstruction with a modified arthroscopic, implant-free J-bone graft. Preoperatively, the instability severity index score was documented. Patients were followed for a minimum of 2 years using the Rowe score and the Constant score. Subjective outcome was assessed using a visual analog scale (VAS) for pain and the subjective shoulder value for sports (SSVS); satisfaction with procedure outcome was also rated. Range of motion was recorded. Incidence of recurrent instability, defined as dislocation, subluxation, or persistent apprehensiveness, was documented. Pre- and postoperative (1 day and 3, 12, and 24 months) computed tomographic images were used to evaluate glenoid bone loss, reconstruction of the glenoid, and graft remodeling. Results: All preoperative scores (Rowe score: 57.6 ± 14.4; Constant score: 70.9 ± 8.9; VAS: 4.4 ± 2.6; SSVS: 31.4% ± 19.5%) were significantly (P ≤ .02) improved at final follow-up (Rowe score: 98.6 ± 1.5; Constant score: 96.3 ± 3.9; VAS: 0.2 ± 0.6; SSVS: 95.6% ± 3.8%). The preoperative glenoid area (82.1% ± 4.5%) was significantly increased immediately after surgery to 99.2% ± 6.6% (P < .001). After a physiological remodeling process, the glenoid area remained significantly increased at the latest follow-up (89.5 ± 3.2%, P < .001). J-bone grafting successfully restored glenoid concavity by significantly increasing concavity extent and depth from preoperative (19.8 ± 2.1 and 0.9 ± 0.6 mm, respectively) to postoperative (24.0 ± 2.1 and 2.1 ± 0.8 mm, respectively) (P < .001). There were no recurrent instabilities. One traumatic graft fracture occurred during the follow-up period. Conclusion: The arthroscopic J-bone graft technique permits minimally invasive reconstruction of anteroinferior glenoid defects and provided excellent early clinical outcome without recurrent instability in posttraumatic shoulder dislocations. A physiological remodeling process leads to restoration of a more natural glenoid anatomy.

Primary Versus Revision Arthroscopic Reconstruction With Remplissage for Shoulder Instability With Moderate Bone Loss

This study aims to evaluate our outcomes of arthroscopic remplissage in this setting. A retrospective review was performed to identify patients who underwent arthroscopic remplissage of an engaging Hill-Sachs lesion along with anterior capsulolabral reconstruction for anterior glenohumeral instability with moderate glenohumeral bone loss at our institution. Thirty-five patients, with a minimum of 2years' follow-up, were identified. We assessed the American Shoulder and Elbow Surgeons score, incidence of recurrent instability, and postoperative Rowe instability score. Follow-up was available for 30 patients (31 shoulders). The mean age was 24.6years, with a mean follow-up period of 41months. Prior instability surgery had failed in 11 patients, and they underwent capsulolabral reconstruction and remplissage ("revision surgery"). The failure rate in revision cases (36%) was significantly higher than the failure rate in primary surgery cases (0%) (P= .01). Failure resulted from trauma in all 4 patients, and none required further surgery. The mean American Shoulder and Elbow Surgeons score for all patients improved from 50 preoperatively to 91 postoperatively (P < .001), with no significant postoperative difference between primary and revision patients (P= .13). The patients with clinical failure showed nonsignificant improvement from 41 preoperatively to 72 postoperatively (P= .08). The mean postoperative Rowe score for the entire cohort was 90. The Rowe score was significantly lower in the 4 cases of failure than in the 27 non-failure cases (51 v 96, P < .001). In our experience, aggressive capsulolabral reconstruction with remplissage in traumatic instability patients with moderate bone loss and engaging humeral Hill-Sachs lesions yields acceptable outcomes for primary instability surgery. However, a significantly higher failure rate occurred when arthroscopic reconstruction with remplissage was performed in the revision setting. Level IV, therapeutic case series.

Arthroscopic Reconstruction in Patients with Shoulder Instability and Moderate Bone Loss (SS-02)

Reconstruction in patients with instability with moderate bone loss has been shown to have a much higher failure rate than standard Bankart repair. It has been postulated that the addition of an arthroscopic infraspinatus tenodesis with posterior capsulodesis (“remplissage”) may improve the success rate of arthroscopic reconstruction in these higher risk patients. We report our results with this technique in this patient population. A retrospective review was performed to identify patients who underwent arthroscopic remplissage in conjunction with anterior capsulolabral reconstruction for anterior glenohumeral instability with moderate glenoid bone loss (greater than 10% but less than 40%) at our institution. Thirty-six shoulders in 35 patients with minimum 2 years follow-up were identified. The following data was reviewed: American Shoulder and Elbow Surgeons (ASES) score, physical exam, incidence of recurrent instability, patient satisfaction level and return to sport. Follow up was available for 31 patients (32 shoulders). Mean age at the time of surgery was 23.8 years (range 15-44), with a mean follow-up of 35 months (range 24-60). The mean pre-operative ASES score was 61. Eleven patients (34%) had failed prior instability surgery and underwent capsulolabral reconstruction and remplissage in the context of revision surgery. Twenty-eight of the 31 patients (29 shoulders) were satisfied with their results. The mean post-operative ASES score was 95. Two failures (6.3%) occurred (zero dislocations, two patients with subluxation). There were no limitations in range of motion as compared to the opposite shoulder. Selective biodex testing of the infraspinatus showed no significant deficit in external rotation strength. Although no failures occurred in the eleven patients who underwent reconstruction with remplissage in a revision setting, two of these patients had persistent pain in the operative shoulder without instability symptoms. Aggressive capsulolabral reconstruction with posterior infraspinatus tenodesis in traumatic instability patients with moderate glenoid bone loss and a large Hill-Sachs lesion yields acceptable outcomes. There was no difference in outcome between primary and revision surgery in this case series.

Shoulder instability surgery in Norway

Background and purpose In January 2008, we established the Norwegian Register for Shoulder Instability Surgery. We report on the establishment, the baseline data, and the results at 1-year follow-up.Methods Primary and revision shoulder stabilization is reported by the surgeon on a 1-page paper form containing the patient's history of shoulder injury, clinical findings, and perioperative findings. The WOSI questionnaire for self-assessment of shoulder function is completed at baseline and at follow-up after 1, 2, and 5 years. To evaluate the completeness of registration, we compared our data with those in the Norwegian Patient Registry (NPR).Results The NPR reported 39 hospitals performing shoulder stabilizations. 20 of these started to report to our register during 2009, and 464 procedures (404 primary, 59 revisions) were included up to December 31, 2009, which represented 54% of the procedures reported to NPR. Of the 404 primary procedures, 83% were operations due to anterior instability, 10% were operations due to posterior instability, and 7% were operations due to multidirectional instability. Arthroscopic soft tissue techniques were used in 88% of the patients treated for primary anterior instability and open coracoid transfer was used in 10% of such patients. At 1-year follow-up of 213 patients, we found a statistically significantly improved WOSI score in all types of instability. 10% of the patients treated with arthroscopic anterior labral repair and 16% treated with arthroscopic posterior labral repair reported recurrent instability. No statistically significant difference in functional improvement or rate of recurrence was found between these groups.Interpretation The functional results are in accordance with those in previous studies. However, the incidence of recurrent instability 1 year after arthroscopic labral repair is higher than expected.

Arthroscopic Stabilization of the Shoulder: A Prospective Randomized Study of Absorbable Versus Nonabsorbable Suture Anchors

The aim of this study was to evaluate, prospectively, outcomes following arthroscopic Bankart repair performed with 2 types of suture anchor--the G II (DePuy Mitek, Raynham, MA) nonabsorbable anchor and the Panalok (DePuy Mitek) absorbable anchor. Patients with a diagnosis of recurrent traumatic anterior instability of the shoulder who were seen in a single unit between April of 2000 and June of 2003 were considered for inclusion in the study. Patients were assessed preoperatively and postoperatively by means of a subjective, patient-related outcome measurement tool (Oxford Instability Score), a visual analogue scale for pain and instability (VAS Pain and VAS Instability), and a quality-of-life questionnaire (Short Form-12 [SF-12]). Length of follow-up was 1.5 to 5 years (mean, 2.6 y). The incidence of recurrent instability and the level of sporting ability were recorded. Patients were randomized to undergo surgical repair with nonabsorbable or absorbable anchors. A total of 130 patients were included in this study, of whom 6 were lost to follow-up; therefore 124 patients (95%) completed the study. Both types of anchor were highly effective. No differences in rate of recurrence or in any of the scores were noted between the 2 groups. In all, 4 patients in the nonabsorbable group and 3 in the absorbable group experienced additional episodes of dislocation after a traumatic event. Rate of redislocation in the whole series was therefore 6%. In addition, 4 patients, all of them from the absorbable group (4%), described ongoing symptoms of instability but no true dislocations. In all, 85% of the patient group have returned to their previous level of sporting activity. No differences in outcomes of arthroscopic Bankart repair were seen whether absorbable or nonabsorbable anchors were used. Both are highly effective, with a redislocation rate of 6%. Level I, therapeutic randomized controlled trial.

Glenohumeral instability

Glenohumeral instability is an important cause of shoulder pain and disability in an active population. An awareness of the prevalence of recurrent instability, either in the form of dislocation or subluxation, is particularly useful in the assessment of the young athlete presenting with shoulder pain. Young adults presenting with rotator cuff tendinitis may have an underlying instability as the primary cause of their problem. A careful clinical examination should determine whether the instability is voluntary or involuntary, of traumatic or atraumatic onset, and the primary direction of the instability, as these factors have important implications with regard to treatment. Anterior glenohumeral instability is most common and the incidence of recurrent instability following on from an initial dislocation is high in the young active patient. An intensive rehabilitation programme is indicated for all initial dislocations or subluxations but surgery may become necessary after failure of conservative treatment. Care must be taken to determine accurately those patients with voluntary or multi-directional instability and a longer trial of conservative treatment is indicated here, as results of operative treatment in those cases are less favourable. Conservative treatment should be directed at strengthening the dynamic stabilizers of the shoulder joint, notably the rotator cuff muscles. Additional X-ray views are needed to demonstrate all the radiological changes associated with recurrent instability and further evaluation with examination under anaesthesia and arthroscopy is beneficial in the assessment of these patients. Arthroscopic surgery also has a role in the treatment of patients with symptomatic labral pathology and is now being used to perform stabilization procedures in selected cases. Many operative procedures have been described for stabilization of the shoulder and these should be directed at correcting the pathology present. Restoration of the patient's flexibility and strength postoperatively is essential, especially in the athlete in order to allow a full return to sporting activity.