Management Of Anterior Shoulder Instability Research Articles

Arthroscopic Management of Anterior Shoulder Instability: A Study of Functional Outcome and Analysis.

Background The remarkable range of motion of the shoulder comes at the cost of increased instability, especially anterior instability. Arthroscopic Bankart repairwith or without remplissage, which is a minimally invasive surgery, is the preferred treatment for recurrent anterior instability. This study investigated the effectiveness of Bankart repair, with or without remplissage, in restoring function, preventing redislocation, and improving patient satisfaction. Methods A prospective observational study examined 40 patients (19-50years old) with recurrent anterior instability and MRI-confirmed Bankart or Bankartwith Hill-Sachs lesions. Patients underwent arthroscopic Bankart repair with or without remplissage based on the inclusioncriteria of this study. Preoperative assessments included demographics, history, physical examination, American Shoulder and Elbow Surgeons (ASES) score, Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score, ROWE score,and plain MRIof the shoulder joint. Post-operative radiographs and rehabilitation were advised. Functional recovery was evaluated at three months and six months after surgery. Results All patients underwent Bankart repair. Among them, 22 with engaging Hill-Sachs lesions received an additional remplissage procedure. Both groups showed significant improvements in their functional scores (p<0.05) and returned to their prior activities. However, the additional remplissage group had a slightly reduced meanexternal rotation (86.59°) compared with the Bankart repair-onlygroup (90°). Notably, the recurrence rate was very low, with only one patient (2.5%) experiencing instability. Conclusion Our study emphasizes the importance of propercapsulolabraltissue elevationto achieve a sufficient labral bump during Bankart repair. This technique allowed us to efficiently use only two suture anchors in 35 cases (87.5%). Additionally, remplissage was performed on all identified engaging Hill-Sachs lesions. We found that proper anchor placement and suturing techniques were crucial for successful Bankart repair.The emphasis on the potential cost benefits of a two-anchor approach is a valuable contribution to the field.

Distal Tibial Allograft for the Treatment of Anterior Shoulder Instability With Glenoid Bone Loss: A Systematic Review and Meta-analysis.

The use of a distal tibial allograft (DTA) for reconstruction of a glenoid defect in anterior shoulder instability has grown significantly over the past decade. However, few large-scale clinical studies have investigated the clinical and radiographic outcomes of the DTA procedure. To conduct a systematic review and meta-analysis of clinical studies with data on outcomes and complications in patients who underwent the DTA procedure for recurrent anterior shoulder instability with glenoid bone loss. Systematic review and meta-analysis; Level of evidence, 4. A comprehensive search of major bibliographic databases was conducted for articles pertaining to the use of a DTA for the management of anterior shoulder instability with associated glenoid bone loss. Postoperative complications and outcomes were extracted and compiled in a meta-analysis. Of the 8 included studies with 329 total participants, the mean patient age was 28.1 ± 10.8 years, 192 (83.8%) patients were male, and the mean follow-up was 38.4 ± 20.5 months. The overall complication rate was 7.1%, with hardware complications (3.8%) being the most common. Partial graft resorption was observed in 36.5% of the participants. Recurrent subluxation was reported in 1.2% of the participants, and recurrent dislocation prompting a reoperation was noted in 0.3% of the participants. There were significant improvements in clinical outcomes, including American Shoulder and Elbow Surgeons score (40.9-point increase; P < .01), Single Assessment Numeric Evaluation (47.2-point increase; P < .01), Western Ontario Shoulder Instability Index (49.4-point decrease; P < .01), Disabilities of the Arm, Shoulder and Hand (20.0-point decrease; P = .03), and visual analog scale (2.1-point decrease; P = .05). Additionally, postoperative shoulder range of motion significantly increased from baseline values. The DTA procedure was associated with a low complication rate, good clinical outcomes, and improved range of motion among patients with anterior shoulder instability and associated glenoid defects.

Return to play following operative management of anterior shoulder instability in overhead athletes-A systematic review.

The purpose of this study was to systematically review the rate and timing of return to play in overhead athletes following operative management of anterior shoulder instability. A systematic literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to play among overhead athletes following arthroscopic Bankart repair, open Latarjet procedure or Remplissage procedure. There are 23 studies included with 961 patients. Among those undergoing arthroscopic Bankart repair, the rate of return to play was 86.2%, with 70.6% returning to the same level of play and the mean time to return to play was 7.1 months. Among those undergoing an open Latarjet procedure, the rate of return to play was 80.9%, with 77.7% returning to the same level of play and the mean time to return to play was 5.1 months. Among those undergoing a Remplissage procedure, the rate of return to play was 70.6%, with 70.0% returning to the same level of play or mean time to return to play. Overall, there were high rates of return to play following operative management of anterior shoulder instability in overhead athletes.

Transglenoid Fixation Technique for Arthroscopic Subscapularis Augmentation Using an Adjustable-Length Loop Cortical Suspensory Fixation Device

The optimal surgical management of anterior shoulder instability remains controversial. Although it has low recurrence rates and good clinical results, the Latarjet procedure has some disadvantages and is considered “overtreatment” in inactive patients with moderate glenoid bone loss. Several studies have described an arthroscopic technique called arthroscopic subscapularis augmentation. We developed a technical variation of the arthroscopic subscapularis augmentation technique involving tenodesis of the upper third of the subscapularis tendon using a graft. This technique uses a transglenoid fixation—immobilization with 2 knotless TightRope devices instead of anchors.

Recurrent Anterior Shoulder Instability Treated Using the Arthroscopic Bankart-Latarjet Technique: Experience of a Peripheral Hospital.

The arthroscopic Bankart-Latarjet procedure is used in the surgical management of anterior shoulder instability. This technique is mainly performed in referral centers due to its high technicity. This study aimed to evaluate surgical outcomes in a peripheral hospital center. This is a retrospective study of patients treated for recurrent anterior shoulder instability. The clinical scores (Walch-Duplay, Rowe, and Western Ontario Shoulder Instability Index (WOSI)) were assessed preoperatively and at 12 months after surgery. The consolidation and the position of the bone block were evaluated at 6 months using a CT scan. Between 2016 and 2020, 40 patients had been operated on (mean age: 28.5 ± 7.9 years). During a mean follow-up of 29.5 ± 11.6 months, we noted only one complication, a case of fracture of the callus of a consolidated bone block. No recurrence of instability was recorded. The Walch-Duplay score increased from 17.8 to 94.6, the Rowe score from 24.9 to 96.8, and the WOSI score decreased from 52.1% to 6.9%. The bone block was consolidated in 35 patients (87.5%), and a flush position with the anterior edge of the glenoid was noted for all patients. At one year, 67.0% of the patients practicing sport had returned to sports. The arthroscopic Bankart-Latarjet technique was a reliable procedure in the hands of an experienced shoulder surgeon, even in a peripheral hospital center.

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

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

Arthroscopic Bankart Repair With Remplissage as an Alternative to Latarjet for Anterior Glenohumeral Instability With More Than 15% Glenoid Bone Loss.

Surgical management of anterior shoulder instability continues to evolve. The clinical effectiveness of arthroscopic Bankart repair with remplissage (REMP) in patients with increasing glenoid bone loss (GBL) has not been thoroughly compared with Latarjet. The purpose of this study was to compare 2-year outcomes of REMP versus open Latarjet in patients with >15% GBL. We hypothesized that there would be no difference. Cohort study; Level of evidence, 3. A multicenter, retrospective study was performed on a consecutive series of patients who underwent primary REMP or Latarjet by 4 shoulder specialists between August 2013 and December 2019 for >15% GBL. Procedure performance was based on shared decision making between the surgeon and patient. Baseline and 2-year postoperative range of motion (ROM) and the following patient-reported outcomes (PROs) were collected: Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation, and visual analog scale for pain. Return to sport, satisfaction, complications, recurrence, and revisions were reviewed. A total of 47 patients were available for study, including 22 who underwent REMP and 25 who underwent Latarjet. Baseline demographic characteristics, ROM, and PROs were similar between the groups. Mean preoperative GBL (REMP 25.8% ± 7.8% vs Latarjet 25.1% ± 9.0%; P = .800) and off-track lesions (REMP 59.1% vs Latarjet 44.0%; P = .302) were similar. Postoperative change in external rotation favored Latarjet (10° ± 22° vs -4° ± 13°; P = .017). Postoperative PROs, return to the sports (86.4% vs 87.5%; P = .99), and satisfaction (95.5% vs 95.8%; P = .99) were similar between groups. There were no recurrent dislocations in either group. One infected hematoma was encountered in the Latarjet cohort. At short-term follow-up, the hypothesis was upheld. REMP and Latarjet provided similar outcomes for patients with >15% GBL, although REMP patients experienced slightly decreased external rotation. Although larger series and longer-term follow-ups are required, remplissage may be considered in patients with >15% glenoid bone loss.

Poster 156: Investigating Disparity in Follow-Up Rates of Non-Operative Treatment for Anterior Shoulder Instability

Objectives:Racial and ethnic disparities have been documented in numerous aspects of musculoskeletal care. Specifically, the Multicenter Orthopedic Outcomes Network (MOON) Shoulder Instability Group found that amongst patients undergoing surgery for anterior shoulder instability, minorities had a higher frequency of articular cartilage lesions, and increased frequencies of both glenoid bone loss >10% and Hill-Sachs lesions at the time of surgery. Loss to follow-up and failure to comply with initial non-operative management may play a role in the increased disease burden in this group. This study sought to investigate patient demographics associated with poor follow-up after initiation of nonoperative management regimens for anterior shoulder instability. We hypothesized that significant disparities would be observed with nonoperative follow-up rates. More specifically, we predicted that minority patients and those with state or federal dependent insurances such as Medicaid or Medicare will have lower rates of follow-up.Methods:After obtaining IRB approval, demographics and ambulatory care appointment data for new patient visits and subsequent follow-up encounters associated with a diagnosis of “shoulder instability” or/and “labral tear” were extracted from our electronic medical records from 01/01/2010 to 01/31/2020. National Institute of Health (NIH) guidelines were followed for race, ethnicity, and insurance type categorizations. With the standard of care for non-operative management of anterior shoulder instability ranging from 6-12 weeks of physical therapy, the optimal time window for follow-up used for analysis was defined as 4-12 weeks after the initial visit. Chi-squared tests, pairwise comparisons for multiple variables of interest, and parametric between-group comparison and analyses were performed.Results:A total of 10,854 patient visits were identified. After excluding patients that underwent surgical intervention, a total of 2,679 unique patients and their subsequent encounters were analyzed. These patients had a mean age of 31.4 ± 13.6 years, 77.9% were male and 43.9% were white (Table 1). Of these patients, 1,217 (45.4%) followed up at any point and 420 (34.5%) of this subset of patients followed up within 4-12 weeks of their first visit. There was no significant difference between the overall rates of follow up of white versus minority patients (50.6% versus 49.0%, p = 0.64), nor in the rates of follow up within the optimal time window (16.6% versus 16.9%, p = 0.85) (Table 2). There was no significant difference between rates of follow-up at any point based on insurance types (commercial/ managed care, Medicaid, Medicare, self-pay, and workers compensation) (p = 0.084). However, there was a significant difference between rates of optimally timed follow-up based upon insurance type (p = 0.002) (Table 3). 23.2% of patients with Medicare or Medicaid followed up within 4-12 weeks, as compared to 17.2% of patients who paid out-of-pocket and 14.5% of patients with commercial/ managed care insurance.Conclusions:There were no significant racial disparities seen between white and minority patients in regard to the rates of non-operative follow up for anterior shoulder instability in this study. Furthermore, patients with governmental insurance plans successfully followed up within the optimal 4-12 week time period at a higher rate when compared to patients with commercial or self-pay insurance. These findings suggest that a large, urban academic tertiary care center, can successfully employ strategies to retain patients of different minority status and insurance type for follow-up. The presence of satellite clinics minimizing the distance burden of access to care, use of interpreters to bridge language gaps, and systemic implementation of comprehensive discharge instructions used at our institution may be contributing factors to the findings of the investigation. This study may be enhanced by a multicenter investigation in the future in various geographic locations with a diverse patient population and payer mix. The investigation is limited by the large overall number of patients (54.6%) who never followed up. Further investigations are needed to determine what factors may have influenced these patients to not seek follow-up within our institution. In conclusion, this study found that a single tertiary care system equitably retains patients for follow-up for treatment of their anterior shoulder instability. Further work is needed to better understand if this equitable follow-up results in similar outcomes in different patient populations at our institution, and if disparities in follow-up quantity, quality, and timing are associated with the increased burden of disease for minorities with anterior shoulder instability seen at other institutions in previous studies.Table 1.Patient Demographics (2,679 patients)Table 2.Analysis of Follow-Up within 4-12 Week Window Stratified by Racial Groups Table 3.Analysis of Follow-Up within 4-12 Week Window Stratified by Insurance Type

Poster 170: Preoperative Advanced Imaging Predicts Coracoid Graft Size and Restoration of the Glenoid Track in Patients Undergoing Latarjet Procedures

Objectives:The Latarjet procedure is commonly used in management of anterior shoulder instability with bipolar bone deficiency. Persistent off-track Hill-Sachs (HS) lesions after Latarjet procedure is associated with significantly higher rates of failure and recurrent instability. Preoperative prediction of which lesions will remain off-track is crucial for improving outcomes and decreasing failure rates. The purpose of this study was to determine if preoperative advanced imaging can predict coracoid graft size and conversion of off-track to on-track Hill-Sachs lesions in patients undergoing Latarjet procedures.Methods:Patients who underwent Latarjet procedure for shoulder instability at a single institution from 2012-2020 were evaluated. Inclusion criteria consisted of pre- and post-operative advanced imaging - computerized topography or magnetic resonance imaging. Glenoid diameter, HS interval (HSI), and coracoid length, depth, and height were measured on preoperative imaging. Glenoid track (GT), percent glenoid bone loss, predicted restoration of glenoid track, and the difference between HSI and GT (DHSI-GT) were calculated. These values were then compared with postoperative measurements of the glenoid diameter and coracoid graft width and height.Results:Seventeen patients with a mean age of 24.6 ± 8.6 years met inclusion criteria. The average glenoid bone loss preoperatively was 23.6 ± 7.3% and the average HSI was 27.2 ± 4.9mm. The Latarjet procedure was able to reconstruct 115.8 ± 7.6% of the native glenoid, and 103.8 ± 7.9% of the predicted diameter. Of the 15 patients that had off-track lesions preoperatively, 11 were successfully converted to on-track lesions (73.3%). The 4 lesions that remained off-track postoperatively had a significantly higher HSI (32.4 ± 2.4 mm vs. 25.6 ± 4.3 mm, p=0.002) and 3 of these had insufficient coracoid graft to convert to an on-track lesion based on the preoperative DHSI-GT values in comparison to coracoid graft size. Preoperative measurements accurately predicted postoperative glenoid track status 94.1% of cases.Conclusions:The Latarjet procedure was able to reconstruct 115.8 ± 7.6% of the native glenoid and converted 73.3% of off-track lesions to on-track lesions. The glenoid was reconstructed to 103.8 ± 7.9% of the predicted diameter. Preoperative advanced imaging measurements accurately predicted graft size, restoration of the glenoid track, and ability to convert off-track to on-track lesions.

The Fragility Index of Statistically Significant Findings From Randomized Controlled Trials Comparing the Management Strategies of Anterior Shoulder Instability

Background: Debate centering on the management of anterior shoulder instability (ASI) in recent years has led to many randomized controlled trials (RCTs) being published on the topic. The fragility index (FI) has subsequently emerged as a novel method of assessing significant findings reported in RCTs, particularly those with small sample sizes. Purpose: To evaluate the FI of statistically significant findings in RCTs that reported the outcomes of management strategies of patients with ASI. Study Design: Systematic review; Level of evidence, 1. Methods: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent reviewers performed a systematic review of RCTs focusing on the outcomes of management strategies of patients with ASI. There were 3 main categories of RCTs included: (1) nonoperative management in internal rotation (IR) versus external rotation (ER), (2) nonoperative management versus a surgical intervention, and (3) surgical management with arthroscopic Bankart repair versus open Bankart repair. The Fisher exact test was utilized to calculate the FI for the reversal of statistical significance in all statistically significant dichotomous outcomes. Results: A total of 21 RCTs were included, including 1589 shoulders (mean age, 29.4 years) with a mean follow–up of 26.8 months. There were 10 RCTs (831 shoulders) that reported outcomes after the nonoperative management of ASI in IR versus ER, with a mean FI of 6.8. There were 5 RCTs (324 shoulders) that reported outcomes comparing the nonoperative and operative management of ASI, with a mean FI of 3.5. There were 6 RCTs (434 shoulders) that reported outcomes after the operative management of ASI with either arthroscopic Bankart repair or open Bankart repair, with a mean FI of 9.6. Conclusion: The overall FI of RCTs reporting the outcomes of management strategies for patients with ASI was high, suggesting a moderate fragility of statistically significant outcomes including recurrence, revision stabilization, and return to play.

Nonoperative management of anterior shoulder instability can result in high rates of recurrent instability and pain at long-term follow-up.

Data on the long-term outcomes of nonoperative treatment of anterior shoulder instability are lacking, particularly for the US population. The purpose was to (1) describe the characteristics of patients with anterior shoulder instability treated nonoperatively, (2) assess the long-term outcomes of nonoperative management in a US population, and (3) identify risk factors for poor outcomes following nonoperative management. A geographic cohort of >500,000 subjects was used to identify patients treated nonoperatively for anterior shoulder instability. Only patients aged <40 years at the time of initial instability with minimum 10-year follow-up were included. Medical records were reviewed to obtain demographic characteristics, physical examination findings, clinical history data, imaging results, treatment details, and clinical and/or radiographic progression. Recurrent pain, recurrent instability, and the development of symptomatic osteoarthritis (OA) were the primary outcomes evaluated. The study included 254 patients (73% male) with a median age of 19 years (range, 16-26 years) at the time of initial instability. At median 17-year follow-up, 37.5% experienced recurrent instability, 58.4% had recurrent pain, and 12.2% had symptomatic OA development. Factors associated with recurrent pain at final follow-up were multiple instability events prior to presentation (hazard ratio [HR], 2.43; P < .01) and increased pain at the initial visit (HRs of 0.79 for mild, 1.74 for moderate, and 1.39 for severe; P < .01); patients with multiple instability events prior to presentation also had an increased risk of recurrence (P < .01). Factors increasing the risk of the development of symptomatic OA included increased pain at the initial visit (P = .05), seizure disorder (HR, 27.01; P< .01), and smoking (HR, 5.15; P < .01). At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability. Overall, 37.5% of patients experienced recurrent shoulder instability, 58.4% had recurrent shoulder pain, and 12.2% had symptomatic OA development. Risk factors associated with adverse clinical outcomes included increased pain at the initial visit, recurrent instability prior to presentation, seizure disorder, and smoking.

Understanding Anterior Shoulder Instability Through Machine Learning: New Models That Predict Recurrence, Progression to Surgery, and Development of Arthritis.

Background:Management of anterior shoulder instability (ASI) aims to reduce risk of future recurrence and prevent complications via nonoperative and surgical management. Machine learning may be able to reliably provide predictions to improve decision making for this condition.Purpose:To develop and internally validate a machine-learning model to predict the following outcomes after ASI: (1) recurrent instability, (2) progression to surgery, and (3) the development of symptomatic osteoarthritis (OA) over long-term follow-up.Study Design:Cohort study (prognosis); Level of evidence, 2.Methods:An established geographic database of >500,000 patients was used to identify 654 patients aged <40 years with an initial diagnosis of ASI between 1994 and 2016; the mean follow-up was 11.1 years. Medical records were reviewed to obtain patient information, and models were generated to predict the outcomes of interest. Five candidate algorithms were trained in the development of each of the models, as well as an additional ensemble of the algorithms. Performance of the algorithms was assessed using discrimination, calibration, and decision curve analysis.Results:Of the 654 included patients, 443 (67.7%) experienced multiple instability events, 228 (34.9%) underwent surgery, and 39 (5.9%) developed symptomatic OA. The ensemble gradient-boosted machines achieved the best performances based on discrimination (via area under the receiver operating characteristic curve [AUC]: AUCrecurrence = 0.86), AUCsurgery = 0.76, AUCOA = 0.78), calibration, decision curve analysis, and Brier score (Brierrecurrence = 0.138, Briersurgery = 0.185, BrierOA = 0.05). For demonstration purposes, models were integrated into a single web-based open-access application able to provide predictions and explanations for practitioners and researchers.Conclusion:After identification of key features, including time from initial instability, age at initial instability, sports involvement, and radiographic findings, machine-learning models were developed that effectively and reliably predicted recurrent instability, progression to surgery, and the development of OA in patients with ASI. After careful external validation, these models can be incorporated into open-access digital applications to inform patients, clinicians, and researchers regarding quantifiable risks of relevant outcomes in the clinic.

Arthroscopic Bankart repair for first time versus recurrent anterior shoulder instability in athletes- comparative Study

Background: Following an initial traumatic anterior shoulder dislocation, the incidence of recurrent instability ranges from 14% to 100%. The risk of recurrent dislocations is influenced by the age at the time of initial dislocation. The aim of the present study was to evaluate the results of arthroscopic bankart repair of acute anterior shoulder dislocation for first time in athletes and comparison the results with delayed arthroscopic bankart repair Patient and methods: The present study included 40 patients complaining of anterior shoulder dislocation, 20 patients of them were with first time anterior shoulder dislocation and 20 patients with recurrent dislocation. All patients underwent Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability. The constant shoulder score was used for assess the outcomes Results: There was statistically significant difference between pre and post-operative outcome in first time dislocation patients. There was statistically significant difference between pre and post-operative outcome in recurrent dislocation patients. There was no statistically significant difference according to post-operative outcomes between in first time and recurrent dislocation patients. Conclusion: there were no differences in outcomes and constant shoulder score among patients undergoing surgery after the primary dislocation when compared with those undergoing surgery after recurrent shoulder dislocation.

Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long-term results

IntroductionArthroscopic stabilisation is a well-recognised surgical technique with a variable rate of failure reported between 0–35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate. Material and methods41 patients that underwent arthroscopic shoulder stabilisation for glenohumeral instability between 2001–2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognised in order to assess possible risk factors. ResultsThe overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent/good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery. ConclusionThe arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favourable outcome, with a redislocation rate of 9% and low complication rate.

Arthroscopic Distal Clavicle Glenoid Augmentation: Rationale and Surgical Technique

Glenoid bone loss remains an important determinant of outcome in the surgical management of anterior shoulder instability. Multiple options are available to address this bone loss including autograft bone transfers, such as coracoid or iliac crest grafts. Allograft options include both bone and osteochondral options, such as the distal tibial allograft. Each of these choices has potential advantages and disadvantages. An ideal approach would provide an autograft source of osteochondral material that is well-matched to the defect, readily available, cost effective, and with minimal morbidity. In this article, we present the distal clavicle autograft as an ideal option for consideration in the treatment of glenoid bone loss. The graft has a cortical and cancellous side for direct fixation and is amenable to arthroscopic techniques using standard portals and obviating the need to go near the neurovascular structures of the shoulder. Recent work has demonstrated the utility of this graft in providing an anatomic restoration of the glenoid articular surface with a cartilage cap comparable in thickness to that of the native glenoid. Along with a summary of the pertinent literature, this article outlines the rationale, indications, and technical evolution for this procedure.

Arthroscopic evaluation and management of anterior shoulder instability

Arthroscopic evaluation and management of anterior shoulder instability - IJOS- Print ISSN No: - 2395-1354 Online ISSN No:- 2395-1362 Article DOI No:- 10.18231/j.ijos.2020.050, Indian Journal of Orthopaedics Surgery-Indian J Orthop Surg

Arthroscopic Acute Bony Bankart Repair in Lateral Decubitus

The optimal management of anterior shoulder instability continues to be a challenge. The presence of an anterior glenoid rim fracture in the context of a glenohumeral dislocation, also called “bony Bankart lesion,” can alter therapeutic behavior. Reduction and fixation of the bone fragment has been shown to greatly reduce the risk of recurrence once bone consolidation is achieved. However, there is no gold standard surgical technique. Stability of fixation and the healing of the bony fragment are still a concern, and there are no clinical studies comparing the different techniques to date. The aim of this report is to describe an arthroscopic double-point fragment fixation technique in lateral decubitus for the treatment of an acute traumatic shoulder dislocation with a bony Bankart lesion.

In-Season Management of Anterior Shoulder Instability.

Anterior shoulder instability commonly occurs in young and active individuals, particularly those participating in contact or collision sports. At the intercollegiate level, rates of anterior instability have been reported to be 0.12 events per 1000 athlete exposures. The treatment of in-season athletes with anterior instability presents a challenge for the team physician. The desire to return to play within the same season with nonoperative management must be weighed against the increased risk of recurrence as well as athlete and team specific demands. The purpose of this chapter is to discuss the key considerations for the management of the athlete with anterior shoulder instability that occurs within the competitive season.

Maximal Medical Improvement Following Shoulder Stabilization Surgery May Require up to 1Year: A Systematic Review.

There is increased emphasis on properly allocating healthcare resources to optimize value within orthopedic surgery. Establishing time to maximal medical improvement (MMI) can inform clinical decision-making and practice guidelines. We sought (1) to evaluate the time to MMI as predicted by commonly used patient-reported outcome measures (PROMs) for evaluation of shoulder stabilization and (2) to evaluate typical time to return to sports and employment following surgery. A systematic review of the Medline database was conducted to identify outcome studies reporting sequential follow-up at multiple time points, up to a minimum of 2years after shoulder stabilization surgery. The included studies examined the outcomes of arthroscopic or open surgical techniques on anterior instability. Clinically significant improvements were evaluated utilizing the minimal clinically important difference specific to each PROM. Secondary outcomes included range of motion, return to sport/work, and recurrent instability. Ten studies comprising 590 surgically managed cases of anterior shoulder instability were included (78% arthroscopic, 22% open). Clinically significant improvements in PROMs were achieved up to 1year post-operatively for Rowe, Western Ontario Instability Index (WOSI), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) scores. For the three most utilized tools (Rowe, WOSI, ASES), the majority of improvement occurred in the first 6 post-operative months. Clinically significant improvements in Constant Score and Oxford Shoulder Instability Score (OSIS) were achieved up to 6months and 2years after surgery, respectively. No clinically significant improvements were achieved on the Disabilities of the Arm, Shoulder, and Hand (DASH) tool. Maximal medical improvement as determined by commonly utilized PROMs occurs by 1year after operative management of anterior shoulder instability. The DASH tool does not appear to demonstrate a reliable time frame for clinically significant outcome improvement.

Outcomes are comparable using free bone block autografts versus allografts for the management of anterior shoulder instability with glenoid bone loss: a systematic review and meta-analysis of "The Non-Latarjet".

Glenoid augmentation using free bone blocks for anterior shoulder instability has been proposed as an alternative to or bail-out for the Latarjet procedure. The purpose of this investigation was to systematically review and compare outcomes of patients undergoing glenoid augmentation using free bone block autografts versus allografts. A systematic review using PubMed, MEDLINE, Embase, and the Cochrane Library databases was performed in line with the PRISMA statement. Studies reporting outcomes of patients treated with free bone block procedures for anterior shoulder instability with minimum 2-year follow-up were included. Random effects modelling was used to compare patient-reported outcomes, return to sports, recurrent instability, non-instability related complications, and development of arthritis between free bone block autografts and allografts. Eighteen studies comprising of 623 patients met the inclusion criteria for this investigation. There were six studies reporting on the use of allografts (of these, two used distal tibial, three iliac crest, and one femoral head allograft) in 173 patients and twelve studies utilizing autografts (of these, ten used iliac crest and two used free coracoid autograft) in 450 patients. Mean age was 28.7 ± 4.1years for the allograft group and 27.8 ± 3.8years for the autograft group (n.s). Mean follow-up was 98months in autograft studies and 50.8months for allograft studies (range 24-444months, n.s). Overall mean increase in Rowe score was 56.2 with comparable increases between autografts and allografts (n.s). Pooled recurrent instability rates were 3% (95% CI, 1-7%; I2 = 77%) and did not differ between the groups (n.s). Arthritic progression was evident in 11% of autografts (95% CI, 2-27%; I2 = 90%) and 1% (95% CI, 0-8%; I2 = 63%) of allografts (n.s). The overall incidence of non-instability related complications was 5% (95% CI, 2-10%; I2 = 81%) and was similar between the groups (n.s). Pooled return to sports rate was 88% (95% CI, 76-96%; I2 = 76%). Glenoid augmentation using free bone block autograft or allograft in the setting of recurrent anterior shoulder instability with glenoid bone loss is effective and safe. Outcomes and complication incidence using autografts and allografts were comparable. Due to the high degree of heterogeneity in the data and outcomes reported in available studies, which consist primarily of retrospective case series, future prospective trials investigating long-term outcomes using free bone block autograft versus allograft for anterior shoulder instability with glenoid bone loss are warranted. IV.