Management Of Anterior Shoulder Instability Research Articles

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.

Incidence of and Risk Factors for Glenohumeral Osteoarthritis following Anterior Shoulder Instability: A U.S. Population-Based Study with an Average 15-year Follow-up

Objectives:The rate of osteoarthritis (OA) in patients with anterior shoulder instability (ASI) varies within the literature, with the majority of studies investigating rates after surgical stabilization. ASI appears to lead to increased rates of OA, although risk factors for developing OA in non-operative and operative cohorts are not well defined. The purpose of this study was to determine the incidence of clinically symptomatic OA and identify potential risk factors for the development of OA following ASI in a U.S. geographic population of patients under the age of 40.Methods:An established geographic database was used to identify patients less than 40 years old diagnosed with anterior should instability between 1994 and 2016. Patient information, including demographics, imaging and surgical details, was collected and comparative analysis was performed between groups with and without OA at final follow-up, as well as patients who underwent surgical and non-surgical management.Results:The study population consisted of 154 patients with a mean follow-up of 15.2 years (range 5.1-29.8). Overall, 22.7% of patients developed clinically symptomatic glenohumeral OA. Twenty-eight percent of patients who underwent at least 1 surgical intervention and 17% of patients who underwent non-operative management of anterior shoulder instability developed glenohumeral OA (p=0.176). Patients who developed arthritis were older at initial instability event (p=0.002) and had higher BMI (p=0.007). Additionally, patients with OA were more likely to be current or former smokers (p=0.004), have a seizure disorder (p=0.033), and be manual laborers (p=0.044). Risk factors for developing OA included seizure disorders (RR 2.61, 95 % CI 1.34-5.07), cartilage injury on initial MRI (RR 2.48, (1.00-6.13), current or former smoker (RR 2.46, 95% CI 1.37-4.42), laborer occupation (RR 2.14, 95% CI 1.14-4.01), and age at initial instability event (OR 1.09 per year, 95% 1.03-1.17). Athletes (RR 0.51, 95% CI 1.08-3.54), specifically contact athletes at the time of initial instability (RR 0.45, 95% CI 0.21-0.97), were less likely to develop OA. There was no difference in the number of dislocations or number of instability events in patients with and without symptomatic osteoarthritis.Conclusions:In a U.S. geographic population of patients less than 40 years old with ASI, approximately one-fourth of patients developed symptomatic OA at a mean follow-up of 15 years from their first instability event. When accounting for differences in patient demographics, there was no significant difference in the rates of OA in patients who underwent surgical and non-surgical management. Overall, there was an increased risk for the development of OA in patients with seizure disorders, cartilage injury on initial MRI, current or former smokers, laborer occupation and increased age at the initial instability event.

The Natural History of Pediatric and Adolescent Shoulder Dislocation.

Twenty percent of shoulder dislocations occur in people younger than 20 years old. Management of anterior shoulder instability in young patients remains an evolving and controversial topic. Herein we review the natural history of anterior shoulder dislocation in young patients. The English-language literature was searched for studies examining the natural history of pediatric and adolescent shoulder dislocation. Recurrent dislocation was the primary outcome of interest in most studies. Most studies found that recurrent instability was likely in young patients. Several systematic reviews reported the recurrence rate for young patients to be >70%. Recurrent instability was likely to cause greater damage to the joint and may result in more extensive and costly surgery. Most studies agree that recurrent anterior shoulder instability is likely in young patients. Some authors advocate for consideration of early surgery in this high-risk population.

Arthroscopic Distal Clavicle Glenoid Augmentation: An Ideal Graft Option

Recent work has demonstrated the importance of addressing bone loss in the surgical management of anterior shoulder instability. Multiple options exist for reconstituting the glenoid articular surface to include anatomic vs nonanatomic techniques, and utilizing autograft vs allograft material. 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 comorbidity. The distal clavicle autograft provides such an option. The graft has a cortical and cancellous side for direct fixation, and is amenable to arthroscopic techniques. Recent work has demonstrated the utility of this graft noting that the distal clavicle graft provides an anatomic restoration of the glenoid radius with an articular cartilage cap comparable in thickness to that of the native glenoid. Along with a summary of the pertinent literature, this review article outlines the rationale, indications, and technical notes for this procedure.

Trends in Surgical Management of Anterior Shoulder Instability: Increased Utilization of Bone Augmentation Techniques†.

The purpose of this study is to evaluate the trends in surgical management for anterior shoulder instability in the U.S. Military. A retrospective analysis of military service members undergoing arthroscopic or open shoulder stabilization from 2012 to 2015 within the U.S. Military Health System was conducted. Demographic and surgical variables were extracted from the medical record. Chi-square and linear regression analysis were performed to identify temporal trends by surgical procedures and concomitant surgery. Associations between demographic variables and surgical procedure were evaluated using logistic regression analysis with odds ratios and 95% confidence intervals. Eight thousand five hundred and eighty nine surgeries were performed for anterior shoulder instability. The arthroscopic Bankart procedure remained the dominant surgical procedure over time (n = 8177, 95.2%), whereas the open Bankart procedure (n = 172, 2.0%) demonstrated a diminishing trend, which was significant on univariate analysis (p = 0.0009), but not statistically significant on linear regression (p = 0.12). Additionally, there was a significant trend toward increased utilization of the Latarjet procedure over the period studied (n = 33, 1.7% - n = 81, 3.56%) (p = 0.009). During the same time period, concomitant superior labrum anterior/posterior repairs decreased (n = 980, 11.4%; p = 0.0045), whereas rates of biceps tenodesis (n = 741, 8.6%; p = 0.05) increased significantly. When analyzing patient age as a continuous variable, increasing age was associated with a significantly higher likelihood of arthroscopic treatment (odds ratio 1.02, 95% confidence interval 1.00-1.03, p = 0.05). The rate of performing an arthroscopic Bankart repair has remained relatively stable as the dominant surgical procedure for shoulder instability in the military patient population. There was a significant trend of increased use of the Latarjet procedure, which likely reflects the recognition of bone loss through use of preoperative advanced imaging and computed tomography with three-dimensional reconstructions. Additionally, there was a significant decrease in adjacent superior labrum anterior/posterior repairs over the study period, followed by a corresponding rise in biceps tenodesis. Level of evidence: level IV.

Return to Sports After Shoulder Stabilization Surgery for Anterior Shoulder Instability.

Young athletes continue to experience traumatic shoulder instability and are often plagued by recurrent instability, limiting their return to sport. The purpose of this paper was to review return to sport in athletes after shoulder stabilization surgery for anterior shoulder instability. Athletes managed nonoperatively demonstrate unacceptably high rates of recurrent instability and are less likely to successfully return to sport. Operative management includes capsuloligamentous repair (arthroscopic versus open) and bone augmentation techniques. While modern arthroscopic techniques have provided favorable outcomes, open techniques have demonstrated lower recurrence rates among young collision athletes. A subset of athletes continue to experience recurrent instability, leading to further investigation of concomitant pathologies, which may put patients at risk of failure following Bankart repair. Bony augmentation procedures remain favorable for patients with glenoid bone loss; however, what constitutes critical bone loss in the decision between anterior labral repair versus bone augmentation has recently been questioned. Operative management of anterior shoulder instability provides superior results, including lower recurrent instability and return to sport. Future research on patient-specific risk factors may aid surgical decision-making and optimization of outcomes.

Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability: Indications and Outcomes.

Arthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability. Improvements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome. When indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.

Trends in Surgical Management of Shoulder Instability.

Background:Optimal surgical management of anterior shoulder instability remains controversial. There is a need to assess the most recent trends for primary and revision shoulder stabilization surgery using a national database significantly larger than those previously utilized.Hypothesis:Most shoulder stabilization procedures are performed arthroscopically. Examining revision procedures, we hypothesized that open procedures would result in decreased revision stabilizations compared with arthroscopic procedures and that most revision procedures would be open Bankart or bone transfer procedures regardless of the index procedure technique.Study Design:Descriptive epidemiology study.Methods:The MarketScan Database was searched using International Classification of Diseases–Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes to identify patients who underwent any shoulder stabilization procedure between 2008 and 2012. Regression analysis was used to evaluate trends between patient groups. The Cochran-Armitage trend test was used to identify differences in trends seen yearly. Odds ratios (ORs) were calculated to compare the likelihood of undergoing a revision stabilization procedure.Results:A total of 66,564 shoulder stabilization procedures were identified from 2008 through 2012: 60,248 arthroscopic stabilization procedures (90.5%) and 6316 open stabilization procedures (9.5%), including 1623 bone block procedures. Arthroscopic stabilization procedures increased in total number and percentage of all procedures in each year of the study. Bone block procedures increased in number each year, although other open procedures decreased during the study period. Males underwent more stabilization procedures, while patients between the ages of 10 and 19 years were most likely to undergo any procedure. Patients who underwent bone block stabilization were significantly less likely to undergo a second stabilization procedure during the study period when compared with open Bankart repair (OR, 0.582; 95% CI, 0.405-0.836; P < .05) and arthroscopic Bankart repair (OR, 0.587; 95% CI, 0.418-0.824; P < .05). No statistically significant difference in revision stabilization was seen when comparing arthroscopic versus open Bankart repair (OR, 0.934; 95% CI, 0.863-1.139).Conclusion:Although the number of arthroscopic shoulder stabilization surgeries continues to increase, our data show a consistent increase, not seen in prior studies, in the number of bone block procedures. Contrary to some studies, there was no significant difference in the likelihood of a second procedure between patients initially undergoing arthroscopic compared with open Bankart repair.

Classification and Analysis of Attritional Glenoid Bone Loss in Recurrent Anterior Shoulder Instability

Proper recognition and treatment of glenoid bone loss (GBL) is important for successful management of anterior shoulder instability. Although GBL has been thoroughly described in the literature, there is also a fragment of bone that is usually displaced and often undergoes attrition that has been little described. Thus, the purposes of this study include (1) to evaluate ABL of the glenoid fragment in recurrent anterior shoulder instability and (2) correlate ABL with clinical history, fragment size and radiographic findings. GBL was evaluated on 3-dimensional (3D) computed topography (CT) en face view, and measured as percent loss. The bone fragment size was measured and attrition of the fragment was determined by evaluating the amount remaining relative to the initial defect; patients were stratified into minimal (<34%), moderate (34-67%) and severe (>67%) attritional loss groups. Clinical history and demographics were correlated to ABL, and comparison of GBL and ABL was performed. The overall median percent GBL was 15.3% (IQR, 9.9% - 20.0%) with a mean (SD) percent GBL of 16.5% (9.0%). Study participants had a corresponding median percent ABL of 75.8% (IQR, 53.8% - 95.7%) and a mean (SD) percent ABL of 72.0% (24.4%). A total of 61.2% of patients (n=85) exhibited severe ABL, while 30% had moderate ABL and 8.6% had minimal ABL. The total time of instability was significantly associated with percent attritional bone loss (p<0.05). This study highlights that GBL, in most patients with recurrent anterior instability, presents with extensive attrition of the bone fragment independent of initial glenoid bone loss; therefore, surgeons should be cognizant that the remaining bone fragment is unable to reconstitute glenoid bone stock. In addition, there was more attritional bone loss in patients with a longer duration of instability symptoms, indicating need for incorporating symptom duration in determining proper management.

Distal clavicle autograft—I would like to use my own osteochondral graft please

Recent work has demonstrated the importance of addressing bone loss in the surgical management of anterior shoulder instability. Multiple options exist for reconstituting the glenoid articular surface to include: anatomic versus non-anatomic techniques and utilizing autograft versus allograft material. Anatomic restoration via an arthroscopic approach with distal clavicle osteochondral autograft (DCA) is the senior author’s preferred technique when bone grafting is indicated for instability cases. This technique offers a low cost, readily available, and reproducible means of obtaining autograft material. Moreover, the distal clavicle graft provides an anatomic restoration of the glenoid radius with an articular cartilage cap comparable in thickness to that of the native glenoid. Along with a summary of the pertinent literature, this review article outlines the rationale, indications, and technical notes for this procedure.

Classification and Analysis of Attritional Glenoid Bone Loss in Recurrent Anterior Shoulder Instability

Background: Recognition and proper treatment of glenoid bone loss (GBL) are important for successful management of anterior shoulder instability. Although GBL has been described as the amount of bony loss from the front of the glenoid, there is also a fragment of bone that is usually displaced and often undergoes attrition. Thus, due to attritional bone loss (ABL) of the fragment, insufficient bone is left to fully reconstruct the glenoid. Purpose: To (1) evaluate ABL of the glenoid fragment in recurrent anterior shoulder instability and (2) correlate ABL with clinical history, fragment size, and radiographic findings. Study Design: Cross-sectional study; Level of evidence, 3. Methods: GBL was evaluated on 3-dimensional computed tomography (3D CT) en-face view and was measured as percentage loss. The bone fragment size was measured, and attrition of the fragment was determined by evaluation of the amount remaining relative to the initial defect; patients were stratified into minimal (<34%), moderate (34% to <67%), and severe (≥67%) attritional loss groups. Clinical history and demographics were correlated to ABL, and GBL and ABL were compared. Results: The overall median percentage GBL was 15.3% (interquartile range [IQR], 9.9%-20.0%), with a mean (±SD) percentage GBL of 16.5% ± 9.0%. Study participants had a corresponding median percentage ABL of 75.8% (IQR, 53.8%-95.7%) and a mean percentage ABL of 72.0% ± 24.4%. A total of 61.2% of patients (n = 85) exhibited severe ABL, while 30.2% had moderate ABL and 8.6% had minimal ABL. The total time of instability was significantly associated with percentage of attritional bone loss (P < .05). In addition, the time of instability was greatest in patients in the third tertile of ABL (≥87.5%; P = .08). A significant difference was found in total time of instability among patients in the highest tertile of ABL (38.6 months) versus both the middle (26.7 months) and lowest (32.8 months) tertiles (P < .05). Conclusion: The study results indicate that in the majority of patients with recurrent anterior instability, GBL presents with extensive attrition of the bone fragment independent of initial glenoid bone loss; therefore, surgeons should be cognizant that the remaining bone fragment is unable to reconstitute glenoid bone stock. In addition, the results showed more attritional bone loss in patients with a longer duration of instability symptoms, indicating a role for incorporating symptom duration in determining proper management.

Anterior Shoulder Instability in the Military Athlete.

Context:Given its young, predominately male demographics and intense physical demands, the US military remains an ideal cohort for the study of anterior shoulder instability.Evidence Acquisition:A literature search of PubMed, MEDLINE, and the Cochrane Database was performed to identify all peer-reviewed publications from 1950 to 2016 from US military orthopaedic surgeons focusing on the management of anterior shoulder instability.Study Design:Clinical review.Level of Evidence:Level 4.Results:The incidence of anterior shoulder instability events in the military occurs at an order of magnitude greater than in civilian populations, with rates as high as 3% per year among high-risk groups. With more than 90% risk of a Bankart lesion and high risk for instability recurrence, the military has advocated for early intervention of first-time shoulder instability while documenting up to 76% relative risk reduction versus nonoperative treatment. Preoperative evaluation with advanced radiographic imaging should be used to evaluate for attritional bone loss or “off-track” engaging defects to guide comprehensive surgical management. With complex recurrent shoulder instability and/or cases of clinically significant osseous lesions, potential options such as remplissage, anterior open capsular procedures, or bone augmentation procedures may be preferentially considered.Conclusion:Careful risk stratification, clinical evaluation, and selective surgical management for at-risk military patients with anterior shoulder instability can optimize the recurrence risk and functional outcome in this population.

Evaluation of functional outcomes and complications following modified Latarjet reconstruction in athletes with anterior shoulder instability.

The optimal management of anterior shoulder instability in athletes continues to be a challenge. The present study aimed to evaluate the functional outcomes of athletes with anterior shoulder instability following modified Latarjet reconstruction through assessing the timing of return to sport and complications. Retrospective assessment was performed of athletes (n = 56) who presented with recurrent anterior shoulder instability and were treated with modified congruent arc Latarjet reconstruction over a 1-year period. Rugby union was the predominant sport performed. Pre-operative instability severity index scores were assessed. Postoperative complications were recorded as was the time taken for the athlete to return to sport. Arthroscopic evaluation revealed that 86% of patients had associated bony lesions affecting the glenohumeral joint. The overall complication rate relating to the Latarjet reconstruction was 7%. No episodes of recurrent shoulder instability were noted. Of the patients, 89% returned to competitive sport at the same level as that prior to surgery. The mean time post surgery to returning to full training was 3.2 months. The modified congruent arc Latarjet procedure facilitates early rehabilitation and return to sport. These results support our systematic management protocol of performing modified Latarjet surgery in contact sport athletes with recurrent anterior instability.

Increasing preoperative dislocations and total time of dislocation affect surgical management of anterior shoulder instability.

Purpose:Our purpose was to determine the relationship between number of preoperative shoulder dislocations and total dislocation time and the need to perform bone deficiency procedures at the time of primary anterior instability surgery. Our hypothesis was that need for bone deficiency procedures would increase with the total number and hours of dislocation.Materials and Methods:A retrospective review was performed of primary instability surgeries performed by a single surgeon. Patients with <25% glenoid bone loss were treated with an isolated arthroscopic Bankart repair. Those who also had an engaging Hill-Sachs lesion underwent arthroscopic Bankart repair with remplissage. Patients with >25% glenoid bone loss were treated with Latarjet reconstruction. Number of dislocations and total dislocation time were examined for their relationship with the treatment method.Results:Ten arthroscopic Bankart repairs, 13 arthroscopic Bankart plus remplissage procedures, and 9 Latarjet reconstructions were available for review. Total dislocations (P = 0.012) and total hours of dislocation (P = 0.019) increased from the Bankart, to the remplissage, to the Latarjet groups. Patients with a total dislocation time of 5 h or more were more likely to require a Latarjet reconstruction (P = 0.039). Patients with only 1 preoperative dislocation were treated with an isolated Bankart repair in 64% (7 of 11) of cases, whereas those with 2 or more dislocations required a bone loss procedure in 86% (18 of 21) of cases (P = 0.013).Conclusion:Increasing number of dislocations and total dislocation time are associated with the development of glenoid and humeral head bony lesions that alter surgical management of anterior shoulder instability. The necessity for the addition of a remplissage to an arthroscopic Bankart repair or the use of a Latarjet reconstruction increases with only 1 recurrent dislocation.Level of evidence:Level III, retrospective comparative study.

Recurrent anterior shoulder instability: Review of the literature and current concepts.

The purpose of this review article is to discuss the clinical spectrum of recurrent traumatic anterior shoulder instability with the current concepts and controversies at the scientific level. Because of increasing participation of people from any age group of the population in sports activities, health care professionals dealing with the care of trauma patients must have a thorough understanding of the anatomy, patho-physiology, risk factors, and management of anterior shoulder instability. The risk factors for recurrent shoulder dislocation are young age, participation in high demand contact sports activities, presence of Hill-Sachs or osseous Bankart lesion, previous history of ipsilateral traumatic dislocation, ipsilateral rotator cuff or deltoid muscle insufficiency, and underlying ligamentous laxity. Achieving the best result for any particular patient depends on the procedure that allows observation of the joint surfaces, provides the anatomical repair, maintains range of motion, and also can be applied with low rates of complications and recurrence. Although various surgical techniques have been described, a consensus does not exist and thus, orthopedic surgeons should follow and try to improve the current evidence-based treatment modalities for the patients.

Arthroscopic management of anterior shoulder instability with glenoid bone defects

Bony deficiency of the anterior glenoid rim may significantly contribute to recurrent shoulder instability. Today, based on clinical and biomechanical data, a bony reconstruction is recommended in patients with bone loss of greater than 20-25 % of the glenoid surface area. Recent advances in arthroscopic instruments and techniques presently allow minimally invasive and arthroscopic reconstruction of glenoid bone defects and osteosynthesis of glenoid fractures. This article underlines the role of glenoid bone deficiency in recurrent shoulder instability, provides an update on the current management regarding this pathology and highlights the modern techniques for surgical treatment. Therefore, it can help orthopaedic surgeons in the treatment and decision-making when dealing with these difficult to treat patients in daily clinical practice.

골 결손을 동반한 견관절 불안정성의 관절경적 재건술

Purpose: We reviewed arthroscopic reconstruction among the several treatment options for anterior shoulder instability with a bony Bankart lesion. Materials and Methods: Although open Bankart repair has long been considered the optimal surgical management of anterior shoulder instability, advancements in arthroscopic techniques have led to a recent shift to arthroscopic Bankart repair. However, for cases of a glenoid bony defect, several authors have reported various methods to accurately measure the amount of bony defect. Results: The arthroscopic technique of bony Bankart reconstruction continues to evolve and various methods have followed. To overcome the limitations of single fixation of a Bankart lesion, arthroscopic dual fixation (2 point fixation) has recently been tried to anatomically repair and restore the rigid fixation of a bony fragment. The concept of performing the Bristow-Latarjet transfer procedure under arthroscopy has also recently emerged. However, a large series of cases and long term follow up are required to prove the better results. Conclusion: To obtain a successful outcome for patients with anterior instability with a glenoid bony defect, it is imperative that the surgeon be aware of the accurate status of the bony defect and the intraoperative, postoperative factors associated with the proper treatment of this unstable pathology.

Arthroscopic Suture Anchor Capsulorrhaphy Versus Suture Capsulorrhaphy in a Cadaveric Model (SS-01)

Introduction Recurrent anterior glenohumeral instability is challenging to treat. Arthroscopic capsulorrhaphy utilizing either a solitary suture or suture anchor has proven effective in alleviating instability symptoms. To date, no study was found that determined whether suture capsulorrhaphy or suture anchor capsulorrhaphy is more effective at reducing anterior translation. Thus, the purpose of this study is to establish whether there is biomechanical benefit for the use of anchor capsulorrhaphy versus suture capsulorrhaphy in the management of anterior shoulder instability. Methods Twelve matched pairs of fresh, frozen shoulders were randomized to either anchor or suture capsulorrhaphy group. Specimens were mounted in 60-degrees of abduction and 90-degrees of external rotation in the plane of the scapula. Testing was conducted on an MTS with the use of Vicon motion capture system. Compressive load of 22N was applied to each shoulder and subsequent 2N anterior and posterior force was applied to establish zero point. Translation with 10N anterior and posterior loads was then recorded. Arthroscopic capsulorrhaphy was performed with either three solitary sutures or three suture anchors. Specimens were remounted and returned to the zero-point. A 10N anterior force, 10N posterior force, and an anterior load to failure force were applied, respectively. Translation from zero was measured. Load to failure was defined as the amount of force required to return to preoperative zero point. Specimens were loaded-to-failure at a rate of 0.1mm/sec. Data were reported in millimeters ±SEM with significance set at p Results Load-to-failure was significantly greater (p=0.02) in the anchor capsulorrhaphy group (20.5N±2.8) versus suture capsulorrhaphy group (13.6N±1.0). When comparing reduction of anterior translation with a 10N load, no differences were found between suture capsulorrhaphy (2.7mm±0.7) and anchor capsulorrhaphy (2.3mm±0.6). Percent reduction of anterior displacement with a 10N load was not different for the suture capsulorrhaphy (49.9%) versus anchor capsulorrhaphy (49.6%) groups. Tissue pull-through of the suture was the dominant mode of failure in the study. Conclusion Suture capsulorrhaphy and anchor capsulorrhaphy reduce anterior glenohumeral translation at low loading conditions. Load-to-failure studies indicate that anchor capsulorrhaphy exhibits significantly greater resistance to translation at higher loading conditions. Thus, it is concluded that the use of arthroscopic suture anchors is more effective than suture capsulorrhaphy in reducing catastrophic anterior glenohumeral translation in cadavers. Our study suggests that the use of a suture anchor when performing a capsulorrhaphy may provide biomechanical advantage at high loading conditions. Potential benefits of suture anchor capsulorrhaphy include increased resistance to glenohumeral translation and higher load to failure. This may represent better clinical outcomes and a reduction in the rate of recurrent instability as a result.