Number Of Preoperative Dislocations Research Articles

Open Latarjet reduces residual apprehension, redislocation and possibility of dislocation arthropathy compared to arthroscopic Bankart repair despite greater bipolar bone loss in anterior glenohumeral instability

BackgroundArthroscopic Bankart repair (ABR) and the open Latarjet (OL) procedure are the most frequently preferred methods in the treatment of anterior glenohumeral instability. The aim of this study was to compare patients who underwent ABR or OL due to anterior glenohumeral instability in terms of functional capacity, glenohumeral bone loss, residual apprehension, redislocation and dislocation arthropathy. MethodsA total of 56 patients who underwent ABR or OL due to anterior glenohumeral instability between January 2018 and December 2021 were evaluated retrospectively. There were 32 patients in the ABR group and 24 patients in the OL group. Patients’ demographic characteristics, number of preoperative dislocations, and return-to-work and follow-up periods were recorded. Glenoid bone loss, Hill-Sachs interval, and Hill-Sachs depth were measured from preoperative computed tomography sections. The ASES score, WOSI score, Rowe score, and joint range of motion were calculated. Patients were also asked about residual apprehension, postoperative redislocations, dislocation arthropathy and surgery satisfaction. ResultsThe mean age of the ABR group was 22.5±3.9 years (28 men, 4 women), while that of the OL group was 25.0±4.8 years (22 men, 2 women). The mean number of dislocations was 2.7±1.3 in the ABR and 10.9±5.5 in the OL (p=0.001). Higher values of glenoid bone loss (%) (ABR: 6±2; OL: 20±4), Hill-Sachs interval (mm) (ABR: 8±3; OL: 21±3), and Hill-Sachs depth (mm) (ABR: 5±2; OL: 8±2) were measured in the OL (p=0.001 for all), reflecting significantly more bone loss. Residual apprehension was detected in 10 patients in the ABR and 2 patients in the OL (p=0.007). While 4 patients in the ABR had a history of redislocation, no redislocation occurred in the OL (p=0.012). Dislocation arthropathy development was observed in 9 patients in the ABR and 4 patients in the OL (p=0.038) according to the modified Samilson and Prieto classification. External rotation in adduction and external rotation in 90° abduction were approximately 5° higher in the OL (p=0.011 and p=0.016, respectively). ConclusionThe ABR and OL methods both provide satisfactory outcomes in the treatment of anterior glenohumeral instability with appropriate indications. The OL procedure is preferred for patients with more dislocations and greater bipolar bone loss. Despite greater bipolar bone loss, the OL procedure provides lower rates of residual apprehension, redislocation and dislocation arthropathy. Additionally, due to the stability it provides, there is less loss in external rotation.

Arthroscopic Latarjet Versus Arthroscopic Free Bone Block Procedures for Anterior Shoulder Instability: A Proportional Meta-analysis Comparing Recurrence, Complication, and Reoperation Rates

Background: Several arthroscopic glenoid bone augmentation techniques have been introduced to treat patients affected by anterior shoulder instability associated with critical bone loss. The efficacy of the different arthroscopic bony procedures has not been compared yet. Purpose: To compare the recurrence, complication, and reoperation rates of the arthroscopic Latarjet (AL) and arthroscopic free bone block (ABB) procedures for anterior shoulder instability. Study Design: Meta-analysis and systematic review; Level of evidence, 4. Methods: A systematic search was conducted in MEDLINE/PubMed, Web of Science, and Embase to identify clinical studies reporting the outcomes of the AL and ABB procedures. The following search phrases were used: “Arthroscopic” AND “Bone Block” OR “Bone Graft,” and “Arthroscopic” AND “Glenoid Augmentation” OR “Glenoid Reconstruction,” and “Arthroscopic” AND “Latarjet” OR “Coracoid Graft” OR “Coracoid Transfer.” Exclusion criteria were <24 months of minimum follow-up, sample size <10 cases, revision after previous glenoid bone grafting, epilepsy, and multidirectional instability. Data regarding the study design, patient characteristics, surgical technique, and outcomes were extracted and analyzed. A proportional meta-analysis was conducted to compare the complication, recurrence, and reoperation rates between the 2 groups. Multiple subgroup analyses were performed to analyze the incidence of each complication and assess the weight of different fixation methods (in the whole cohort) or different graft types (in the ABB group). The modified Coleman Methodology Score was used to assess the risk of bias. Results: Of 5010 potentially relevant studies, 18 studies regarding the AL procedure (908 cases) and 15 studies regarding the ABB procedure (469 cases) were included. The 2 groups were comparable in age (P = .07), sex (P = .14), glenoid bone loss (P = .14), number of preoperative dislocations (P = .62), proportion of primary and revision procedures (P = .95), length of follow-up (P = .81), modified Coleman Methodology Score (P = .21), and level of evidence (P = .49). There was no difference in the recurrence (P = .88), reoperation (P = .79), and complication (P = .08) rates. The subgroup analyses showed a higher rate of hardware-related complications for screw fixation compared with flexible fixation (P = .01). Conclusion: The AL and ABB procedures had similar recurrence, reoperation, and complication rates. Screw fixation of the bone graft was related to an increased risk of complications compared with flexible fixation. Registration: CRD42022368153 (PROSPERO).

Comparison of Failure Rates at Long-term Follow-up Between MPFL Repair and Reconstruction for Recurrent Lateral Patellar Instability.

The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation and is often disrupted by lateral patellar dislocation. Surgical management for recurrent patellar instability focuses on restoring the MPFL function with repair or reconstruction techniques. Recent studies have favored reconstruction over repair; however, long-term comparative studies are limited. To compare long-term clinical outcomes, complications, and recurrence rates of isolated MPFL reconstruction and MPFL repair for recurrent lateral patellar instability. Cohort study; Level of evidence, 3. A total of 55 patients (n = 58 knees) with recurrent lateral patellar instability were treated between 2005 and 2012 with either MPFL repair or MPFL reconstruction. The exclusion criteria were previous or concomitant tibial tubercle osteotomy or trochleoplasty and follow-up of <8 years. Pre- and postoperative descriptive, surgical, imaging, and clinical data were recorded for each patient. MPFL repair was performed on 26 patients (n = 29 knees; 14 women, 15 men), with a mean age of 18.4 years. MPFL reconstruction was performed on 29 patients (n = 29 knees; 18 women, 11 men), with a mean age of 18.2 years. At a mean follow-up of 12 years (range, 8.3-18.9 years), the reconstruction group had a significantly lower rate of recurrent dislocation compared with the repair group (14% vs 41%; P = .019). There were no differences in the number of preoperative dislocations or tibial tubercle-trochlear groove distance. The reconstruction group had significantly more time from initial injury to surgery compared with the repair group (median, 1460 days vs 627 days; P = .007). There were no differences in postoperative Tegner, Lysholm, or Kujala scores at the final follow-up. In addition, no statistically significant differences were detected in return to sport (RTS) rates (repair [81%] vs reconstruction [75%]; P = .610) or reoperation rates for recurrent instability (repair [21%] vs reconstruction [7%]; P = .13). MPFL repair resulted in a nearly 3-fold higher rate of recurrent patellar dislocation (41% vs 14%) at the long-term follow-up compared with MPFL reconstruction. Given this disparate rate, the authors recommend MPFL reconstruction over repair because of the lower failure rate and similar, if not superior, clinical outcomes and RTS.

Clinical Results of Knot-tying Versus Knotless Suture Anchors in Arthroscopic Anteroinferior Labral Repair.

Background Arthroscopic repair of glenohumeral instability is becoming an increasingly common procedure. These repairs can be undertaken using knot-tying and knotless suture anchors; there is currently no clear consensus in the literature about what type of repair is most cost-effective and provides superior outcomes. The purpose of this study is to examine postoperative outcomes of patients undergoing arthroscopic anteroinferior labral repair (AALR) with either knot-tying or knotless anchors. Methods A single institution retrospective observational cohort study of 122 patients undergoing AALR from January 2014 to June 2021 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes between repair types; multivariate analysis was used to evaluate risk factors for recurrent instability and reoperation. Results Patients undergoing AALR with knotless anchors had a shorter case duration than those with knot-tying anchors (112.64 vs. 89.86 minutes, p<0.001). There were no significant differences between groups in the size of labral tear, presence of a glenoid bone defect, or Hill-Sachs lesion. After controlling for age, BMI,sex, glenoid bone defect, number of preoperative dislocations, and fixation type, only age (OR=0.896, p=0.010) and female sex (OR=5.341, p=0.008) were independent risk factors for recurrent instability and no factors were independent predictors of reoperation. Conclusion Patients undergoing AALR experienced similar rates of reoperation and recurrent instability regardless of whether a knot-tying or knotless repair was performed. The use of knotless suture anchors may improve cost-effectiveness due to decreased surgical time without diminishing postoperative outcomes.

Paper 54: MPFL Repair has a Higher Failure Rate at Long-term Follow-up compared to MPFL Reconstruction for Recurrent Patellar Instability

Objectives:The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation and is often disrupted with a lateral patellar dislocation. Surgical management for recurrent patellar instability focuses on restoring MPFL function with repair or reconstruction techniques. Recent studies have favored reconstruction over repair, but no long-term, comparative studies are available in the literature.Methods:A total of 55 patients (58 knees) with recurrent lateral instability were treated between 2005 and 2012 with either MPFL repair or MPFL reconstruction. Exclusion criteria included prior or concomitant tibial tubercle osteotomy or trochleoplasty, and follow-up less than 8 years. Pre- and post-operative demographic, surgical, imaging and clinical data were recorded for each patient.Results:MPFL repair was performed on 26 patients (29 knees; 14 females, 15 males) at a mean age of 19.1 years. MPFL reconstruction was performed on 29 patients (29 knees; 18 females, 11 males) at a mean age of 18.2 years. Mean follow-up was 12.0 years (range 8.3-18.9). The reconstruction group had a significantly lower rate of recurrent dislocation compared to the repair group (14% vs 41%, p=0.019) at final follow up. There were no differences in the number of pre-operative dislocations (greater than or less than 3), degree of patellar facet chondromalacia, TT-TG distance, or Tegner scores. The reconstruction group had significantly more time from injury to surgery compared to the repair group (median, 1,460 days vs 627 days, p =0.007). There were no differences in post-operative Tegner, Lysholm or Kujala scores at final follow-up. Additionally, there were no differences in return to play rates (repair 80.8% vs reconstruction 75.0%, p=0.610) or reoperation rates (repair 20.7% vs reconstruction 13.8%, p=0.487).Conclusions:Repair of the MPFL leads to nearly 3-fold higher rate of recurrent patellar dislocation (41% vs. 14%) at long term follow-up compared to MPFL reconstruction. However, MPFL repair and reconstruction provide similar clinical results, return to play rates and reoperation rates.

Risk Factors for Recurrence of Anterior-Inferior Instability of the Shoulder After Arthroscopic Bankart Repair in Patients Younger Than 30 Years

To identify the risk factors for recurrent instability after arthroscopic Bankart repair and evaluate the recurrence rate and functional outcomes. A retrospective review was performed of patients with anterior-inferior shoulder instability who underwent arthroscopic Bankart repair between 2008 and 2014. Patients below 30years of age who were available for follow-up at least for 2years were sorted into 2 groups according to the presence of recurrent instability. Furthermore, statistical analysis by binary logistic regression analysis included the significance of various risk factors including gender, demographic factors, number of preoperative dislocations, time interval between the first dislocation and the surgery (shorter than 6months or not), generalized hyperlaxity, concomitant injury, bony Bankart, and off-track lesion. The functional outcomes were assessed with the Rowe and Walch-Duplay scores. A total of 170 shoulders were included (without-recurrence group: 138, recurrent group: 32). The overall postoperative recurrent instability rate was 18.8%. SLAP repair, interval closure, and capsular plication were performed when necessary. However, these additional procedures were not influenced by recurrence (P= .37). The 2 groups showed significant differences in the number of preoperative dislocations (P= .048; adjusted odds ratio [OR] 2-5 times, 6.41; more than 5 times, 8.77), time interval between the first dislocation and surgery (P= .003, adjusted OR 5.62), and off-track Hill-Sachs lesion (P= .04, adjusted OR 4.31). There was significant improvement in the mean Rowe and Walch-Duplay scores at 2years postoperatively (P < .001 in both cases), but the mean scores were lower in the group with recurrence than in the group without (P= .021 and .014, respectively). The overall results suggest that surgery within 6months of the first dislocation should be considered, with meticulous attention in patients with a high number of preoperative dislocations or off-track Hill-Sachs lesions. Level III, retrospective case-control study.

Midterm Clinical Results in Rugby Players Treated With the Bristow Procedure

Background: Although surgical shoulder stabilization by coracoid transfer is effective for collision athletes and has a low reinjury rate, no reports have described the midterm results of this procedure in specific patient cohorts of sufficient number or provided subjective assessments of these patients. Purpose: To evaluate midterm results after treatment of shoulder instability with the Bristow procedure in a large cohort of rugby players. Study Design: Case series; Level of evidence, 4. Methods: This study included 176 shoulders of 152 competitive rugby players who underwent shoulder stabilization surgery (Bristow procedure with Bankart repair) with a mean follow-up of 4 years (minimum of 2 years) in our institute. The primary outcome measure was the difference in the presurgical and postsurgical functional Rowe score and Western Ontario Shoulder Instability index (WOSI) score and factors affecting these scores. Complication rates and associated factors were also investigated. Results: In total, 176 shoulders of 152 patients underwent the Bristow procedure with Bankart repair, and 93.2% of the players returned to their preinjury competition level at a mean of 6.3 months postoperatively. All Rowe and WOSI scores were significantly improved after surgery. The numbers of shoulders with functional failure as indicated by the Rowe score, WOSI score, and inability to return to the previous level of play were 28 (15.9%), 54 (30.7%), and 12 (6.8%), respectively. Multiple logistic regression analyses demonstrated that reinjury after surgery (odds ratio [OR] = 35.1) and the number of shoulder dislocations (OR = 11.2-11.4) negatively affected the competition level after return to play, while reinjury (OR = 11.1-17.8), the number of shoulder subluxations (OR = 1.1-2.9), injury in the dominant shoulder (OR = 1.2-2.2), and large bone defects (OR = 1.1-11.5) negatively affected functional scores. Reinjury after shoulder stabilization occurred in 6 of 176 shoulders (3.4%). Multiple logistic regression analysis demonstrated that reinjury after surgery occurred more frequently in players at lower versus higher grade levels of competition (OR = 21.0). Although differences were not significant, a trend was noted toward higher postoperative reinjury rates in forward players, those in the upper categories (professional and college), and those with injury in the nondominant shoulder. Conclusion: The Bristow procedure provides good midterm outcomes for competitive collision athletes, while postsurgical reinjury, the number of preoperative dislocations and subluxations, and large bone defects negatively affect postsurgical shoulder function. This information may be useful for treatment of shoulder dislocations in collision athletes.

Outcomes After Arthroscopic Bankart Repair in Adolescent Athletes Participating in Collision and Contact Sports

To review the outcomes of arthroscopic Bankart repair for anterior shoulder instability in an adolescent population participating in collision and contact sports. A retrospective review of 39 shoulders in 37 adolescent (≤ 19 years) athletes who underwent primary arthroscopic Bankart repair using suture anchors with at least 2-year follow-up. All patients had a history of trauma to their shoulder resulting in an anterior dislocation. Outcome measures included patient satisfaction, the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES), and Rowe scores. Recurrence of dislocation, and return to sporting activity were also assessed. The average age at the time of surgery was 16.9 years (range, 15-19 years), and the average follow-up was 6.4 years (range, 4.3-10.0 years). 58.6% of patients participated in collision sports. Time to surgery after the initial dislocation episode was 9.2 months (range, 0.5-36.2 months). Four shoulders (10.3%) had dislocation events postoperatively. 78.1% of patients returned to sports at the same level of competition. Average VAS was 0.49 ± 1.01 and the average ASES and Rowe scores were 92.8 ± 12.59 and 85.0 ± 24.19, respectively. Univariate analyses demonstrated that subjective functional outcomes were negatively correlated with recurrence (ASES, P = 0.005; Rowe, P = 0.001) and failure to return to sport (ASES, P = 0.016; Rowe, P = 0.004). Independent variables shown to have no significant relationship to functional outcomes included age, follow-up, number of preoperative dislocations, time to surgery, sport classification, competition level, tear extent, number of anchors, concurrent Hill-Sachs lesions, and repair of a SLAP lesion. Arthroscopic Bankart repair is an effective surgical option for traumatic shoulder instability in adolescents participating in collision and contact sports. At a minimum of 4-year follow-up, arthroscopic Bankart repair effectively restored stability in 90% of cases; 80% returned to their preinjury level of sport.

Outcomes After Arthroscopic Bankart Repair in Adolescent Athletes Participating in Collision and Contact Sports.

Background:Literature on arthroscopic stabilization in adolescent patients participating in collision and contact sports is limited, as most studies include adolescents within a larger sample group comprised primarily of adults.Purpose:To review the outcomes of arthroscopic Bankart repair for anterior shoulder instability in an adolescent population participating in collision and contact sports.Study Design:Case series; Level of evidence, 4.Methods:This retrospective review included 39 shoulders in 37 adolescent (≤19 years) athletes who underwent primary arthroscopic Bankart repair using suture anchors with at least 2-year follow-up. All patients had a history of trauma to their shoulder resulting in an anterior dislocation. Outcome measures included patient satisfaction, the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, and Rowe score. Recurrence of dislocation and return to sporting activity were also assessed.Results:The mean age at the time of surgery was 16.9 years (range, 15-19 years), and the mean follow-up was 6.3 years (range, 4.3-10.0 years); 58.6% of patients participated in collision sports. Time to surgery after the initial dislocation episode was 9.2 months (range, 0.5-36.2 months). Four shoulders (10.3%) had dislocation events postoperatively. The majority (78.1%) of patients returned to sports at the same level of competition. Mean VAS was 0.49 ± 1.0, and the mean ASES and Rowe scores were 92.8 ± 12.6 and 85.0 ± 24.2, respectively. Univariate analyses demonstrated that subjective functional outcomes were negatively correlated with recurrence (ASES, P = .005; Rowe, P = .001) and failure to return to sport (ASES, P = .016; Rowe, P = .004). Independent variables shown to have no significant relationship to functional outcomes included age, follow-up, number of preoperative dislocations, time to surgery, sport classification, competition level, tear extent, number of anchors, concurrent Hill-Sachs lesion, and repair of a superior labral anterior-posterior (SLAP) lesion.Conclusion:Arthroscopic Bankart repair is an effective surgical option for traumatic shoulder instability in adolescents participating in collision and contact sports. At a minimum 4-year follow-up, arthroscopic Bankart repair effectively restored stability in 90% of cases; 80% returned to their preinjury level of sport.

Results of Arthroscopic Bankart Repair for Anterior-Inferior Shoulder Instability at 13-Year Follow-up

Background: Anterior-inferior shoulder instability is a common injury in young patients, particularly those practicing overhead-throwing sports. Long-term results after open procedures are well studied and evaluated. However, the long-term results after arthroscopic repair and risk factors of recurrence require further assessment. Hypothesis: Arthroscopic Bankart repair results are comparable with those of open repair as described in the literature. Study Design: Case series; Level of evidence, 4. Methods: A total of 180 shoulders with anterior-inferior shoulder instability were stabilized arthroscopically, met the inclusion criteria and the patients were able to be contacted at a minimum of 10-year follow-up. Of these patients, 143 agreed to participate in the study. Assessment was performed clinically in 104 patients using the American Shoulder and Elbow Surgeons score, Constant score, American Academy of Orthopaedic Surgeons score, Rowe score, and the Dawson 12-item questionnaire. The Samilson-Prieto score was used to assess degenerative arthropathy in radiographs available for 100 shoulders. Additionally, 15 patients participated through a specific questionnaire and 24 patients through a telephone survey. Results: The overall redislocation rate was 18.18%. Redislocation rates for the different types of fixation devices were as follows: FASTak/Bio-FASTak, 15.1% (17/112); SureTac, 26.3% (5/19); and Panalok, 33.3% (4/12). Concomitant superior labral anterior-posterior repair had no effect on clinical outcome. Redislocation rate was significantly affected by the patient’s age and duration of postoperative rehabilitation. Redislocation rate tended to be higher if there had been more than 1 dislocation preoperatively (P = .098). Severe dislocation arthropathy was observed in 12% of patients, and degenerative changes were significantly correlated with the number of preoperative dislocations, patient age, and number of anchors. The patient satisfaction rate was 92.3%, and return to the preinjury sport level was possible in 49.5%. Conclusion: Clinical outcome at a mean follow-up of 13 years after arthroscopic repair of anterior-inferior shoulder instability is comparable with the reported results of open Bankart repair in the literature and allows management of concomitant lesions arthroscopically. Modifiable risk factors of postoperative redislocation and arthropathy must be considered. Stabilization after the first-time dislocation achieves better clinical and radiological outcomes than after multiple dislocations.

Prevalence of and Risk Factors for Dislocation Arthropathy

Background: Glenohumeral osteoarthritis is a well-documented, long-term complication of open stabilization procedures. However, there is a lack of knowledge about long-term radiographic outcome after arthroscopic Bankart procedures. Hypothesis: Glenohumeral osteoarthritis will develop less frequently in arthroscopic Bankart repair compared with open repairs reported in the literature. Study Design: Case series; Level of evidence, 4. Methods: The inclusion criteria for this study were (1) all-arthroscopic Bankart repair for a (2) symptomatic anteroinferior shoulder instability and (3) a minimum follow-up of 10 years. True anteroposterior and lateral radiographs were obtained to evaluate the prevalence and grade of osteoarthritis according to the Samilson classification. Patients were assessed by the Constant score and examined for passive external rotation deficits. Results: Of 165 shoulders that fulfilled the inclusion criteria, 100 were available for evaluation. The median Constant score at an average ± SD 156.2 ± 18.5 months after Bankart repair was 94 (range, 46-100). Twenty-one shoulders (21%) sustained a recurrent dislocation. Overall, 31% of shoulders showed no evidence of glenohumeral osteoarthritis; 41% showed mild, 16% moderate, and 12% severe degenerative changes. Osteoarthritis did not correlate with Constant score results (P = .427). The grade of osteoarthritis was significantly associated with the number of preoperative dislocations (P = .016), age at initial dislocation (P = .005) and at surgery (P = .002), and the number of anchors used (P = .001), whereas time from initial dislocation to surgery (P = .854) and external rotation deficit at 0° and 90° of abduction (P = .104 and .348, respectively) showed no significant correlation. Recurrent dislocation did not affect the presence or grade of osteoarthritis (P = .796 and .665, respectively). Conclusion: At an average 13 years after arthroscopic Bankart repair, osteoarthritic changes are a common finding and, overall, are comparable with reports in the literature regarding open procedures as well as nonoperative treatment. The extent of trauma sustained during preoperative dislocations and the age of the patient seem to be more relevant for long-term dislocation arthropathy than the kind of treatment. Accordingly, the study hypothesis must be rejected. Avoiding preoperative dislocations is more important for the prevention of osteoarthritis than short-term treatment. The number of anchors used was found to be a predictor for long-term development of osteoarthritis.

Structural and clinical integrity of the rotator cuff in athletes after arthroscopic Bankart repair using the three-portal technique.

Muscular recovery of structural integrity after arthroscopic Bankart repair using the para- and trans-musculotendinous three-portal technique has not been investigated. Twenty-seven athletes [mean age 26.9years, (group 1; G1)] were prospectively and longitudinally monitored after arthroscopic Bankart repair using the three-portal technique by magnetic resonance imaging (MRI) and specific clinical muscular testing. The muscular integrity was assessed at the subscapularis (SSC) for the para-tendinous anteroinferior portal, the supraspinatus (SSP) for the trans-tendinous suprabicipital portal, and the infraspinatus (ISP) for the trans-tendinous posterior portal. Muscular atrophy was assessed by standardized ratios of transverse and vertical diameters for the SSC and ISP, as defined by cross-sectional area ratios for the SSP. Fatty infiltration was assessed by signal intensity analysis for the upper and lower SSC, SSP, and upper ISP as a ratio with the lower ISP. These parameters were analyzed for pre-operative (T0), 1-year (T1), and 2-year status (T2), and compared to 27 healthy volunteers [mean age 29.4years, (group 2, G2)]. The structural integrity assessments were performed after 14.8 (T1) and 32.0months (T2). The SSC analysis revealed no muscular impairments in the upper and lower portions between T0 and T2 or compared to G2. MRI analysis for SSP and ISP showed full muscular recovery without any changes between T0 and T2 or deficits compared to G2. The number of pre-operative dislocations had no influence on the muscular integrity. MR analysis detected signs of overuse syndrome in 15% at T0, 41% at T1, and 63% at T2; 77, 22, and 26% of patients at T0, T1, and T2, respectively, were symptomatic. Arthroscopic Bankart repair using the three-portal technique prevents full muscular integrity for para-tendinous anteroinferior portals at the SSC, the trans-tendinous suprabicipital portal through the SSP, and the trans-tendinous portal through the ISP.

Risk factors for recurrence after Bankart repair a systematic review

Arthroscopic Bankart repair of anterior shoulder instability is a common practice in orthopedics. The aim of this study was to evaluate pre-operative risks factors associated with recurrent instability and to delineate possible indications for revision surgery. A systematic review was performed including the following keywords: arthroscopy, Bankart repair, anterior shoulder instability, recurrence of instability, suture anchors and treatment outcome. Studies eligible for inclusion in the review were clinical trials published in the last 10years investigating patients with anterior shoulder instability managed by an arthroscopic repair technique with suture anchors. The studies had to report data about recurrence of instability and investigational parameters (risk factors) that influenced the results referred to the rate of recurrence. Twenty-four articles were identified that met the inclusion criteria and underwent further review. Data from these studies were collected, and the risk of treatment failure was statistically recalculated. An estimate of the overall recurrence rate was obtained by pooling data about failure from the trials. The rate of recurrent instability at 10years of follow-up ranged from 3.4 to 35%. Epidemiological parameters significantly associated with the recurrence of instability were age below 22years old, male gender, the number of preoperative dislocations and participation in competitive sports. Surgical parameters significantly associated with recurrence of instability were repair with fewer than three anchors and the use of knotless anchors. The patho-anatomical factors significantly associated with recurrences were substantial associated glenoid or humeral head bone loss and the presence of anterior labroligamentous periosteal sleeve avulsion. Knowledge of risk factors for post-operative outcomes allows surgeons to provide appropriate preoperative counselling to patients and support more realistic expectations. An accurate analysis of causes of failure should enable the correct revision strategy to be adopted. II.

MRI assessment of the structural labrum integrity after Bankart repair using knotless bio-anchors

Adequate labral restorations after Bankart repair have been demonstrated in cadaver models for knot-tying and knotless anchors and in vivo by magnetic resonance imaging for knot tying. The influence of glenoidal bio-degradation on clinical outcome, and conclusions regarding drill hole enlargement and foreign body reactions remain controversial. The labrum was analyzed in magnetic resonance images for 37 consecutive patients with Bankart repair using knotless PLLA anchors and for 31 volunteers as radiologic controls. The labrum was assessed regarding slope, height index (quotient between labral height to the glenoid height), and labrum morphology in axial and coronal T2 images. Glenoidal bio-degradation was graded in terms of the drill hole configuration in T1 images and the corresponding osseous reaction in T2 images. Constant-Murley, Walch-Duplay, and Rowe scoring were carried out preoperatively and at follow-up. At 15months after arthroscopy, the anterior slope (24.8°), height index (3.0), inferior slope (25.4°), and height index (2.5) were not significantly different from control values. Morphologic analysis revealed significant changes in the Bankart group (P<0.05) that were influenced by the number of preoperative dislocations. Bio-degradation proceeded slowly with no evidence of drill hole enlargement. Osseous reactions were significantly greater in inferior compared to superior implants. The clinical scores were excellent and were not influenced by bio-degradation. Knotless anchors facilitate labral restoration that is comparable to the knot-tying approach. Bio-degradation proceeds slowly without clinical or radiologic evidence of foreign body reactions. III.

Arthroscopic Bankart Suture-Anchor Repair

Background There are not many reports in the literature about the long-term outcomes in terms of recurrence and degenerative changes after arthroscopic capsulolabral reconstruction for anterior shoulder instability. Purpose The aim of this study was to evaluate long-term follow-up (minimum 10 years) of arthroscopic suture-anchor repair for traumatic unidirectional anterior instability, with special emphasis on the radiological evidence of arthritis and clinical outcome. Study Design Case series; Level of evidence, 4. Methods Forty-two patients (43 shoulders) treated at our institute from 1995 to 1997 were included in the study. Thirty patients (31 shoulders) were available for clinical and radiological examination (71%). The mean follow-up was 10.9 years (range, 9.8-14.3 years). Patients were evaluated preoperatively and after surgery using the University of California, Los Angeles (UCLA), Simple Shoulder Test (SST), and Rowe score. Patient satisfaction was determined by asking the patients if they would do this operation again. Radiological outcome was used to evaluate the incidence and grade of arthritis according to the Samilson-Prieto classification. Results At the final follow-up examination, 5 patients (16%) reported an atraumatic recurrent instability, while 2 recurrences (7%) occurred after a major injury. Three of the 7 recurrences occurred 6 years after surgery. All of the patients in the recurrence group except 1 were contact or overhead athletes. Twenty-six patients were satisfied (84%) with the outcome. The SST showed an improvement of shoulder function in 23 cases, the UCLA score improved from 21.8 to 32.1, and the Rowe score showed excellent or good results in 77.3% of cases. Twenty-two patients (71%) were able to return to their preoperative sports level. Radiographic findings showed 9 cases with mild arthritis (29%) and 3 cases with moderate arthritis (10%). Conclusion The recurrence rate deteriorated with time. Involvement in contact sports and overhead activities appears to be a risk factor for recurrence of instability, although this could not be proved statistically with the numbers available, whereas age, gender, and number of preoperative dislocations did not reveal any correlation with recurrence. Degenerative changes of the glenohumeral joint were noted but had no significant effect on the clinical outcomes.

Arthroscopic Labrum Reconstruction With Capsular Shift in Anterior Shoulder Instability: Improved Midterm Results by Using a Standardized Suprabicipital Camera Position

To investigate the midterm results of a standardized arthroscopic technique for labrum reconstruction by using a third suprabicipital portal for better visualization of the anterior glenoid rim. Thirty-three of 36 patients treated for recurrent anterior shoulder dislocation were followed up by telephone and/or in clinical examinations. The average age of the patients (12 women and 21 men) at the time of surgery was 25.2 years, with a mean follow-up of 35 months. On average, 7.8 dislocations occurred between the first dislocation and the stabilization procedure (mean, 45.4 months). Two patients suffered again from redislocations (recurrence rate 6.1%), and 3 patients had 1 or 2 subluxations (9.1%) at the time of follow-up. In the Rowe score, the patients reached 77.5 points on average; 81.8% of the patients returned to sports and leisure activities as in the time before the first dislocation, and 18.2% (6 patients) did not. Limitations for external rotation were 7.8 degrees on average postoperatively. No statistical correlation between the number of preoperative dislocations and the level of the postoperative Rowe score was found. The arthroscopic labrum reconstruction with capsular shift using the 3-portal technique combined with a standardized suprabicipital camera position revealed a recurrence rate and midterm results that were close to results achieved after open procedures. The failure rate, according to the number of dislocations, was 6.1% based on the patient's satisfaction of 12.1%. Level IV, therapeutic case series.

Quantitative Assessment of Glenohumeral Translation after Anterior Shoulder Dislocation and Subsequent Arthroscopic Bankart Repair

Background During the past decade, developments in arthroscopic technology have made arthroscopic repair of labral lesions feasible. However, results with the use of the transglenoid suture technique, or with the use of bioabsorbable tacks, have remained variable in the literature, and the recurrence rates are still inferior to those of open Bankart repair. Hypothesis Arthroscopic Bankart repair with suture anchors can re-create translational and rotational range of motion of the intact glenohumeral joint, and the number of preoperative dislocations has an influence on the result. Study Design Controlled laboratory study. Materials Twelve cadaveric shoulders were tested in a robot-assisted shoulder simulator. Anterior and posterior translation and external rotation were measured for intact, dislocated (shoulders were randomly selected to 1 of 3 groups, which were dislocated 1, 3, or 7 times), and repaired conditions at 0° and 90° of glenohumeral elevation. Results After shoulder dislocation, a significant increase was found in translation and rotation, confirming the creation of a traumatic shoulder instability model. Further testing of the specimen revealed that translational and rotational ranges of motion were reduced by arthroscopic Bankart repair at both testing positions. External rotation was decreased significantly at 0° and 90° of abduction. No significant differences were found between the 3 dislocation groups. Conclusion The results demonstrate a sufficient biomechanical performance of arthroscopic Bankart repair using suture anchors in a traumatic anterior shoulder instability model. With the numbers available, no relationship was found between the number of dislocations and the postoperative result concerning translational or rotational motion. Clinical Relevance Glenohumeral translation and rotation after arthroscopic Bankart repair with use of suture anchors approached near normal values, confirming the clinical success of this technique.

Arthroscopic labrum refixation for post-traumatic anterior shoulder instability: Suture anchor versus transglenoid fixation technique

The aim of this retrospective study was to compare recurrence rates following transglenoid labrum refixation or fixation using the suture anchor (FASTak, Arthrex, Naples, FL) technique. Additionally, parameters that apparently influence the rate of redislocation were investigated. There were 163 patients with post-traumatic anterior shoulder instability treated with an arthroscopic labrum refixation; 108 patients (66.3%) were stabilized with the transglenoid suture technique (group I) and 55 patients (33.7%) with the suture anchor (FASTak) technique (group II). The average follow-up was 4.5 years (range, 2.0 to 7.9 years) in group I and 3.2 years (range, 2.0 to 5.0 years) in group II. The Rowe score increased from a preoperative average of 35.0 points in group I and 35.4 points in group II to a postoperative average of 68.3 points in group I and 84.6 points in group II (P < .01). There was recurrence in 35 patients (32.4%) in group I and 9 patients (16.4%) in group II (P < .05). All incidents of redislocation occurred during the first 21 postoperative months; 58.4% of the patients (n = 63) in group I and 16.4% of the patients in group II (n = 9) had to reduce their sporting activity (P < .001). Independent of the type of surgery, there was a significant correlation of the postoperative rate of redislocation and age (P < .001), number of preoperative dislocations (P < .01), and degree of labrum lesion (P < .001). No correlation with the rate of redislocation was shown for gender, handedness, dislocation-operation interval, degree of Hill-Sachs lesion, or number of transglenoid sutures or anchors. Concerning post-traumatic anterior shoulder instability, the arthroscopic labrum reconstruction with the suture anchor (FASTak) technique was superior to the transglenoid technique but has not yet achieved the level of success obtained by open surgery. With fewer than 5 preoperative redislocations after a first traumatic shoulder dislocation, the arthroscopic treatment is recommended. In cases of more frequent preoperative dislocations, open surgery in combination with a capsular shift should be performed.

Arthroscopic Bankart Repair of Anterior Detachments of the Glenoid Labrum. A Prospective Study*

The purpose of this study was to evaluate the results of an arthroscopic transglenoid suture-stabilization procedure in athletically active patients who had recurrent, unilateral, unidirectional anterior dislocations of the shoulder and an isolated anterior detachment of the glenoid labrum. Forty-one patients who had unilateral, unidirectional anterior dislocations of the shoulder and an isolated anterior detachment of the glenoid labrum were managed with arthroscopic repair. All patients were athletic, and seventeen of the male patients were football players. No patient had inferior or posterior laxity or a posterior detachment. The sutures were anchored to the posterior aspect of the scapula, and the knots were tied anteriorly to secure the detached region of the labrum and the inferior glenohumeral ligament to the anterior aspect of the scapula. The mean duration of follow-up was fifty-two months (range, twenty-five months to seven years). The patients were evaluated annually with a physical examination, radiographs, isokinetic strength-testing, the modified shoulder-rating scale of Rowe and Zarins, and the scoring system of the American Shoulder and Elbow Surgeons. Forty (98 percent) of the forty-one athletes returned to their preoperative sport postoperatively. Thirty-nine patients (95 percent) had no additional dislocations or subluxations, and two (5 percent), both of whom were football players, had a single episode of subluxation. Thirty-seven patients (90 percent) had a score of at least 80 points on the scale of Rowe and Zarins, and thirty-four (83 percent) had a score of at least 90 points. Thirty-nine patients (95 percent) had a score of at least 80 points on the scale of the American Shoulder and Elbow Surgeons, and twenty-five (61 percent) had a score of at least 90 points. Lower scores were associated with loose bodies seen on arthroscopy (p = 0.001), osseous lesions seen on postoperative radiographs (p = 0.036), and subluxation (p = 0.000). Twenty-two shoulders (54 percent) had a full range of motion in all planes, and eighteen (44 percent) had no strength deficit in any position on isokinetic testing. With the numbers available for study, no significant association was found between the presence of a Hill-Sachs or an osseous Bankart lesion on preoperative radiographs and the overall score on the scale of Rowe and Zarins or the scale of the American Shoulder and Elbow Surgeons; however, there was a significant association between the range of motion and an osseous Bankart lesion on preoperative radiographs (p = 0.002) and between decreased strength on isokinetic testing and a Hill-Sachs lesion on preoperative radiographs and an osseous lesion on postoperative radiographs (p = 0.022). There also was a significant association between a decreased range of motion (p < 0.002) and decreased strength (p = 0.014) and the arthroscopic finding of loose bodies. Muscle strength also was affected by arm dominance and the number of preoperative dislocations. Arthroscopic transglenoid repair of isolated anterior labral detachments restored stability of the shoulder and led to a favorable outcome in thirty-nine (95 percent) of the forty-one athletes. Only the two football players who had postoperative subluxation had a score of less than 80 points according to the scale of the American Shoulder and Elbow Surgeons.