Off-track Lesions Research Articles

The role of Hill-Sachs localization on the failure of arthroscopic shoulder stabilization. The results of a prospective cohort study

Objectives:Recurrent glenohumeral instability is frequently associated with glenoid and humeral bone loss. It is predictive of capsulolabral repair failure. However, the best way to quantify these shortcomings remains controversial. The aim of our study is to determine the best predictor of recurrent instability after arthroscopic shoulder stabilization.Methods:Over the past 10 years, all the patients recruited for shoulder stabilization surgery in 4 academic centers have been included in the prospective cohort called "LUXE". The ISIS score is used to stratify patients for surgery (Bankart, Bankart + Remplissage, Latarjet). Only patients with a preoperative CT scan with 3D reconstruction and clinical follow-up ≥1 year were included. Of a total of 262 patients included in the “LUXE” cohort, 103 met the inclusion criteria. The majority of patients were male (79%) with an average age of 28 years. The median number of dislocations before stabilization surgery was six. Bone deficits were measured on the 3D reconstructions using the Glenoid Clock and Ratio, the Humeral Clock and Ratio and the Glenoid Track methods and the angle of engagement of the Hill-Sachs lesion in the axial plane.Results:Seventy patients had arthroscopic stabilization and 33 a Latarjet procedure. The ISIS scores for the two groups were 2.7 and 4.8 (p<0.001) respectively. The average glenoid bone loss was 9+/-10% (0-37%), humeral bone loss was 15+/-6% (0-36%) and the angle of engagement of the Hill-Sachs lesion was 71+/-30° in external rotation. Fifty-three patients (51%) had an off-track lesion. Eighteen patients had recurrent instability after arthroscopic stabilization (23%) versus only 2 patients (6%) for Latarjets (OR= 4.6, p=0.034). Preoperative bone loss was not related to failure after a Latarjet procedure. The risk factors identified after arthroscopic stabilization were a lower engaging Hill-Sachs angle in external rotation (65° vs. 72°; p=0.05), less humeral bone loss (humeral clock of 42° vs. 58°; p=0.034) and an extended follow-up time (p=0.006). Glenoid bone loss, or the combined measurement (glenoid track) was not predictive of failure.Conclusion:Despite a lower ISIS score, arthroscopic management with Bankart +/- Remplissage is correlated with a significantly higher recurrence rate compared to the Latarjet procedure. Failure was related to humeral bone loss and to the morphology/orientation of the Hill-Sachs lesion rather than the volume of bone loss.

Distal tibia allograft glenoid reconstruction for shoulder instability: outcomes after lesser tuberosity osteotomy.

BackgroundDistal tibia allograft reconstruction of the glenoid in shoulder instability has garnered significant attention over the last decade. Prior studies demonstrate significant improvement in all reported patient outcomes albeit the approach is through a subscapularis split. There have not been prior studies evaluating outcomes after lesser tuberosity osteotomy which provides excellent exposure to the anterior glenoid.We hypothesize there is significant improvement in functional outcomes and no deleterious effects after lesser tuberosity osteotomy for distal tibia allograft reconstruction of the glenoid for shoulder instability.MethodsA retrospective review was performed from 2016 of 2019 of patients undergoing distal tibia allograft reconstruction of the glenoid through a lesser tuberosity osteotomy. Patients were indicated if they had recurrent anterior shoulder instability with >20% glenoid bone loss and evidence of an off-track lesion. Clinical, imaging, and operative data were evaluated. Objective follow-up data evaluated at minimum 2 years included radiographs, range of motion, DASH, SANE, VAS, SST, ASES, and Constant scores.ResultsA total of 12 patients were available with average follow-up 28 months, average age 26 years old, and average glenoid bone loss of 33%. The patients demonstrated significant improvement in their clinical outcomes at final follow-up: DASH 42.9-8.9 (P = .004), SANE 32.2-85 (P = .00005), VAS 4.6-1.1 (P = .003), SST 7-11.4 (P = .01), ASES 50.2-90.5 (P = .001), and Constant 37.6-86.2 (P = .01). Range of motion at final follow-up was forward flexion to 161.4° (135-170°), external rotation 49.5° (40-65°), and internal rotation to T12-L1 (T7-L2) vertebral body.ConclusionThe present study demonstrates the effectiveness of a lesser tuberosity osteotomy in exposure of the glenoid for reconstruction with a distal tibia allograft. The functional integrity of the subscapularis is maintained and the patient-reported outcomes are comparable with current literature.

Does an “Off-Track” Hill-Sachs Lesion That Is Misclassified as “Non-Engaging” Affect Outcomes From Bankart Repair Alone Compared With Bankart Repair Combined With Remplissage?

To determine how intraoperative assessment (engagement test) may affect recurrent dislocation rate and to compare the clinical outcomes, recurrence rates, and presence of on-/off-track conditions between cases that received arthroscopic Bankart repair alone (nonengaged Hill-Sachs lesion) and Bankart repair with remplissage (engaged Hill-Sachs lesion). We retrospectively reviewed 213 patients who underwent arthroscopic Bankart repair alone (186 patients with nonengaging lesions, group A) or with remplissage (27 patients with engaging lesion, group B) for recurrent anterior shoulder instability with <25% glenoid bone defect. The presence of an engaging Hill-Sachs lesion was determined during arthroscopic evaluation. On-track or off-track lesions were assessed retrospectively from preoperative 3-dimensional (3D) computed tomography (CT). Mean glenoid bone defect was 13.7% in group A and 20.7% in group B (P < .001). Off-track lesions were identified in 8.1% (15/186) and 100% (27/27) in group B. At the final follow-up (minimum 2 years; mean follow-up periods after surgery of 50.1 months in group A and 47.7 months in group B), there were no significant differences in shoulder functional scores and recurrence rates between groups, despite improvement after surgery. In the off-track lesion (group A-1: nonengaging but off-track lesion), recurrence instability occurred in 9 patients (60%, 9/15). Also, comparing group A-1 and group B, we noted significant differences in shoulder functional scores and recurrence rates (P < .001). Of 186 patients, 8.1% with nonengaging Hill-Sachs lesions during direct arthroscopic examination under anesthesia actually demonstrated off-track lesions on preoperative 3D CT scans retrospectively, with 60% experiencing recurrent instability. Intraoperative manual assessment for Hill-Sachs engagement was inferior to 3D CT scan in establishing the presence of off-track defects. III, retrospective comparative study.

Off-track Hill–Sachs lesions predispose to recurrence after nonoperative management of first-time anterior shoulder dislocations

The purpose of this study was to evaluate whether the presence of an off-track Hill-Sachs lesion has an impact on the recurrence rate after nonoperative management of first-time anterior shoulder dislocations. A retrospective cohort study was planned with a follow-up via questionnaire after a minimum of 24months. Fifty four patients were included in the study (mean age: 29.5years; 16 female, 38 male). All of these patients opted for primary nonoperative management after first-time traumatic anterior shoulder dislocation, in some cases even against the clinician's advice. The glenoid track and the Hill-Sachs interval were evaluated in the MRI scans. The clinical outcome was evaluated via a shoulder-specific questionnaire, ASES-Score and Constant Score. Further, patients were asked to report on recurrent dislocation (yes/no), time to recurrent dislocation, pain, feeling of instability and satisfaction with nonoperative management. In 7 (13%) patients, an off-track Hill-Sachs lesion was present, while in 36 (67%) the lesion was on-track and 11 (20%) did not have a structural Hill-Sachs lesion at all. In total, 31 (57%) patients suffered recurrent dislocations. In the off-track group, all shoulders dislocated again (100%), while 21 (58%) in the on-track group and 3 (27%) in the no structural Hill--Sachs lesion group had a recurrent dislocation, p = 0.008. The mean age in the group with a recurrence was 23.7 ± 10.1years, while those patients without recurrent dislocation were 37.4 ± 13.1years old, p < 0.01. The risk for recurrence in patients under 30years of age was higher than in those older than 30years (OR = 12.66, p < 0.001). There were no significant differences between patients with on- and off-track lesions regarding patients' sex, height, weight and time to reduction and glenoid diameter. Off-track patients were younger than on-track patients (24.9 ± 7.3years vs. 29.6 ± 13.6years). However, this difference was not statistically significant. The presence of an off-track Hill-Sachs lesion leads to significantly higher recurrence rates compared to on-track or no structural Hill--Sachs lesions in patients with nonoperative management and should be considered when choosing the right treatment option. Therefore, surgical intervention should be considered in patients with off-track Hill-Sachs lesions. IV.

Risk Factors for Recurrent Anterior Glenohumeral Instability Following a Primary Latarjet Procedure: A Prospective Analysis of 358 Patients

Objectives:The purpose of this study was to identify historical and demographic risk factors influencing failure rates and inferior clinical outcomes in patients reporting recurrent anterior glenohumeral instability following a primary Latarjet procedure. It was hypothesized that patients who have a greater risk of recurrent instability and worse clinical outcomes following a primary Latarjet procedure can be preoperatively identified on the basis of clinical, demographic, and radiological criteria.Methods:Between 2004 and 2014, patients who were treated with a primary Latarjet by the senior author (GDG) for unidirectional anterior shoulder instability were reviewed. Further inclusion criteria were ≥ 2 traumatic or atraumatic anterior instability events and physical examination and imaging findings consistent with anterior instability. Patients were excluded if they underwent previous ipsilateral shoulder surgery, had a rotator cuff tear, or had voluntary and/or multidirectional instability. Gender, age at first dislocation, duration of instability symptoms, number of dislocation events, age at surgery, bilateral instability, mechanism of dislocation, and quantification of glenoid and humeral head bone loss were recorded. Western Ontario Score Index (WOSI) and Single Assessment Numeric Evaluation (SANE) outcomes scores were collected at minimum five-year follow-up, along with clinical outcomes parameters including evidence of recurrent instability.Results:358 consecutive patients (372 shoulders) with a mean age of 29.2 years (range = 16 to 68 years) met inclusion criteria at a mean follow-up of 75 months (range = 61 to 89 months). There were 299 men (83.5%) and 59 women (16.5%), of which 86 had bilateral dislocations (24%). Bilateral Latarjet procedures were performed on 14 patients (4.1%). There was a total of 173 patients (48.3%) with an on-track lesion and glenoid bone loss ≤ 13.5%, 154 patients (43%) with on-track lesion but glenoid bone loss >13.5%, and 31 patients (8.7%) with off-track lesions. 17 patients (4.9%) experienced an instability episode following treatment with primary Latarjet. The mean WOSI was 818.2 ± 156.9 for recurrent instability patients while it was 296.4 ± 207.3 for patients with no postoperative instability (F1,356 = 104.6, p < 0.05). SANE scores were also lower in cases of recurrence (65.9 ± 9.0) when compared to patients that did not report postoperative recurrence (85.8 ± 8.1) (F1,356 = 98.4 p < 0.05). The mean WOSI score of bilateral instability subjects (438.6 ± 205.8) was higher than those with unilateral instability (256.3 ± 189.6) (F2,339 = 427.0; p < 0.05), while SANE was similarly worse for bilateral subjects (79.7 ± 8.4) compared to unilateral subjects (87.6 ± 7.1) (F2,339=23168.9; p < 0.05). The patients with atraumatic dislocations reported WOSI scores that were, on average, higher than those reported for patients with traumatic ones (396.3 ± 216.3 versus 270.6 ± 197.2, respectively; F2,339 = 380.7; p < 0.05) and mean SANE scores that were lower than the others (81.7 ± 9.4 versus 86.9 ± 7.3, respectively; F2,339 = 20,722.3; p < 0.05). The mean postoperative WOSI for female patients in this cohort was higher than that of males (397.3±227.9 and 276.5±197.4 respectively; F2,339 = 372.9; p < 0.05), while SANE was lower (82.6 ± 8.4 for females and 86.5±7.8 for males; F2,339 = 19959.6; p < 0.05). The mean postoperative WOSI for subjects who were between 31 and 40 years old at the first instability episode was higher (366.5 ± 236.6) than who were less than 30 years old (F4,337 = 181.1; p < 0.05). There was no significant difference across age groups with respect to postoperative SANE scores. The mean WOSI score for patients over 40 years old at the time of the surgery was higher (347.2 ± 269.0) than for those under 22 years old (233.3 ± 217.7) and those between 23 and 30 years old (272.0 ± 182.5; (F4,337 = 181.9; p < 0.05)). SANE scores were not significantly different with respect to patient age at the time of treatment. There was found to be no correlation between the pattern of bone loss (OFF-track, ON-track < 13.5%, ON -track > 13.5%) recurrent instability and clinical outcomes.Conclusion:4.9% of patients treated with primary Latarjet experienced recurrent anterior instability postoperatively. Preoperative risk factors included history of bilateral shoulder instability and atraumatic mechanism of dislocation. Poorer postoperative outcome scores independent of recurrent instability included age > 31 years, female gender, having more than seven instability events prior to surgery, bilateral instability, and atraumatic mechanism of first-time dislocation. This is the first clinical study to provide evidence behind specific demographic and historical factors that predispose patients to a greater risk of recurrent instability and inferior clinical outcomes following a Latarjet. This has implications on both clinical treatment and patient education to more accurately evaluate Latarjet candidates.

Outcomes of arthroscopic capsulolabral reconstruction for anterior instability with greater than 20% glenoid bone defects: are Latarjet procedures absolutely indicated for these patients?

BackgroundRecent studies have reported high rates of recurrence of shoulder instability in patients with glenoid bone defects greater than 20% after capsulolabral reconstruction. The purpose of the present study was to evaluate the failure rate of arthroscopic capsulolabral reconstruction for the treatment of anterior instability in the presence of glenoid bone deficits >20%.MethodsRetrospective analyses were conducted among cases with anterior shoulder instability and glenoid bone defects of >20% that were treated by arthroscopic capsulolabral reconstruction with a minimum 2-year follow-up (30 cases). We included the following variables: age, bone defect size, instability severity index score (ISIS), on-/off-track assessment, incidence recurrent instability, and return to sports.ResultsThe mean glenoid bone defect size was 25.8%±4.2% (range, 20.4%–37.2%), and 18 cases (60%) had defects of >25%. Bony Bankart lesions were identified in 11 cases (36.7%). Eleven cases (36.7%) had ISIS scores >6 points and 21 cases (70%) had off-track lesions. No cases of recurrent instability were identified over a mean follow-up of 39.9 months (range, 24–86 months), but a sense of subluxation was reported by three patients. Return to sports at the preinjury level was possible in 24 cases (80%), and the average satisfaction rating was 92%.ConclusionsArthroscopic soft tissue reconstruction was successful for treating anterior shoulder instability among patients with glenoid bone defects >20%, even enabling return to sports. Future studies should focus on determining the range of bone defect sizes that can be successfully managed by soft tissue repair.

Predicting Failure After Primary Arthroscopic Bankart Repair: Analysis of a Statistical Model Using Anatomic Risk Factors

The purpose of this study was to establish and analyze a simplified scoring system based on anatomic imaging measurements to predict recurrent instability after primary arthroscopic shoulder capsulolabral repair. All patients undergoing primary arthroscopic anterior capsulolabral repair of the shoulder were reviewed. Patients were contacted and charts were reviewed for endpoint of recurrent instability and return to prior level of activity. Predictive variables for recurrent instability studied included age, sex, amount of glenoid bone loss, intact anterior articular arc (IAAA), glenohumeral tracking (off-track), contact sports and overhead sports participation. 540 patients met inclusion criteria and follow-up data with magnetic resonance imaging data were available for 337 shoulders. Average follow-up was 6.2 years(range 3.4-9.3 years). Symptomatic recurrent instability occurred in 102 patients (30.3%) and 68% of contacted patients returned to pre-injury activities. In univariate analysis, age under 21 years, off-track lesions, IAAA <150°, and glenoid bone loss (GBL) of 10% or greater displayed an increased risk of recurrent instability. Multivariable analysis showed these factors remained significant: age <21 (odds ratio [ratio] 2.37), off-track glenoid (OR 2.86), IAAA <150 (OR 3.90), and GBL ≥10% (OR 7.47). A scoring system assigning 1 point each for age and off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10% yielded 79% sensitivity, 75% specificity, 58% positive predictive value, and 89% negative predictive value using a probability value of 20 percent for recurrent instability. At mid-term follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series. Younger age, glenoid bone loss of 10% or more, IAAA <150° and off-track glenoid lesion conferred the greatest risk for postoperative instability. We propose a scoring system assigning 1 point for age, 1 point for off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10%. This schema demonstrated moderate accuracy for predicting recurrent instability when using a cutoff threshold score above 2 points for failure. Level III, Retrospective Cohort Study.

Does Bone Loss Imaging Modality, Measurement Methodology, and Interobserver Reliability Alter Treatment in Glenohumeral Instability?

To determine, in the context of measuring bone loss in shoulder instability, whether measurement differences between magnetic resonance imaging (MRI) and computed tomography (CT), linear-based and area-based methods, and observers altered the proposed treatment when a standardized algorithm was applied. This was a retrospective, comparative imaging study of preoperative patients with anterior shoulder instability with both an MRI and CT scan within 1year of one another. On parasagittal images reoriented en face to the glenoid, 2 attending orthopaedic surgeons measured glenoid width, glenoid area, glenoid defect width, and glenoid defect area. On axial images maximal Hill-Sachs width was measured. From these, linear percent glenoid bone loss (%GBL) and area %GBL were calculated, and on-versus off-track was determined. With these results, a recommended treatment was determined by applying a standardized algorithm, in which the Latarjet procedure was selected for %GBL >20%, arthroscopic labral repair and remplissage for off-track lesions with %GBL <20%, and arthroscopic labral repair on-track shoulders with %GBL <20%. In total, 53 patients with mean ± standard deviation 45 ± 83days between scans were include with a CT linear %GBL of 23.5 ± 9.6% (range 0%-47%). CT lead to larger measurements of %GBL than MRI (linear P= .008, area P=.003), and fewer shoulders being considered on-track (33.0% vs 40.5%), which would alter treatment in 25% to 34%. Linear measurements produced larger values for %GBL (CT, P < .001; MRI, P < .001), which would alter treatment in 25%. For %GBL, inter-rater reliability was good, with intraclass correlation coefficients varying from 0.727 to 0.832 and Kappa varying from 0.57 to 0.62, but these inter-rater differences would alter treatment in 31%. The significant differences in bone loss measurement between imaging modality, measurement method, and observers may lead to differences in treatment in up to 34% of cases. Linear CT measurements resulted in the most aggressive treatment recommendations. Retrospective Comparative Study: Diagnostic, Level III.

Postoperative Recurrence of Instability After Arthroscopic Bankart Repair for Shoulders With Primary Instability Compared With Recurrent Instability: Influence of Bipolar Bone Defect Size

Background: In shoulders with traumatic anterior instability, a bipolar bone defect has recently been recognized as an important indicator of the prognosis. Purpose: To investigate the influence of bipolar bone defects on postoperative recurrence after arthroscopic Bankart repair performed at primary instability. Study Design: Cohort study; Level of evidence, 3. Methods: The study group consisted of 45 patients (45 shoulders) who underwent arthroscopic Bankart repair at primary instability before recurrence and were followed for at least 2 years. The control group consisted of 95 patients (95 shoulders) with recurrent instability who underwent Bankart repair and were followed for at least 2 years. Glenoid defects and Hill-Sachs lesions were classified into 5 size categories on 3-dimensional computed tomography and were allocated scores ranging from 0 for no defect to 4 for the largest defect. The shoulders were classified according to the total score for both lesions (0-8 points). The postoperative recurrence rate was investigated for each score of bipolar bone defects and was compared between patients with primary instability and patients with recurrent instability. The same analysis was performed for the age at operation (<20 years, 20-29 years, or ≥30 years) and for the presence of an off-track Hill-Sachs lesion. Results: Bipolar bone defects were smaller in shoulders with primary instability (mean ± SD defect score, 1.4 ± 1.5 points) than in those with recurrent instability (3.6 ± 1.9 points) and were larger in older patients than in younger patients at the time of primary instability. The postoperative recurrence rate was low (6.7%) in shoulders with primary instability regardless of the size of the bipolar bone defect and the patient’s age, whereas the postoperative recurrence rate was high (23.2%) in shoulders with recurrent instability, especially among patients younger than 20 years with bipolar bone defects of 2 points or greater. An off-track Hill-Sachs lesion was found in only 1 patient in the oldest age group (2.2%) at primary instability, but it was found in 19 patients (20%) at recurrent instability, including 14 patients younger than 30 years. Among patients with an off-track lesion, the postoperative recurrence rate was significantly higher in patients younger than 20 years with recurrent instability (recurrence rates: <20 years, 71.4%; 20-29 years, 14.3%; ≥30 years, 0%). Conclusion: The recurrence rate was consistently low in patients with primary instability and was significantly influenced by bipolar bone defect size and patient age in patients with recurrent instability.

Changes of Bipolar Bone Defect Size After Arthroscopic Bankart Repair for Traumatic Anterior Shoulder Instability: Evaluation Using a Scoring System and Influence on Postoperative Recurrence.

Background:The combination of a glenoid defect and a Hill-Sachs lesion in shoulders with traumatic anterior instability has been termed bipolar bone loss, and the preoperative size of these lesions has been reported to influence postoperative recurrence of instability after arthroscopic Bankart repair.Purpose:To investigate the influence of postoperative bipolar bone defect size on postoperative recurrence of instability.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 64 male collision/contact athletes (69 shoulders) were evaluated for a minimum of 2 years after surgery, and the pre- and postoperative sizes of both lesions (glenoid defect and Hill-Sachs) were evaluated retrospectively with 3-dimensional computed tomography. The sports played by the athletes included rugby (n = 28 shoulders), American football (n = 24 shoulders), and other collision/contact sports (n = 17 shoulders). Glenoid defects and Hill-Sachs lesions were classified into 5 size categories and assigned scores from 0 (no defect) to 4 (very large defect). Patients were then classified according to the total score (sum of the scores for both lesions). The influence of pre- and postoperative bipolar bone defect sizes on recurrence of instability was investigated by using the total scores for bipolar bone defects. The influence of postoperative glenoid morphology (normal preoperative glenoid, preoperative glenoid erosion, bone union after arthroscopic bony Bankart repair [ABBR], or nonunion after ABBR) was also investigated, as well as changes in shoulders with a preoperative off-track Hill-Sachs lesion.Results:Of 69 shoulders, 15 (21.7%) developed recurrent instability after surgery. The postoperative recurrence rate was 0% in shoulders with a total score ≤1, while the recurrence rate was consistently higher in shoulders with a total score ≥2 at both pre- and postoperative evaluation (mean, 28.8% and 32.6%, respectively). Postoperative recurrence was uncommon when there was a normal preoperative glenoid or bone union after ABBR, while it was frequent in shoulders with preoperative glenoid erosion or shoulders with nonunion after ABBR and a total score ≥2. An off-track lesion was recognized in 9 shoulders preoperatively. It was transformed to on-track lesions in 4 of the 5 shoulders showing bone union after ABBR, and there was no recurrence in the 5 shoulders with bone union. In contrast, postoperative recurrence of instability occurred in 3 of the 4 shoulders without bone union.Conclusion:Postoperative recurrence was influenced by the pre- and postoperative size of bipolar bone defects. Recurrence was uncommon if bone union was achieved after ABBR, even if there had been an off-track lesion preoperatively.

Remplissage Procedure: When and How?

Hill-Sachs lesions were first described in 1940 as grooved defect in the posterior aspect of the humeral head associated with traumatic anterior glenohumeral dislocation. The reported incidence of ...

Risk of Recurrent Instability After Arthroscopic Stabilization for Shoulder Instability in Adolescent Patients.

Background:With the rise of adolescent sports participation, there has been a concomitant increase in not only the incidence but also the treatment of traumatic shoulder instability. Yet, there have been limited data on the failure rates of arthroscopic shoulder stabilization in this population as well as the potential risk factors.Purpose/Hypothesis:The purpose of this study was to determine the failure rates of adolescent patients who underwent arthroscopic labral reconstruction for traumatic anterior shoulder instability. We hypothesized that adolescent failure rates would be significantly higher than what has been reported in the adult population with regard to recurrent instability after surgical intervention.Study Design:Case series; Level of evidence, 4.Methods:This was a retrospective cohort study performed at a single center. Inclusion criteria consisted of all adolescent-aged patients identified who (1) had traumatic anterior shoulder instability, (2) had radiographic findings consistent with anteroinferior capsulolabral injury, and (3) underwent arthroscopic shoulder stabilization. Patient demographics, clinical presentation, imaging, intraoperative findings, and postoperative outcomes were analyzed.Results:A total of 36 patients were identified, with a mean ± SD follow-up of 35.6 ± 13.8 months. The mean patient age at the time of the index procedure was 16.03 ± 1.67 years. All patients underwent arthroscopic shoulder stabilization consisting of arthroscopic Bankart repair. Twelve patients (33.3%) reported either recurrent instability or apprehension, of whom 9 (25.0%) developed recurrent dislocation/subluxation at a mean of 20.67 months postoperatively (range, 16-51 months). No single sport was associated with a statistically significant increased risk of redislocation, although a trend was seen toward those with postoperative participation in high-risk sporting activity. Patients who redislocated their shoulders had a higher frequency of a Hill-Sachs lesion on magnetic resonance imaging (89%) compared with those who did not (52%, P = .048). History of multiple preoperative dislocations, presence of bony Bankart pathology, off-track lesions, and number of anchors utilized were not associated with postoperative dislocation/subluxation.Conclusion:This study demonstrates that adolescent patients treated with arthroscopic shoulder stabilization have a high rate of recurrent instability. The adolescent population may benefit from other stabilization strategies and/or activity modification. Further studies are necessary to determine the reasons for the high rate of redislocation and to develop strategies for prevention.

A retrospective cohort analysis of arthroscopic Bankart repair with or without remplissage in patients with off-track Hill-Sachs lesion evaluated for functional outcomes, recurrent instability, and range of motion

Lone Bankart repair is associated with high rates of recurrence, especially in off-track Hill-Sachs (HS) lesion. The objective of the study was to assess the impact of remplissage in off-track HS lesion influencing the rate of redislocation and range of motion (ROM) of the shoulder. We retrospectively reviewed 136 patients for arthroscopic Bankart repair without remplissage (group 1, n = 77) or with remplissage (group 2, n =59) for recurrent anterior dislocation of the shoulder with glenoid bone loss of <25%. Further subgroups of on- and off-track HS lesion were based on computed tomographic assessment. At a minimum follow-up of 2 years; patients were evaluated for functional scores (Rowe, Constant-Murley, Western Ontario Shoulder Instability Index), redislocations, and ROM. At a mean follow-up of 54 and 44 months in group 1 and 2, respectively, there was no difference in postoperative functional scores. There were significantly more dislocations in patients with Bankart repair with off-track lesionthan in patients with Bankart repair with on-track lesion(P = .02). There were significantly fewer redislocations in patients with off-track lesion who underwent Bankart repair and remplissage than in those who did not undergo remplissage (P = .0007). Compared with group 1 patients, those in group 2 revealed a statistically significant loss of ROM. Although a nonremplissaged off-track HS lesion remains an important risk factor for recurrent instability, remplissage also results in significant loss of shoulder ROM compared with those who do not undergo remplissage.

Bipolar Bone Loss And Glenoid Bone Loss Alone are Both Associated with Failure After Arthroscopic Anterior Shoulder Stabilization

Objectives: Glenoid and humeral bone loss are both known risk factors for failure after anterior shoulder stabilization. Several models have previously been proposed to characterize bone loss and its association with recurrent instability. The purpose of this study was to determine the association of failure after arthroscopic anterior stabilization with three different models of shoulder instability. Methods: 128 individuals who underwent primary anterior shoulder stabilization between 2007-2015 were included in this study. Subjects were excluded on the basis of prior shoulder surgery, multidirectional instability, presence of connective tissue disorder, and concomitant rotator cuff pathology. Glenoid bone loss and Hill-Sachs lesion size were measured using previously reported methods. Cases were defined as individuals who sustained either a subluxation or dislocation event after the index procedure, while controls were defined as individuals who did not. The association between failure and three different models of instability were investigated. In the first model, a receiver-operating curve was constructed to determine the amount of glenoid bone loss alone that would best predict failure. In the second model, lesions were classified as on-track or off-track based on the glenoid track concept. In the third model, a distance-to-dislocation was determined based on the glenoid track concept. Combinations of glenoid bone loss and distance-to-dislocation were varied to determine the combination that was most closely associated with failure. T-test, chi-square, and Fisher exact testing was conducted to determine associations between categorical and continuous variables with failure. Results: There were 44 cases and 80 controls. There was no difference in age (p =.72) and sex (p= .69) between the two cohorts. Receiver-operator analysis of glenoid bone loss alone demonstrated that a threshold value of approximately 12% could best predict failure (AOC = 0.72). 21/25 (84%) of individuals with at least 12% bone loss failed surgery compared to 23/103 (22.3%) who had less than 12% bone loss (p &lt; .001). Using the glenoid track model, 4/4 (100%) of individuals with off-track lesions failed surgery compared to 40/124 (32%) with on-track lesions (p &lt; .001). Using a bipolar bone loss model, the combination thresholds of 9% glenoid bone loss and 11 mm distance-to-dislocation was associated with failure in 18/20 (90%) of subjects while 26/108 (24.1%) of subjects who did not meet this threshold failed surgery (p &lt; .001). Intra-rater reliability for glenoid bone loss (ICC = 0.79) and Hill-Sachs lesion size (ICC = 0.75) were excellent. Conclusion: In our study, a threshold value of 12% glenoid bone loss predicted failure following an arthroscopic Bankart repair and all off-track Hill-Sachs lesions failed as well. Further, when both glenoid bone loss and glenoid track were subcritical, the combined use of a bipolar bone loss model accurately predicted failure. This model may be particularly useful for lesions felt to be on the cusp but not beyond threshold values for critical glenoid bone loss and off-track Hill-Sachs defects.

Is CT scan a predictor of instability in recurrent dislocation shoulder?

PurposeGlenoid bone defect and the defect on the posterior-superior surface of the humerus “Hill-Sachs lesion” are the commonly seen bony lesions in patients with recurrent dislocation shoulder. Computed tomography (CT) scan is considered as the best option in assessing the bony defects in the recurrent dislocation shoulder. The aim of this study was to assess the clinical and radiological co-relation in the patients with recurrent dislocation shoulder. MethodsForty-four patients of recurrent dislocation shoulder who were evaluated between January 2015 and December 2017 at a tertiary care center, clinically and radiologically using CT scan and meeting the inclusion criteria, were included. The correlation between the clinical history of the number of dislocations and the bone loss using CT scan was evaluated. Two sided statistical tests were performed at a significance level of α = 0.05. The analysis was conducted using IBM SPSS STATISTICS (version 22.0). ResultsAll the patients were male with mean age of 25.95 (SD ± 4.2) years were evaluated. Twenty-four patients sustained injury in sporting activities while 20 patients sustained injury in training. There were an average of 4.68 (SD ± 3.1, range 2–15, median 3) episodes of dislocation. Forty-one patients had the glenoid bone loss while 40 had the Hill-Sachs lesions. The mean glenoid width defect was 10.80% (range 0–27%) while the mean Hill-Sachs defect was 14.27 mm (range 0–26.6 mm). The mean area of bone loss of the glenoid surface was 10.81% (range 0–22.4%). The lesions were on track in 34 patients and off track in 10 patients. ConclusionsCT scan of the shoulder joint is an effective method for assessing the amount of bone loss. The number of dislocations are correlated significantly with off-track lesions and the amount of bone loss on the glenoid and Hill-Sachs lesion. The glenoid width bone loss of more than 9.80% or Hill-Sachs defect of more than 14.80 mm are the critical defects after which the frequency of dislocations increases.

Arthroscopic Latarjet: Tips for Success

The Latarjet procedure remains the most favored technique in dealing with patients with recurrent shoulder instability, instability secondary to bony Bankart lesions, off-track lesions, bipolar lesions and in patients with Humeral avulsion of glenohumeral ligament (HAGL lesions). Traditionally this procedure has been performed as an open procedure; however, the Arthroscopic Latarjet procedure has been described with similar outcomes to that of open technique. This article describes our preferred technique for the Arthroscopic Latarjet procedure.

Surgical decision making based on the on-track/off-track concept for anterior shoulder instability: a case-control study

BackgroundThe purpose of this study was to assess the clinical outcomes of patients with anterior shoulder instability who underwent surgical treatment according to the on-track/off-track concept.MethodsWe retrospectively analyzed patients who underwent surgical treatment according to the glenoid track concept with a minimum of 2 years’ follow-up. By use of preoperative 3-dimensional computed tomography images, surgical options were selected: arthroscopic Bankart repair (ABR) for patients with on-track lesions and the Latarjet procedure or ABR with the remplissage procedure for patients with off-track lesions. The recurrence rate was assessed at 2-year follow-up after surgery.ResultsAmong 92 patients enrolled in this study, 81 had on-track lesions and underwent ABR. Of the 11 patients with off-track lesions, 1 underwent ABR with the remplissage procedure and 10 underwent the Latarjet procedure. Recurrences occurred in 4 patients treated by ABR (5%), whereas no recurrences were observed in off-track cases treated by the remplissage or Latarjet procedure.ConclusionClinical application of the on-track/off-track concept for determining surgical options in preoperative planning seems to be useful to prevent recurrent instability after surgery.

OUTCOMES OF ARTHROSCOPIC BANKART REPAIR IN THE PEDIATRIC AND ADOLESCENT POPULATION: HIGH RATES OF FAILURE

BACKGROUND Shoulder instability is an increasingly common problem in the pediatric and adolescent population. As with anterior cruciate ligament reconstruction, surgical intervention in this population is becomingly increasingly common. Yet, although failure rates are much higher in this active population there has been limited examination of this population in the literature. The purpose this study was to review treatment of adolescent shoulder instability and to discuss factors influencing its management; particularly recurrent instability. METHODS A retrospective cohort study was performed at a single center. Inclusion criteria consisted of all adolescent aged patients identified who (1) had complaints of shoulder instability, (2) had radiographic findings consistent with anterior-inferior capsulolabral injury, (3) had documented evidence of a dislocation event, and (4) underwent arthroscopic shoulder stabilization. Patient demographics, pre-operative history and physical, imaging, surgical details, and post-operative complications were analyzed. RESULTS Thirty-six patients were identified with a mean follow-up 3.07 ± 1.2 years. The average patient age at the time the index procedure was 16.03 ± 1.67 years. All patients underwent arthroscopic shoulder stabilization consisting of arthroscopic Bankart repair. Five patients also underwent a remplissage. Nine patients (25.0%) developed a repeat dislocation following surgery. This occurred on average 20.67 months postoperatively (range 5-51 months). No single sport was associated with a statistically significant increased risk of re-dislocation. American football was the most common sport in both the stable and re-dislocated groups. Patients who re-dislocated had a higher frequency of a Hill-Sachs lesion on MRI (89%) compared to those who did not re-dislocate (52%) (p=0.048). Off-track lesions were not associated with repeat instability. CONCLUSIONS / SIGNIFICANCE The current study demonstrates that adolescent patients treated with arthroscopic shoulder stabilization have a high rate of recurrence of shoulder dislocations, particularly in the setting of a concomitant Hills-Sachs lesion. Patients may benefit from more aggressive stabilization strategies and techniques. Further prospective multi-center studies are necessary to determine the reasons for the high rate of re-dislocation in this population and develop strategies for prevention.

Off-track Hill-Sachs lesions do not increase postoperative recurrent instability after arthroscopic Bankart repair with selective Remplissage procedure.

This study aimed to compare clinical outcomes and recurrence rates after arthroscopic Bankart repair with selective Remplissage procedure, between patients with off-track and on-track Hill-Sachs lesions. Patients who underwent arthroscopic Bankart repair with selective Remplissage procedure for recurrent anterior shoulder instability and were followed up for at least 2years were included. Patients with a glenoid defect greater than 25% were excluded. According to the glenoid track concept, patients were divided into group I (off-track lesions) and group II (on-track lesions). After Bankart repair, an additional Remplissage procedure was performed selectively in patients who sustained engagement of the humeral head. The clinical outcomes and recurrence rates were evaluated. A total of 193 patients (23 in group I and 170 in group II) were enrolled. No significant differences were found in clinical outcomes (n.s.) or recurrence rates (n.s.) between the two groups, despite larger glenoid defects in group I (group I:17.1 ± 6.1%, and group II:13.0 ± 6.4%, P = 0.003). In all patients, the incidence of off-track lesions was not significantly different according to the occurrence of postoperative recurrence (n.s.), whereas the glenoid defect size showed a significant difference (with recurrence: 17.9 ± 3.9%, and without recurrence: 13.2 ± 6.5%, P = 0.002). The presence of an off-track lesion did not alter the clinical outcomes and recurrence rates after arthroscopic Bankart repair with selective Remplissage procedure. The glenoid defect size rather than the presence of an off-track lesion can more reliably predict postoperative recurrence. Arthroscopic Bankart repair with selective Remplissage procedure is considered one surgical option for the treatment of off-track lesions. III.

The Development Process of Bipolar Bone Defects From Primary to Recurrent Instability in Shoulders With Traumatic Anterior Instability

Background: Recurrence of glenohumeral joint instability after primary traumatic anterior instability is not rare, and bipolar bone loss is one of the most critical factors for recurrent instability, but the development process of bipolar bone defects is still unclear. Purpose: To investigate the development process of bipolar bone defects from primary to recurrent instability among shoulders with traumatic anterior instability evaluated at least twice by computed tomography (CT). Study Design: Case series; Level of evidence, 4. Methods: There were 44 patients (47 shoulders) with recurrence after primary instability in which bone morphology was evaluated by 3-dimensional reconstructed CT at primary instability (initial CT) and after recurrence. As CT was performed 3 times for 3 shoulders including primary injury and the second episode of instability (first recurrence), there were 50 CT evaluations. Morphological changes between the initial CT evaluation at primary instability and the second CT evaluation at first recurrence were investigated for 25 shoulders, with the mean interval since initial CT being 9.8 months (range, 2-23 months). Changes between initial CT evaluation and final CT evaluation after ≥2 recurrences were also investigated for 25 shoulders, while the mean number of instability episodes including primary instability was 8.0 (range, 3-40) and the mean interval since initial CT was 18.5 months (range, 5-56 months). Results: At primary instability, the prevalence of Hill-Sachs lesions (66.0%) was almost double that of glenoid defects (34.0%), but their prevalence was different between shoulders with primary subluxation (42.3% and 23.8%, respectively) and those with primary dislocation (84.7% and 42.3%, respectively). After recurrence, glenoid defects became significantly more frequent (at first recurrence, 72%; after ≥2 recurrences, 76%), while Hill-Sachs lesions showed a smaller increase (88% and 80%, respectively), so there was no difference between the prevalence of the 2 lesions. The sizes of glenoid defects and Hill-Sachs lesions also enlarged after recurrence, and large bone defects were frequently recognized after recurrence. While bipolar bone loss was not so frequent at primary instability (29.8%), bipolar bone loss increased significantly after recurrence (at first recurrence, 72%; after ≥2 recurrences, 72%). All Hill-Sachs lesions were on track at primary instability, but off-track lesions were recognized in 3 of 47 shoulders (6.4%) after recurrence. Conclusion: In most shoulders with recurrent instability, a Hill-Sachs lesion developed first, followed by a glenoid defect, leading to bipolar bone loss. Off-track Hill-Sachs lesions were detected only after recurrence.