Rate Of Recurrent Dislocation Research Articles

Arthroscopic Bankart with remplissage results in lower rates of recurrent instability with similar range of motion compared to isolated arthroscopic Bankart for anterior glenohumeral instability: Asystematic review and meta-analysis.

The addition of the remplissage procedure to an arthroscopic Bankart procedure has been shown to improve clinical outcomes, yet at the expense of potentially decreasing shoulder range of motion. The purpose of this study was to assess recurrent instability, range of motion, functional outcomesand rates of return to sport outcomes in patients undergoing an isolated arthroscopic Bankart repair compared to those undergoing arthroscopic Bankart repair in addition to the remplissage procedure. According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, a search was conducted using threedatabases (MEDLINE/OVID, EMBASEand PubMed). Retrieved studies were screened based on predefined inclusion and exclusion criteria for comparative studies. Data were extracted and meta-analysis performed using a random-effects model. A total of 16 studies (13 level III studies, 2 level II studiesand 1 level I) were included with a total of 507 and 704 patients in the Bankart plus remplissage and isolated Bankart repair groups, respectively. No studies reported glenoid bone loss of >20% with the least percentage of glenoid bone loss reported amongstudies being <1%. There was a significantly increased rate of recurrent dislocations (odds ratio [OR] = 4.22, 95% confidence interval [CI]: 2.380-7.48, p < 0.00001) and revision procedures (OR = 3.36, 95% CI: 1.52-7.41, p = 0.003) in the isolated Bankart repair group compared to the Bankart plus remplissage group. Additionally, there were no significant differences between groups in terms of external rotation at side (n.s.), in abduction (n.s.)or at forward flexion (n.s.) at final follow-up. Furthermore, return to preinjury level of sport favoured the Bankart plus remplissage group (OR = 0.54, 95% CI: 0.35-0.85, p = 0.007). Patients undergoing arthroscopic Bankart plus remplissage for anterior shoulder instability have lower rates of recurrent instability, higher rates of return to sport, and no significant difference in range of motion at final follow-up when compared to an isolated arthroscopic Bankart repair. Further large, prospective studies are needed to further determine which patients and degree of bone loss would benefit most from augmentation with the remplissage procedure. Level III.

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.

Recurrent Instability After Arthroscopic Bankart Repair in Patients With Hyperlaxity and Near-Track Lesions.

Recurrent anterior shoulder instability after arthroscopic Bankart repair presents a challenging clinical problem, with the primary stabilization procedure often portending the best chance for clinical success. To determine if capsuloligamentous laxity affects failure (recurrent dislocation, subluxation, and/or perceived instability symptoms) after arthroscopic Bankart repair in patients with near-track lesions (ie, those with smaller distance to dislocation [DTD]). Case-control study; Level of evidence, 3. The authors retrospectively reviewed consecutive patients who underwent primary arthroscopic Bankart repair for recurrent anterior glenohumeral instability at a single institution between 2007 and 2019 and who had at least 2 years of follow-up data. Patients with glenoid bone loss >20%, off-track lesions, concomitant remplissage, or rotator cuff tear were excluded. Capsuloligamentous laxity, or hyperlaxity, was defined as external rotation >85° with the arm at the side and/or grade ≥2 in at least 2 planes with the shoulder at 90° of abduction. Near-track lesions were defined as those with a DTD <10 mm. Included were 173 patients (mean age, 20.5 years; mean DTD, 16.2 mm), of whom 16.8% sustained a recurrent dislocation and 6.4% had recurrent subluxations (defined as any subjective complaint of recurrent instability without frank dislocation), for an overall recurrent instability rate of 23.1%. The rate of revision stabilization was 15.6%. The mean time to follow-up was 7.4 years. Independent predictors of recurrent instability were younger age (P = .001), smaller DTD (P = .021), >1 preoperative instability episode (P < .001), and the presence of hyperlaxity during examination under anesthesia (P = .013). Among patients with near-track lesions, those with hyperlaxity had a recurrent instability rate almost double that of patients without hyperlaxity (odds ratio, 34.1; P = .04). The increased rate of failure and recurrent dislocation in the near-track hyperlaxity cohort remained elevated, even in patients with no bone loss. Capsuloligamentous shoulder laxity was a significant independent risk factor for failure after primary arthroscopic Bankart repair without remplissage and was more predictive of failure in patients with versus without near-track lesions.

Poster 165: Non-Rigid Fixation Results in Higher Failure Rates Following Arthroscopic Glenoid Reconstruction

Objectives: It has previously been established that screw fixation results in better outcomes than button fixation for arthroscopic anatomic glenoid reconstruction (AAGR) with frozen allograft. There has been considerable debate on the causes for the higher dislocation rates with non-rigid fixation. The purpose of this study was to evaluate which factors may affect failure rates for AAGR with non-rigid fixation. Methods: This was a retrospective review of patients who had AAGR using non-rigid fixation that were age-, gender-, and followup-matched with screw fixation patients. Arthroscopic videos were used to evaluate surgical factors including graft placement, fixation quality, tensioning, graft contact, soft tissue quality, quality of soft tissue repair, presence of Hill-Sachs, and addition of Remplissage. Patient demographic factors (age, gender, medical history etc) were also assessed. XRays and CTs were used to evaluate graft union, screw and button angle, graft remodeling, and button pull through. Results: A total of 36 patients were included in our study who had AAGR between 2014 and 2019 (18 non-rigid fixation matched to 18 screw fixation). Seven patients who had non-rigid fixation had a dislocation requiring reoperation. Of these, 4/7 had poor anterior soft tissue. All but one patient had excellent soft tissue repair and balance at end of surgery. All seven patients had complete graft resorption compared with those did not fail who had a normal post-operative glenoid A-P dimension. Conclusions: In our case series, AAGR with non-rigid fixation had high rate of recurrent dislocation. These failed patients had appropriate surgical factors that were equivalent between dislocated patients and successful patients. The failure rate was not correlated with surgical technique, patient or radiographic factors but rather only fixation type. Further study is needed to evaluate fixation methods and to assess whether type of graft impacts these clinical outcomes.

Poster 184: Demographics and Outcomes of Shoulder Instability in Individuals with Elevated Body Mass Index

Objectives: Traumatic shoulder dislocations in the adolescent, active adult, and elderly have been well studied. However, to our knowledge, no specific study has investigated the characteristics and outcomes of anterior shoulder dislocations in morbidly obese individuals. The objective of this study is to describe shoulder dislocations in patients with body mass index (BMI) greater than 40. Methods: A retrospective chart review was performed to identify patients 18 years of age and older with a BMI greater than or equal to 40 who presented with a shoulder dislocation within a single institution from 2000-2020 were included in this study. Patients who had a BMI of less than 40, sustained a periprosthetic shoulder dislocation, and patients who were pregnant were excluded from this study. Dislocation pattern, associated injuries, treatment modalities, and associated complications were recorded. Complications were defined to include recurrent instability as demonstrated by a single recurrent dislocation event, infection, arthrofibrosis, and associated neurovascular injury. Results: Seventy-seven patients were included in our study. Fifty-two patients (67.5%) were female. Average age was 47.95 ± 2.06 (range 18-81), with average BMI of 45.01 ± 5.67 (range 40-78). Mean follow up for our patient cohort was 411.5 days (1.13 years). Sixty-five dislocations (84%) were due to a ground level fall whereas 8 (10%) were due to assault and 4 (5%) were due to a motor vehicle collision (MVC) (p&lt;0.01). There was a significant increase in the number of patients with BMI greater than 40 presenting per year (r2 = - 0.831, p &lt; 0.01) over the past 20 years. In addition, there was also a significant increase in the average BMI per year in this population (r2 = 0.504, p=0.028). Fifteen patients (19.5%) experienced at least one recurrent dislocation episode, with average time to recurrent dislocation of 449 days (1.23 years). Hill-Sachs lesions were the most common associated injury (p=0.03). Bankart lesions were the only associated injury that were found to be associated with an elevated BMI (p = 0.04), Nine patients (11.7%) sustained an associated neurologic injury which was found to have no association with BMI. There were 56 patients (72.7%) who were managed non-operatively and 21 patients (27.3%) who underwent surgical intervention. One patient failed nonoperative management and arthroscopic stabilization, going on to require shoulder arthrodesis and biceps tenodesis. They subsequently developed a post-operative infection necessitating revision arthrodesis. Conclusions: Over time, there has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations. These injuries most commonly happen due to low energy mechanisms and can be associated with Bankart lesions and associated neurologic injuries. There was a recurrent dislocation rate of 19.5%, which is consistent with this age cohort. As the current trend continues it will become increasingly important to better understand these injuries. Morbidly obese patients may incur higher health care costs and resource expenditure to treat such injuries. In addition, appropriate patient education and outcome expectations for nonoperative and operative treatment should be provided given the high risk of recurrent dislocations in this patient population.

Remplissage reduces recurrent instability in high-risk patients with on-track Hill-Sachs lesions.

The purpose of this study was to compare recurrent instability rates between patients with on-track Hill-Sachs lesions who underwent arthroscopic labral repair (ALR) alone and those who underwent ALR with remplissage (ALR-R). Our hypothesis was that ALR-R would decrease the rate of recurrent instability, especially among patients at high risk of recurrent instability after ALR, such as contact athletes with near-track Hill-Sachs lesions. We performed a multicenter, retrospective analysis of patients aged 14-50 years with on-track Hill-Sachs lesions who underwent ALR-R or ALR without remplissage between January 2014 and December 2019 with minimum 2-year follow-up. The exclusion criteria included prior ipsilateral shoulder surgery, >15% glenoid bone loss (GBL), off-track Hill-Sachs lesion, concomitant shoulder procedure, and connective tissue disorder. Age, sex, follow-up, and contact sports participation were recorded. GBL, Hills-Sachs interval (HSI), glenoid track, and distance to dislocation (DTD) were determined from preoperative magnetic resonance imaging scans. Affected-shoulder range of motion, Western Ontario Shoulder Instability Index scores, Subjective Shoulder Value scores, and recurrent dislocation and/or revision surgery status were also collected. A subgroup analysis was performed on "high-risk" patients (defined as participants in contact sports with DTD <10 mm) from each cohort. The ALR-R cohort included 56 patients, and the ALR cohort included 127. ALR-R patients had greater GBL (P=.004) and a greater HSI (P<.001). In the ALR-R cohort, only 1 patient (1.8%) had a recurrent dislocation and there were no revision operations. In comparison, in the ALR cohort, 14 patients (11.0%) had recurrent dislocations (P=.040) and 8 (6.3%) underwent revision operations (P=.11). Univariate analysis showed that remplissage protected against recurrent dislocation (P=.040) whereas younger age (P=.004), contact sports participation (P=.001), and increased GBL (P=.048) were associated with recurrent dislocation. Multivariate analysis showed that HSI (P=.001) and contact sports participation (P=.002) predicted recurrent dislocation. Among high-risk patients, only 1 patient (4.2%) in the ALR-R group had a recurrent instability event vs. 6 (66.7%) in the ALR group (P<.001). The high-risk ALR-R subgroup also had significantly better final Western Ontario Shoulder Instability Index (P=.008) and Subjective Shoulder Value (P=.001) scores than the high-risk ALR subgroup. Anterior shoulder instability patients with on-track Hill-Sachs lesions have lower recurrent dislocation rates after ALR plus remplissage when compared with ALR alone. This is especially true for high-risk patients, such as contact athletes with a DTD <10 mm.

Combined quadriceps medial patellofemoral ligament reconstruction and osteochondral fixation offers good patient-reported outcomes and low rates of recurrent instability for osteochondral defects secondary to acute patella dislocation.

Chondral injuries secondary to traumatic patella dislocation are common, and a subgroup of these are significant defects with fragments amenable to fixation. There is a paucity of published evidence assessing patients managed with combined acute patellofemoral stabilisation and osteochondral fixation. The purpose of this study is to report the outcomes of patients with osteochondral injuries secondary to acute traumatic patella dislocation treated with combined early fragment fixation and MPFL reconstruction using a quadriceps tendon turndown technique which has distinct advantages for this cohort, including preventing chondral overloading and non-violation of the patella bone. Patients who underwent combined quadriceps tendon MPFL reconstruction and osteochondral fixation were included. Patient demographics, defect characteristics, complications and reoperations were evaluated. Patients were assessed with Lysholm, Kujala, KOOS-PF scores and satisfaction scale at follow up. Pre-operative MRI was assessed for presence of radiological risk factors for patella dislocation and post-operative MRI was used to assess cartilage quality with MOCART 2.0 score. A total of 19 patients (63.2% female) were included. The mean age was 17.4 ± 4.8years and patients were followed up at a mean 15.8 ± 5.1months post-surgery. The mean defect size was 2.4 cm2 ± 1.3 cm2, with the most common defect location being the patella (13/19; 68.4%) followed by the lateral femoral condyle (5/19; 26.3%). At final follow up, the overall mean Lysholm, Kujala, and KOOS-PF scores were 84.9 ± 11.1, 89.7 ± 5.8 and 80.6 ± 13.6, respectively. Seventeen patients (89.5%) were satisfied with their outcome. The mean MOCART 2.0 score at final follow-up was 72.5. One patient required medial capsular plication with removal of a loose chondral body and microfracture and 3 knees required minor reoperations. Combined acute osteochondral fragment fixation and MPFL reconstruction using a quadriceps tendon graft offers good radiological and patient-reported outcomes with high satisfaction and low rates of recurrent patella dislocation. To our knowledge, this is currently the largest series of its kind in the literature and the results of this study provide a rationale for a combined approach using a quadriceps tendon graft for this cohort. Level IV.

Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation With Comparable Clinical Outcomes

The purpose of this study was to compare rates of recurrent dislocation and postsurgical outcomes in patients undergoing arthroscopic Bankart repair for anterior shoulder instability immediately after a first-time traumatic anterior dislocation versus patients who sustained a second dislocation event after initial nonoperative management. A retrospective chart review was performed of patients undergoing primary arthroscopic stabilization for anterior shoulder instability without concomitant procedures and minimum 2-year clinical follow-up. Primary outcome was documentation of a recurrent shoulder dislocation. Secondary clinical outcomes included range of motion, Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Shoulder Activity Scale (SAS). Seventy-seven patients (mean age 21.3 years ± 7.3 years) met inclusion criteria. Sixty-three shoulders underwent surgical stabilization after a single shoulder dislocation, and 14 underwent surgery after 2 dislocations. Average follow-up was 35.9 months. The rate of recurrent dislocation was significantly higher in the 2-dislocation group compared to single dislocations (42.8% vs 14.2%, P= .03). No significant difference was present in range of motion, VAS, ASES, and SAS scores. The minimal clinically important difference (MCID) was 1.4 for VAS and 1.8 for SAS scores. The MCID was met or exceeded in the primary dislocation group in 31/38 (81.6%) patients for VAS, 23/31 (74.1%) for ASES, and 24/31 for SES (77.4%) scores. For the second dislocation cohort, MCID was met or exceeded in 7/9 (77.8%) for VAS, 4/7 (57.1%) for ASES, and 5/7 for SES (71.4%) scores. Immediate arthroscopic surgical stabilization after a first-time anterior shoulder dislocation significantly decreases the risk of recurrent dislocation in comparison to those who undergo surgery after 2 dislocation events, with comparable clinical outcome scores. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and sustain just 1 additional dislocation event are at increased risk of a failing arthroscopic repair. Retrospective comparative study; Level of evidence,3.

Distance to Dislocation and Recurrent Shoulder Dislocation After Arthroscopic Bankart Repair: Rethinking the Glenoid Track Concept

Background: The “distance to dislocation” (DTD) calculation has been proposed as 1 method to predict the risk of recurrent dislocation after arthroscopic Bankart repair for an “on-track” shoulder. Rates of recurrent dislocation at specific DTD values are unknown. Hypothesis: Among patients with “on-track” shoulder lesions who underwent primary arthroscopic Bankart repair, the rate of recurrent dislocation would increase as DTD values decrease. Study Design: Case-control study; Level of evidence, 3. Methods: We performed a retrospective analysis of 188 patients with “on-track” shoulder lesions who underwent primary arthroscopic anterior labral repair between 2007 and 2019, with a minimum 2-year follow-up. Glenoid bone loss, Hill-Sachs interval, glenoid track, and DTD were determined from preoperative magnetic resonance imaging scans. The rate of recurrent dislocation was determined at 2-mm DTD intervals. Univariate and multivariate regression analyses were used to evaluate the relationship between recurrent dislocation, patient characteristics, and bone loss variables. A multivariate regression model was created to predict the probability of failure at continuous DTD values. A subgroup analysis of failure rate based on collision sports participation was also performed. Results: A total of 29 patients (15.4%) sustained recurrent dislocations. Patient age (P = .046), multiple dislocations (P = .03), glenoid bone loss (P < .001), Hill-Sachs interval length (P < .001), and DTD (P < .001) were all independent predictors of failure. As the DTD decreased, the rate of recurrent dislocation increased. Below a DTD threshold of 10 mm, the recurrent dislocation rate increased exponentially. Up to a threshold of 24 mm, the failure rate for collision athletes remained >12.3%, independent of the DTD. Conversely, the failure rate among noncollision athletes decreased steadily as the DTD increased. Conclusion: For “on-track” shoulder lesions, as the DTD approached 0 mm (“off-track” threshold), the risk of recurrent dislocation after arthroscopic Bankart repair increased significantly. Below a DTD threshold of 10 mm, the risk of failure increased exponentially. The risk of recurrent dislocation for collision sports athletes remained elevated at higher DTD values than for noncollision athletes.

Analysis of the effectiveness of coracoid osteotomy and concentric coaxial reconstruction of the glenoid cavity in the treatment of recurrent anterior dislocation of the shoulder joint

Objective: To investigate the clinical efficacy of the modified Latarjet procedure in the treatment of recurrent anterior subluxation of the shoulder by "coaxial co-arc" reconstruction of the glenoid cavity. Methods: The clinical data of 103 cases (106 shoulders) of recurrent anterior dislocation of the shoulder admitted to the First Affiliated Hospital of the Army Military Medical University from January 2005 to December 2020 were retrospectively studied. Out of these cases, 84 were males and 19 were females; 31 with left-sided injuries while 75 with right-sided injuries, with a mean age of (29.4±11.5) years (16-61 years). The preoperative anterior fear test was positive, and a modified Latarjet procedure was used to reconstruct the shoulder glenoid defect through a "coaxial co-arc". The Rowe score, simple shoulder test (SST) score, and Visual analogue scale (VAS) score of pain were used to assess the shoulder's function. Parameters such as the postoperative shoulder recurrent dislocation rate, shoulder body external rotation angle, and subscapularis muscle strength changes were recorded postoperatively. Moreover, radiographs and CT scans were used to check for the incidence of osteoarthritis (Samson-Prieto score). Results: After a mean follow-up of 9.0 years (1 to 16 years), bony healing occurred 3 to 6 months postoperatively. The Rowe score improved from 40.4±6.5 preoperatively to 93.2±2.5 (P<0.001), the SST score improved from 5.2±1.3 preoperatively to 10.1±1.5 (P<0.001), and the VAS pain score decreased from 3.5±1.9 preoperatively to 1.1±1.2 (P<0.001) at the final follow-up. The angle of lateral external rotation of the shoulder joint was 58.8°±15.6° preoperatively and 57.6°±14.5° postoperatively with no statistically significant difference (P>0.05). There was no statistically significant difference in the measurement of subscapularis muscle strength between the healthy side and the affected side (P>0.05). In 89.6% of patients after surgery, coaxial co-arc reconstruction of the shoulder glenoid was obtained, and the shoulder glenoid defect and postoperative inclusion angle were significantly improved compared with those before surgery (P<0.001). Postoperatively, new-onset osteoarthritis developed in 7 cases (7/98), arthritis progressed in 2 cases (2/8), incisional healing was poor in 2 cases (2/98), and revision surgery was performed in 2 cases (2/98) due to bone mass detachment. Conclusion: Coracoid osteotomy and concentric coaxial reconstruction of the glenoid cavity elicits adequate good clinical efficacy for cases of recurrent anterior shoulder dislocation, with low recurrence rates, low revision rates and low incidence of osteoarthritis.

Poster 152: Arthroscopic Bankart Repair Following a Second Dislocation Results in Increased Failure Rates Compared to Immediate Repair After Following a Traumatic First Time Dislocation

Objectives:Many surgeons will consider nonoperative treatment following a 1st time dislocation and will consider operative management if a second instability event occurs particularly for the in season athlete. The objective of this study was to compare rates of recurrent dislocation and post-surgical outcomes in patients undergoing arthroscopic bankart repair for anterior shoulder instability immediately following a 1st time traumatic anterior dislocation versus patients who sustained a 2nd dislocation event following initial conservative management. We hypothesized that patients sustaining a 2nd anterior shoulder dislocation would be more at risk for recurrent dislocations after arthroscopic repair and secondarily, would have worse objective and subjective outcomes.Methods:This was a retrospective chart review identifying all patients undergoing primary arthroscopic surgical stabilization for anterior shoulder instability between 2013-2019 at a single academic institution. Demographics, clinical history, physical exam, imaging, operative details, and postoperative course was reviewed. Patients were eligible for inclusion if they underwent arthroscopic Bankart repair without remplissage sustained one or two dislocation events and were clinically followed for a minimum of 12 months postoperatively. Exclusion criteria included posterior instability, multidirectional instability, and previous stabilization surgery, Primary outcome was documentation of recurrent shoulder dislocation during the postoperative period. Secondary clinical outcome measures were assessed including need for revision surgery, need for manipulation under anesthesia (MUA), range of motion, strength, Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), PROMIS mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Brophy shoulder activity scores.Results:A series of 89 patients (mean age 21.3 years ± 7.3 years) met criteria for inclusion. 72 shoulders underwent surgical stabilization after a single shoulder dislocation event and 17 underwent surgery after sustaining two documented shoulder dislocations. No significant difference in demographic and radiographic characteristics, including presence of bony Bankart and off-track Hill Sachs lesions, was present between the groups. The rate of recurrent dislocation was significantly higher in the multiple dislocation group compared to single dislocations (31% vs 12%, p=0.048). There was a trend toward increased rate of revision stabilization in the 2nd dislocation group which did not reach statistical significance (22% vs 58%, p=0.167). No significant difference was present in the need for revision surgery, need for MUA, conversion to Latarjet procedure, range of motion, supraspinatus strength, VAS, PROMIS, ASES, and Brophy scores between the groups.Conclusions:Immediate surgical stabilization following a 1st time dislocation significantly diminishes the risk of recurrent dislocation in comparison to those who undergo surgery following two dislocation events. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and undergo surgical stabilization following just one additional event are at increased risk of failure following surgery. Furthermore, patients who have sustained even one additional dislocation from the primary event may benefit from more aggressive approaches may be necessary including arthroscopic approaches with augmentation or open approaches. Despite differences in recurrence rates, both groups achieved excellent subjective functional outcomes at a minimum of 12 months after surgery.

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.

Beach Chair Versus Lateral Decubitus Surgical Positioning for Arthroscopic Anterior Shoulder Stabilization: A Retrospective Comparison of Clinical and Patient-Reported Outcomes.

Background:Surgical positioning can affect both perioperative and postoperative complication rates. It is unclear whether beach-chair versus lateral decubitus positioning affects outcomes in patients undergoing arthroscopic anterior shoulder stabilization surgery.Purpose:The purpose of this study was to compare recurrent instability, complications, and patient-reported outcomes between patients who underwent arthroscopic anterior shoulder stabilization in the beach-chair versus the lateral decubitus positions. It was hypothesized that recurrent instability, complications, and patient-reported outcomes would not be affected by surgical positioning.Study Design:Cohort study; Level of evidence, 3.Methods:The authors reviewed the medical records of patients who underwent shoulder stabilization (Current Procedural Terminology codes 29806 and 29807) from 2015 to 2019. Patients were included only if anterior instability was confirmed, arthroscopic surgery was performed in response to shoulder instability, and a minimum of 2 years of follow-up data were available. Data collected for eligible patients included perioperative and postoperative complications, recurrent instability, reoperation, and revision. Patients also completed surveys for the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Oxford Shoulder Instability (OSI) score, and a return to any level of sport (RTS) questionnaire.Results:Overall, 294 patients (162 lateral decubitus and 132 beach-chair positions) were included, with an average follow-up of 2.4 ± 1.6 years. There were no significant differences in demographics between groups, nor were there differences in the rates of postoperative dislocations, subjective instability, reoperations, revisions, or complications. There was a trend toward a higher revision rate in the beach-chair group (beach-chair, 6.1% vs lateral decubitus, 1.9%; P = .069). There was no significant difference between groups regarding RTS rates or postoperative ASES, SANE, and OSI scores at 3.3 ± 1.1 years postoperatively.Conclusion:Surgical positioning for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, and patient-reported outcomes. Both beach-chair and lateral decubitus positioning provided good outcomes for anterior shoulder stabilization, with an overall recurrent dislocation rate of 7.8% at a mean of 3.3 years after surgery.

MPFL reconstruction results in lower redislocation rates and higher functional outcomes than rehabilitation: a systematic review and meta-analysis.

To determine the effect of early MPFL reconstruction versus rehabilitation on the rate of recurrent patellar dislocations and functional outcomes in skeletally mature patients with traumatic, first-time patellar dislocation. Three online databases MEDLINE, PubMed and EMBASE were searched from database inception (1946, 1966, and 1974, respectively) to August 20th, 2021 for literature addressing the management of patients sustaining acute first-time patellar dislocations. Data on redislocation rates, functional outcomes using the Kujala score, and complication rates were recorded. A meta-analysis was used to pool the mean postoperative Kujala score, as well as calculate the proportion of patients sustaining redislocation episodes using a random effects model. Quality assessment of included studies was performed for all included studies using the MINORS and Detsky scores. A total of 19 studies and 1,165 patients were included in this review. The pooled mean redislocation rate in 14 studies comprising 734 patients in the rehabilitation group was 30% (95% CI 25-36%, I2 = 67%). Moreover, the pooled mean redislocation rate in 5 studies comprising 318 patients undergoing early MPFL reconstruction was 7% (95% CI 2-17%, I2 = 70%). The pooled mean postoperative Kujala anterior knee pain score in 7 studies comprising 332 patients in the rehabilitation group was 81 (95% CI 78-85, I2 = 78%), compared to a score of 87 (95% CI 85-89, I2 = 0%, Fig.4) in 3 studies comprising 54 patients in the reconstruction group. Management of acute first-time patellar dislocations with MPFL reconstruction resulted in a lower rate of redislocation of 7% in the reconstruction group vs 30% in the rehabilitation group and a higher Kujala score compared to the rehabilitation group. The information this review provides will help surgeons guide their decision to choose early MPFL reconstruction versus rehabilitation when treating patients with first-time patellar dislocations and may guide future studies on the topic. IV.

Outcomes of Isolated Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability in Ehlers-Danlos Syndrome

Background:Ehlers-Danlos syndrome (EDS) -hypermobility type is characterized by generalized hyperlaxity which is considered to be a risk factor for patellar instability. Surgery is discouraged in this subset of patients due to high rates of failure. The outcomes following isolated Medial Patellofemoral Ligament Reconstruction (MPFLR) for patellar instability in EDS population has not been reported.Purpose:To analyze re-dislocation rates and patient-reported outcomes of isolated MPFLR for recurrent patellar instability in adolescents with EDS. The second purpose of the study was to compare allograft vs autograft for MPFL reconstruction in this specific population.Methods:Between 2010 and 2016, 21 knees in 16 consecutive patients underwent isolated MPFLR reconstruction for recurrent patellar instability. The diagnosis of EDS-hypermobility type, was confirmed by genetics for all patients, with Beighton score as the chief determinants. All patients underwent isolated MPFL reconstruction with hamstring tendon graft. Recurrent dislocation rate and patient-reported outcomes, including Pedi-IKDC, Kujala Score, HSS Pedi-FABS, Banff Instability Instrument 2.0, and KOOS Knee Survey were collected at minimum 2 year follow-up.Results:The mean age of the cohort was 15.4 years (range 13-18 years). All patients were females. 16 knees had atraumatic mechanism of patellar dislocation. 2 patients had an osteochondral fracture. 5 patients underwent bilateral MPFLR. 9 patients had prior surgeries on their knee; 6 were failed patellar stabilization procedures but only 1 was failed MPFLR. 14 knees had hamstring autograft and 7 had hamstring allograft. At minimum 2 years follow-up, 3 of 21 knees (14.2%) had recurrent dislocation. There were no other complications. The mean pedi IKDC, Kujala, Pedi-FABS, and BANFF scores were 66.62 (95% CI 8.52), 73.5 (95% CI 8.68), 6.73 (95% CI 2.86) and 57.15 (95% CI 10.24) respectively. The overall mean KOOS pain subscale was 73.85 (95% CI 9.95) and KOOS symptoms subscale score was 48.54 (95% CI 5.56). There were no significant differences in outcome scores and re-dislocation rates between autograft and allograft (p>0.5). There was no significant correlation between functional score and Beighton score.Conclusion:EDS-related patellar instability are primarily atraumatic in origin without an osteochondral fracture. Patients had significant improvements in function following isolated MPFLR at minimum 2 years follow-up. However, these functional improvements were less than historical controls. Re-dislocation rate of 14% is higher than normal population. EDS and joint hypermobility is not a contraindication to MPFLR but caution is recommended in managing patient expectations.

No Difference in Outcomes After Arthroscopic Bankart Repair With Remplissage or Arthroscopic Latarjet Procedure for Anterior Shoulder Instability

PurposeTo evaluate the outcomes of arthroscopic Bankart repair with remplissage (ABRR) compared with the arthroscopic Latarjet (AL) procedure for anterior shoulder instability in patients with a labral tear and a concomitant engaging Hill-Sachs lesion.MethodsA retrospective review of patients who underwent either ABRR or the AL procedure for a diagnosis of anterior shoulder instability with a concomitant engaging Hill-Sachs lesion between 2011 and 2019 was performed. Recurrent instability, the visual analog scale score, the Subjective Shoulder Value, the Western Ontario Shoulder Instability score, patient satisfaction, willingness to undergo surgery again, and return to work or sport were evaluated.ResultsOur study included 41 patients treated with ABRR and 26 treated with the AL procedure. At final follow-up, there was no difference between patients who underwent ABRR and those who underwent the AL procedure in the reported Western Ontario Shoulder Instability score (21.8% vs 28.2%, P = .33) or any of its components, the visual analog scale score (0.9 vs 1.4, P = .32), the Subjective Shoulder Value (78.4 vs 74.5, P = .6062), the rate of satisfaction (81.6% vs 85.6%, P = .54), or whether patients would undergo surgery again (81.6% vs 96.1%, P = .16). Overall, 5 patients in the ABRR group and 2 patients in the AL group had recurrent instability events (12.2% vs 7.8%, P = .70), with no significant difference in the rate of recurrent dislocation (12.2% vs 3.8%, P = .39).ConclusionsIn patients with anterior shoulder instability and a concomitant Hill-Sachs lesion, both ABRR and the AL procedure were shown to be reliable treatments, with a low rate of recurrent instability and excellent patient-reported outcomes in appropriately selected patients. However, our study could not determine whether there was critical glenoid bone loss in patients undergoing ABRR, and surgeons should still exercise caution in performing ABRR in patients with high-grade glenoid bone loss or in those with failed prior stabilizations.Level of EvidenceLevel III, retrospective cohort study.

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up

Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair. Purpose: To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed. Results: A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively (P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 (P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) (P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years (P = .311). Conclusion: Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

The Prevalence of Hip Pathologies in Adolescent Idiopathic Scoliosis

BackgroundAdolescent idiopathic scoliosis (AIS) is the most common form of abnormal spine curvature observed in patients age 10 to 18. Typically characterized by shoulder height and waistline asymmetry, AIS may drive uneven distribution of force in the hips, leading to increased rates of concurrent hip diagnoses. The relationship between AIS and concurrent hip diagnoses is underexplored in the literature, and to date, there has been little research comparing rates of hip diagnoses between patients with AIS and those unaffected. PurposeAssess differences in rates and clusters of hip diagnoses between patients with AIS and those unaffected. Study designRetrospective review of Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS). Patient sample224,504 weighted inpatient discharges. Outcome measuresRates of hip diagnoses. MethodsPatients in the NIS database (2005–2013) ages 10–18 years were isolated. Patients were grouped by those diagnosed with AIS (ICD-9: 737.30) and those unaffected. Patient groups were propensity score matched (PSM) for age. Means comparison tests assessed differences in demographic, comorbidity, and diagnosis profiles between patient groups for corresponding age categories. ICD-9 codes were used to identify specific hip diagnoses. ResultsFollowing PSM, 24,656 AIS and 24,656 unaffected patients were included. The AIS patient group was comprised of more females (66% vs 59%) and had lower rates of obesity (2.4% vs 3.5%, both p < 0.001). Overall, 1.1% of patients had at least one hip diagnosis: congenital deformity (0.31%), developmental dysplasia (0.24%), recurrent dislocation (0.18%), isolated dislocation (0.09%), osteonecrosis (0.08%), osteochondrosis (0.07%), acquired deformity (0.03%), and osteoarthritis (0.02%). AIS patients had lower rates of osteonecrosis (0.04% vs 0.12%, p = 0.003), but higher rates of all other hip diagnoses, including dysplasia (0.41% vs 0.07%, p < 0.001), recurrent dislocation (0.32% vs 0.03%, p < 0.001), isolated dislocation (0.13% vs 0.06%, p < 0.001), and osteoarthritis (0.04% vs 0.01%, p = 0.084. Co-occurrences of hip diagnoses were relatively rare, with 0.03% patients having more than one hip diagnosis. Rates of co-occurring hip diagnoses did not differ between AIS and unaffected groups (0.04% vs 0.02%, p = 0.225). ConclusionsCompared to unaffected patients of similar ages, patients with AIS had higher overall rates of hip diagnoses, including dysplasia and recurrent dislocation. A higher trend of precocious osteoarthritis was also observed at a higher rate in AIS patients, although this difference was not statistically significant. Our results present an argument for surgical realignment in the coronal and sagittal planes to neutralize asymmetrical forces in the hips, and suggest the need for increased awareness and clinical screening for hip-related disorders in AIS patients. Level of EvidenceIII.

Modified Recession Wedge Trochleoplasty

Background: Trochlear dysplasia represents one of the main anatomic risk factors for patellar instability, with risk of failure and unfavorable clinical outcomes in patients with unaddressed dysplasia undergoing patellar stabilization. Indications: Patients with trochlear dysplasia characterized by supratrochlear prominence (DeJour B or D) and recurrent patellar instability, especially following failed soft tissue or bony stabilization. This technique addresses an anterior trochlea without pathologic convexity, as convexity may require conversion to other techniques for groove deepening (eg, DeJour “thick flap” or Schottle “thin flap”). Technique Description: A 6-cm lateral parapatellar arthrotomy is created. A marking pen is used to identify the native center of the trochlea, as well as the location of the planned resection and bony hinge point laterally. An osteotome is used to remove a wedge of bone proximally, such that the posterior aspect of the osteotomy is in line with the anterior femoral cortex. A resection guide is then used to perforate the lateral cortex, with care to avoid damaging the cartilage, and carried laterally and distally to ensure the bony cuts are connected, creating the bony flap. To ensure that all bony bridges are eliminated, the arthroscope is placed into the osteotomy to visualize reduction of the trochlea with manual pressure. A knotless PEEK anchor loaded with 8 loaded sutures is then placed on the roof of the trochlear notch. Sutures are then secured using anchors placed at the center of the trochlea, at the superolateral corner and far lateral edge of the trochlea to reduce the osteotomy, with 2 to 3 sutures placed in each anchor depending on surgeon preference. Results: Trochleoplasty has been reported to decrease the rate of recurrent patellar dislocation while improving mean Kujala score and knee function. Benefits of trochleoplasty must be balanced against the high rate of potential complications, primarily pain and decreased knee range of motion, secondary to the technical challenges and steep learning curve inherent to effectively performing the procedure. Discussion/Conclusion: Patients with recurrent patellar instability with trochlear dysplasia and failed prior stabilization may experience improved stability and outcomes following trochleoplasty.

Both Open and Arthroscopic Latarjet Result in Excellent Outcomes and Low Recurrence Rates for Anterior Shoulder Instability

PurposeThe purpose of this study is to evaluate the patient-reported outcomes of open Latarjet (OL) compared to arthroscopic Latarjet (AL) for anterior shoulder instability.MethodsA retrospective review of patients who underwent either OL or AL for anterior shoulder instability between 2011 and 2019 was performed. Recurrent instability, visual analog scale (VAS) score, Shoulder Instability-Return to Sport after Injury (SIRSI), Subjective Shoulder Value (SSV), Western Ontario Shoulder Instability (WOSI) score, patient satisfaction, willingness to undergo surgery again, and return to work/sport (RTW/RTS) were evaluated. A P value of < .05 was considered to be statistically significant.ResultsOur study included 102 patients in total; 72 patients treated with OL, and 30 treated with AL. There were no demographic differences between the two groups (P > .05 for all). At final follow up (mean of 51.3 months), there was no difference between those that underwent OL or AL in the reported WOSI, VAS, VAS during sports, SSV, and SIRSI scores, nor in patient satisfaction, or whether they would undergo surgery again (P > .05). Overall, there was no significant difference in the total rate of RTP (65% vs 60.9%; P = .74), or timing of RTP (8.1 months vs 7 months; P = .35). Additionally, there was no significant difference in the total rate of RTW (93.5% vs 95.5%; P = .75). Overall, 3 patients in the OL group and 2 patients in the AL group had recurrent instability events (6.9% vs 6.7%; P = .96), with no significant difference in the rate of recurrent dislocation (4.2% vs 3.3%; P = .84).ConclusionIn patients with anterior shoulder instability, both the OL and AL are reliable treatment options, with a low rate of recurrent instability, and similar patient-reported outcomes.