Recurrent Shoulder Instability Research Articles

Female Patients Undergoing Latarjet Surgery Show Similar 2-Year Secondary Surgery Rates but Greater Risk of Emergency Department Visits Compared With a Matched Cohort of Male Patients

To evaluate sex-based differences in 30-day postoperative emergency department (ED) visits, 90-day complication rates, and 2-year secondary surgery rates after the Latarjet procedure for the treatment of recurrent shoulder instability. A national administrative claims database was used to identify patients with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for shoulder subluxation or dislocation on the day of first-time stabilization with the Latarjet technique between 2015 and 2021. Male patients were matched 4:1 to female patients based on age, Elixhauser Comorbidity Index (ECI) score, and body mass index class. Rates of 30-day ED visits and 90-day complications were compared between cohorts, and risk factors for ED visits were identified by multivariate regression. The incidence of secondary surgery within 2 years was compared by Kaplan-Meier analysis. Prior to matching, 1,059 male and 360 female patients met the inclusion and exclusion criteria. Subsequent 4:1 (male-to-female) matching controlling for age, ECI score, and body mass index yielded 694 male and 185 female patients who underwent the Latarjet procedure. The overall incidence of 30-day ED visits was 9.3%, with an incidence of 8.2% for male patients and 13.5% for female patients. On the basis of multivariate logistic regression, these 30-day ED visits were associated with female sex (odds ratio, 1.79; P= .029) and incrementally higher ECI scores; relative to an ECI score of 0, ECI scores of 1 to 2, 3 to 4, and 5 or greater were associated with odds ratios of 5.31 (P= .006), 8.12 (P < .001), and 12.84 (P < .001), respectively. Ninety-day complications occurred in 1.5% of the total cohort, and the incidence was not statistically different between sexes. Overall, 2-year secondary surgery rates were similar between male and female patients (5.1% and 6.7%, respectively; P= .4). Female patients undergoing the Latarjet procedure for recurrent shoulder instability showed similar 90-day complication and 2-year secondary surgery rates to a matched cohort of male patients. Female sex, along with ECI score, however, was associated with a greater rate of 30-day ED visits. Level III, retrospective comparative case series.

Kinematic stabilization after the Latarjet procedure: beyond the triple blocking effect

BackgroundThe rationale for the Latarjet procedure was described as the “triple blocking” effect. Satisfactory surgical outcomes have been reported after surgery. However, it has been reported that the “triple blocking” effect increases joint stability, but it does not fully restore it. Moreover, the procedure is nonanatomic and concerns remain regarding the effects. The study of scapulohumeral rhythm, which is a clinical parameter used for the functional evaluation of shoulder kinematics, can offer new perspectives on the rationale for the procedure. This study aimed to compare the shoulder kinematics of patients after the Latarjet procedure to the shoulders of a healthy population using magnetic and inertial measurement units (MIMUs) with a motion analysis system. MethodsA retrospective study with prospective data collection was conducted on 28 patients who underwent the open Latarjet procedure for recurrent shoulder instability. At a minimum 12-month follow-up, each patient was evaluated by assessing the range of motion (ROM), the Rowe score, and the Constant-Murley score (CMS). Patients were examined using the ShowMotion 3D kinematic tracking system (NCS Lab, Modena, Italy), which uses wireless wearable noninvasive MIMUs sensors to assess the three-dimensional kinematics of the shoulder. For each plane of elevation (i.e., flexion and abduction), the scapulohumeral rhythm (SHR) was described by three scapulothoracic rotations (i.e., protraction–retraction, mediolateral rotation and posterior–anterior tilting) as a function of humeral anteflexion or humeral abduction. ResultsThe mean time from first shoulder dislocation to surgery was 6.6 ± 3 years (range, 1-12 years). No intraoperative complications occurred, and CT performed 3 months after surgery showed graft union in all patients. After a mean follow-up time of 32.4±20 months (range, 12-96), the mean CMS and Rowe scores were 94.5±4.8 (range, 84-100) and 96.7±3.5 (range, 90–100), respectively. All patients showed no signs of glenohumeral arthritis on X-ray examination. Scapular posterior tilt and scapular internal rotation were significantly greater in the patient group than in the healthy population for the flexion–extension and abduction–adduction movements along the whole shoulder range of motion (all p < 0.05); no differences were found in upward/downward scapular rotation. ConclusionA greater scapular posterior tilt and scapular internal rotation were observed after the Latarjet procedure. The modified position of the scapula was maintained during the entire ROM, suggesting a shoulder-stabilizing kinematic effect in addition to the bony, sling and bumper effects.

Current Clinical Concepts: Nonoperative Management of Shoulder Instability.

Non-operative management following a shoulder dislocation or subluxation remains a challenging and complex task. Accurate diagnosis of the condition, and shared decision-making regarding operative and non-operative management, as well as timing of return to play is required. This clinical concept paper introduces a shoulder instability framework that addresses these fundamental clinical dilemmas. Valid clinical prognostic tools which can predict recurrent shoulder instability are reviewed. The process of shared decision-making within the realm of shoulder instability is also presented. Finally, a framework for progressive rehabilitation that addresses deficits in motor control, strength, and endurance in scapula and shoulder musculature is presented to guide patients from an initial instability event, through to return to play.

All-Suture Anchor vs. Knotless Suture Anchor for the Treatment of Anterior Shoulder Instability-A Prospective Cohort Study.

All-suture or soft-anchors (SA) represent a new generation of suture anchor technology with a completely suture-based system. This study's objective was to assess Juggerknot® SA, for arthroscopic Bankart repair in recurrent shoulder instability (RSI), and to compare it to a commonly performed knotless anchor (KA) technique (Pushlock®). In a prospective cohort study, 30 consecutive patients scheduled for reconstruction of the capsulolabral complex without substantial glenoid bone loss were included and operated on using the SA technique. A historical control group was operated on using the KA technique for the same indication. Clinical examinations were performed preoperatively and 12 and 24 months postoperatively. RSI and WOSI at 24 months were the co-primary endpoints, evaluated with logistic and linear regression. A total of 5 out of 30 (16.7%) patients suffered from RSI in the SA group, one out of 31 (3.2%) in the KA group (adjusted odds ratio = 10.12, 95% CI: 0.89-115.35), and 13.3% in the SA group and 3.2% in the KAgroup had a revision. The median WOSI in the SA group was lower than in the KA group (81% vs. 95%) (adjusted regression coefficient = 10.12, 95% CI: 0.89-115.35). Arthroscopic capsulolabral repair for RSI using either the SA or KA technique led to satisfying clinical outcomes. However, there is a tendency for higher RSI and lower WOSI following the SA technique.

To Remplissage or Not to Remplissage Part 1: Prognostic Factors Influencing Recurrent Shoulder Instability in High-Risk Individuals with On-Track Shoulders Undergoing Primary Arthroscopic Anterior Stabilization

Objectives: Recent studies have shown that a subset of on-track Hill-Sachs lesions (HSL), defined as near-track lesions, may have a high risk of failure after primary arthroscopic Bankart repair (ABR) alone. The aim of this study was to evaluate rates of recurrent shoulder instability among patients with on-track HSL who underwent primary ABR with and without remplissage in the setting of numerous risk factors highlighted in recent literature. We hypothesized that primary ABR with remplissage (ABR+R) would lower postoperative rates of recurrent shoulder instability, particularly for “high-risk” patients defined as “near-track” lesions, hyperlaxity, younger age, contact athletes, and &gt;1 preoperative instability episodes. Methods: Prospectively collected data was retrospectively reviewed for consecutive patients aged 14-40 years who underwent either ABR or ABR+R between 2013 and 2021 for anterior glenohumeral instability. Glenoid bone loss, Hills-Sachs Interval (HSI), glenoid track (GT), and distance-to-dislocation (DTD) values (DTD = GT-HSI) were determined via preoperative magnetic resonance imaging. Additionally, “near-track” lesions are a subset of on-track lesions with a DTD from 0 – 10mm. Capsuloligamentous laxity (i.e., hyperlaxity) was defined as external rotation greater than 85 degrees and/or grade 2+ posterior and inferior load-and-shift on examination under anesthesia. Recurrent shoulder instability was defined as recurrent dislocation and/or subjective subluxation postoperatively. Patients were excluded if the indexed surgery was a revision procedure, &lt; 2-year follow-up, or glenoid bone loss (GBL) &gt;20%. Univariate and multivariate Cox regression analysis was used to determine predictors of recurrent shoulder instability and reoperation. Results: One-hundred-and-fifty-five patients were included for analysis (ABR: 116 | ABR+R: 39) with an average age of 21.6 ± 6.2 years and an average follow-up of 5.1 ± 2.0 years (range: 2.0 – 8.7 yrs). Overall, 30 patients (19%) experienced recurrent shoulder instability postoperatively (4.3 per 100 person-years), and 20 (13%) underwent secondary surgery (2.9 per 100 person-years) for revision stabilization. Among the 116 patients who underwent primary ABR only, 27 (23.3%) experienced recurrent shoulder instability, compared with only three of the 39 ABR+R patients (7.7%). Risk factors assessed included: age, gender, sport, number of preoperative instability episodes, shoulder laxity, GBL, and DTD. Multivariate analysis demonstrated that younger age (p=0.003), increased shoulder laxity (p=0.010), 2+ episodes of preoperative instability episodes (p=0.009), and a lower DTD (p=0.046) were independent risk factors for recurrent shoulder instability postoperatively. However, contact athlete status was not identified as a significant predictor of recurrent shoulder instability. According to multivariate results, patients who underwent primary ABR only were roughly 9-times more likely to experience recurrent shoulder instability (HR: 8.7, p=0.002) and 7-times more likely to undergo reoperation (HR:6.8, p=0.019) than those who underwent primary ABR+R. When considering patients with three or more risk factors (i.e., “near-track” lesions, hyperlaxity, age &lt; 25, or 2+ preoperative instability episodes), 9 of 12 ABR patients (75%) and 2 of 16 ABR+R (13%) experienced recurrent shoulder instability (p = 0.001), Table 1. Survival rates for ABR only versus ABR+R for patients with three or more risk factors are plotted in Figure 1 using Kaplan-Meier survival plots. Conclusions: Arthroscopic primary Bankart repair with remplissage may be an effective approach for decreasing the likelihood of recurrent shoulder instability and the need for secondary surgery among patients with on-track HSL. This surgical approach is especially beneficial for patients with lower DTD, increased shoulder laxity, younger age, or 2+ preoperative instability episodes in a dose-dependent manner. Those with higher risks of recurrence may benefit significantly more with the addition of a remplissage than those with fewer risk factors.

To Remplissage or not to Remplissage Part 2: Recurrent Instability After Primary Stabilization Surgery (RIPSS) Risk Tool Assesses Preoperative Failure Rates in On-track Shoulders Undergoing Primary Arthroscopic Anterior Stabilization with or without Remplissage Augmentation

Objectives: Given the high rates of recurrent instability following the initial arthroscopic Bankart repair (ABR), it is crucial to provide recommendations for appropriate surgical interventions for patients at a higher risk of experiencing recurring instability. In Part 1 of the study, it was discovered that on-track Hill-Sachs lesions (HSL) with specific prognostic factors (i.e., younger age, increased shoulder laxity, lower DTD, and 2+ preoperative instability events) were associated with a greater risk of failure. Therefore, the objective of Part 2 was to develop a risk assessment tool that takes into account significant prognostic factors for recurrent shoulder instability following primary ABR and evaluate the role of remplissage augmentation given a patient’s risk profile. Methods: We retrospectively reviewed prospectively collected data of consecutive patients aged 14-40 who underwent either ABR (arthroscopic Bankart repair) or ABR+R (ABR with remplissage) procedures between 2013 and 2021 for anterior glenohumeral instability. Preoperative magnetic resonance imaging was used to determine the values of glenoid bone loss, Hills-Sachs Interval (HSI), glenoid track (GT), and distance-to-dislocation (DTD). On-track lesions have a distance-to-dislocation (DTD) value greater than zero. In addition, within the category of on-track lesions, there is a subset known as “near-track” lesions, with a DTD ranging from 0 to 10 mm. Capsuloligamentous laxity scores were categorized according to hyperlaxity status, defined as external rotation greater than 85 degrees and/or grade 2+ posterior and inferior load-and-shift on examination under anesthesia. Recurrent shoulder instability was defined as recurrent dislocation and/or subjective subluxation postoperatively. Patients were excluded if the indexed surgery was a revision procedure, &lt; 2-year follow-up, or glenoid bone loss (GBL) &gt;20%. A final multivariate survival analysis was constructed using categorical prognostic factors (i.e., patient age, “near-track” status, hyperlaxity, and 2+ preoperative instability episodes) identified in Part 1, while adjusting for GBL. Although contact athlete status was not identified as a significant predictor of recurrent shoulder instability in Part 1, the final model stratified by contact athlete status given its established importance in prior literature. Multivariate hazard ratio estimates were utilized to create a risk assessment tool and correlated with patient-specific risk estimates via post-estimation analysis. Results: One-hundred-and-fifty-five patients were included for analysis (ABR: 116 | ABR+R: 39) with an average age of 21.6 ± 6.2 years and an average follow-up of 5.1 ± 2.0 years (range: 2.0 – 8.7 yrs). Patients with near-track lesions had a three-fold higher risk of recurrent instability (Hazard Ratio [HR]: 2.5, p = 0.03) compared to on-track HSL with DTD &gt; 10mm. Individuals with evidence of hyperlaxity exhibited a five-fold increased risk (HR: 5.4, p=0.03) relative to patients without hyperlaxity. Younger patient groups had twice the risk of recurrent shoulder instability (HR: 2.2, p=0.003) compared to older adjacent groups. Patients with two or more preoperative recurrent instability episodes faced a four-times greater risk (HR: 4.2, p=0.004) for recurrent shoulder instability compared to patients who experienced a single instability event preoperatively. Lastly, patients who underwent primary ABR only had almost 10-times greater risk of recurrent shoulder instability (HR: 9.5, p=0.002) than those who underwent primary ABR+R. The Recurrent Instability after Primary Shoulder Stabilization (RIPSS) risk assessment score considers patient age, near-track status, hyperlaxity, preoperative instability episodes, and surgical technique (ABR vs. ABR+R) as important prognostic indicators, Table 2. The RIPSS score was created with risk stratifying subgroups: Low-risk (0 – 2), Moderate-risk (3 – 6), High-risk (7 – 9), and Extreme-risk (10+). Figure 1 illustrates a strong correlation between patient RIPSS scores with patient-specific hazard ratio estimates derived from the multivariate Cox regression modeling computed in “To Remplissage or not to Remplissage Part 1”. According to RIPSS score subgroups, recurrent shoulder instability rates range from 4.3% among low-risk groups to 54.6% among extreme-risk groups, Figure 1. Conclusions: Patients with a low-risk RIPSS score without ABR+R may not benefit from remplissage augmentation. Their risk for recurrent instability would remain low despite the addition of remplissage. However, patients with a high- or extreme-risk RIPSS score prior to considering ARB+R would likely benefit from remplissage supplementation. The RIPSS score may be an effective risk assessment tool that may help identify patients who may benefit from a primary Bankart repair with remplissage augmentation. The risk assessment tool developed may optimize surgical treatment and allow physicians to determine patient risk scores with and without remplissage augmentation.

Rotator Cuff Tears are Significantly More Frequent in Recurrent Shoulder Instability Patients With Initial Dislocation at Age 40 or Older

PurposeThe purpose of this study was to investigate and compare the pathologies and clinical outcomes of patients with traumatic anterior shoulder instability who underwent arthroscopic stabilization at 40 years or older between shoulders with initial dislocation before and after 40 years old. MethodsShoulders that underwent arthroscopic stabilization for recurrent traumatic anterior shoulder instability at 40 years or older with a minimum of two-year follow-up were included. The subjects were divided into two groups according to the age at initial dislocation after a propensity score matching to reduce potential bias: Group 1, < 40 years old; Group 2, ≥40 years. Radiographic findings, pathologies, clinical outcomes, and complications were compared between the groups ResultsGroup 1 included 56 shoulders in 56 patients (26 males and 30 females) with a mean age of 51 (range, 40-77) years. Group 2 included 28 shoulders in 28 patients (13 males and 15 females) with a mean age of 51 (range, 40-77) years. The glenoid bone loss was greater in Group 1 than in Group 2 (p=.004). Rotator cuff tears were more frequently observed in Group 2 than in Group 1 (P<.001). Both groups demonstrated significant improvement in the West Ontario Shoulder Instability Index (P<.001 for each) and flexion (P<.001 for each). Recurrence was seen in 4% in Group 1 and 7% in Group 2. ConclusionsThe incidence of concomitant rotator cuff tears was significantly higher in shoulders with initial dislocation after 40 years than those before. Arthroscopic stabilization yielded a low recurrence rate and favorable outcomes with good sports return in patients 40 years or older.

Outcome of Modified Open Latarjet Operation in the Treatment of the Recurrent Anterior Shoulder Dislocation: A Cohort Study

Introduction: Shoulder instability is defined as a symptomatic translation of the humeral head about the glenoid fossa during active shoulder motion. Anteroinferior glenoid bone loss or labrum avulsion is most often a consistent finding in recurrent dislocation. The modified open Latarjet procedure is one of the most effective methods of treatment for patients with recurrent shoulder instability with glenoid bone loss. Aim: To determine the functional outcome of the congruent arc modification of the open Latarjet procedure. Materials and Methods: This prospective cohort study was conducted at a tertiary healthcare centre in Bhopal, Madhya Pradesh, India between January 2018 and December 2020. A total of 25 patients with recurrent anterior shoulder dislocation underwent treatment using the modified open Latarjet procedure. Two patients were lost to follow-up, resulting in the evaluation of 23 patients. All patients underwent a 3D Computed Tomography (CT) scan to document glenoid bone loss. The intensity of pain, activity level, strength of abduction, and Range of Motion (ROM) were assessed to calculate the Constant Shoulder Score for pre- and postoperative evaluation of functional outcomes. Follow-ups were conducted at 3 months, 6 months, 1 year, and 2 years after surgery. The data was analysed using the Wilcoxon’s signed-rank test, and Spearman’s correlation coefficient was used to identify associations between various variables. Results: A total of 23 male patients aged between 18 and 63 years were included. The average age of patients was 30.35±11.27 years. Preoperatively, only 3 patients (13.04%) had good to excellent Constant Shoulder Scores. However, no statistically significant variation in Constant Score was observed three months after surgery. Six months post-surgery, 17 patients (73.92%) showed good to excellent scores. Nearly one year after surgery, 21 patients (91.3%) had good to excellent outcomes. At the final follow-up, 22 patients (95.65%) demonstrated good to excellent outcomes. A statistically significant improvement in good to excellent scores was noted six months postoperatively (p-value &lt;0.001). A total of 20 patients (86.96%) achieved full ROM, with only 3 patients (13.04%) reporting mild to moderate limitations in shoulder ROM. None of the patients experienced redislocation, and the apprehension test was positive in only one patient. Conclusion: The modified open Latarjet procedure is a reliable method for providing stability and Self confidence to patients with recurrent shoulder instability and glenoid bone loss.

Beyond guesswork: how accurate are surgeons at determining the degree of glenoid bone loss in instability surgery?

BackgroundAccurate measurement of glenoid bone loss (GBL) is critical to preoperative planning in cases of recurrent shoulder instability. The concept of critical bone loss has been established with a value of GLB >13.5% being associated with higher failure rate following arthroscopic Bankart Repair. Advanced imaging, such as MRI scans, can be used to quantify GBL prior to surgery utilizing the best-fit circle technique. Surgeons have traditionally relied on visual inspection of the MRI scan preoperatively or on visual inspection of the glenoid at the time of arthroscopy to determine whether GBL is present. The purpose of this study is to determine if 3 fellowship-trained shoulder surgeons could adequately quantify GBL without utilizing best-fit circle measurements on MRI. MethodsA retrospective review was performed which included 122 patients over an 8-year period who had an arthroscopic Bankart repair performed by 3 fellowship-trained surgeons. In all patients, preoperative MRI scans were retrospectively measured utilizing best-fit circle technique to determine true GBL and compare that to the surgeons' pre- and intraoperative estimation of GBL. ResultsGBL was correctly identified in only 36% (18/50) of patients when the preoperative best-fit circle measurements were not made. Critical bone loss was missed in 9.8% (15/122) of patients in the study group. The estimated mean bone loss in that group by visual inspection was 11.3% compared to 16% true bone loss measured on MRI. Even in the 18 patients with some identified bone loss prior to surgery, critical bone loss was missed in 6 patients when utilizing visual inspection of the MRI or intraoperative inspection alone. ConclusionsSimple visual inspection of glenoid images on MRI scan as well as visual inspection of the glenoid at the time of surgery are inaccurate in determining the true extent of glenoid bone loss especially in cases of subtle bone deficiency. Preoperative planning is dependent on the exact degree of bone deficiency and measurement on the MRI scan utilizing the best-fit circle technique is recommended on all cases of instability surgery.

Learning curve in the arthroscopic Latarjet procedure: An analysis of the first 171 cases

BackgroundArthroscopic Latarjet procedure is accepted as effective and safe. However, it is more likely to be challenging in execution. Therefore, the analysis of the learning curve remains to be worth examination. ObjectiveTo examine the learning curve in the arthroscopic Latarjet procedure through an analysis of the correlation between the average operative time, complications rate, and the total number of performed surgeries and execution frequency. Materials and methodA total of 171 patients who underwent arthroscopic Latarjet surgery between 2013 and 2020 were included. Clinical findings were recorded postoperatively. We fixed the operative time with account taken of the execution frequency and the number of intra- and postoperative complications. All procedures were completed by one surgeon. ResultsBy statistical analysis, a significant association between the operative time and the number of surgical interventions was found (p < 0.05). After 120 procedures, the average operative time demonstrated a constant reduction and reached 62.8 min (p < 0.05). We detected the relation between the average operative time and surgery frequency. The significant correlation between the number of intraoperative complications and the number of procedures performed manifests after the 20th surgery (p < 0.05). In total, 13 episodes of complications were recorded (7.6 %). 9 cases of intraoperative complications (5.3 %) conversed into the open Latarjet procedure. 4 episodes of postoperative complications (2.3 %) were documented, among them 2 hematomas which were treated conservatively, and 2 cases of recurrent shoulder instability. There were no neurological, neurovascular, and infection complications seen in our cohort. DiscussionIt took more than 120 arthroscopic procedures to reach the stable and reproducible indices in operative time, and more than 20 surgeries to achieve a significant reduction in the intraoperative complications rate. There was no correlation between the postoperative complication rate and the number of performed procedures. The overall level of complications did not exceed the level mentioned in the literature. The high surgical activity could be considered as a favorable factor to increase the efficiency of the learning process. ConclusionGaining clinical experience with the passing of the learning stages impacts significantly the rate of intraoperative complications and operative time. The arthroscopic Latarjet procedure is safe and characterized with good clinical results even within the initial stages of the learning curve.

Readability of Online Information on the Latarjet Procedure.

Introduction A common complication of first-time or recurrent shoulder dislocations is bone loss at the humeral head and glenoid. Recurrent shoulder instability is often a result of bony defects in the glenoid following shoulder dislocations. In the setting of glenoid bone loss, surgical interventions are generally required to restore stability. The Latarjet procedure is a challenging operation and, due to its complexity, may be associated with operative complications. It can be difficult to explain the procedure to patients in a manner that is easily comprehensible, which may lead to confusion or being overwhelmed with information. Hence, it is important that the information available to patients is easily accessible and perceivable to allow for adequate health literacy. Health literacy is defined as the ability to make health decisions in the context of everyday life. Methods The search engines Google and Bing were accessed on a single day in the month of July 2023, searching the terms "Latarjet surgery" and "Latarjet procedure." For each term on both search engines, the first three pages were evaluated, resulting in a total of 114 websites for review. Out of these, 25 websites met the inclusion criteria and underwent further in-depth analysis through the online readability software, WEB FX. This software generated a Flesch Reading Ease Score (FRES) and a Reading Grade Level (RGL) for each website. Results In our study, the mean FRES was 50.3 (SD ±12.5), categorizing the data as 'fairly difficult to read.' The mean RGL score was 8.12 (SD ±2.35), which exceeds the recommended target. Conclusion In conclusion, the results of this study have demonstrated that the material available on the Internet about the Latarjet procedure is above the recommended readability levels for the majority of the population. Our findings align with similar studies assessing the readability of online patient information. Based on these findings, physicians should provide patients with vetted information to facilitate a better understanding of the procedure, thereby enabling patients to make more informed decisions regarding their health.

Effect of open versus minimally invasive surgery on postoperative wound site complications in patients with recurrent shoulder instability: A meta-analysis.

The Latarjet procedure is the accepted method of operation for patients with anterior shoulder instability. However, as arthroscopy becomes more and more popular, more and more patients are being treated with minimally invasive techniques for the treatment of anteriorly unstable shoulder. This research aims to compare the curative effects of arthroscopic Latarjet (AL) and open Latarjet (OL) on postoperative anterior shoulder instability. Our hypothesis is that arthroscopy will produce better results than open surgery. During the study, a review was conducted on four main databases, including EMBASE and Cochrane Library. Six cohort studies comparing AL with OL in the treatment of anterior shoulder instability were included. Patients who were operated by open technique up to 2023 were referred to as OL and those who underwent arthroscopic surgery were referred to as AL. Comparison was made between the two methods of operation. The statistical analysis was done with RevMan 5.3. The analysis included Visual Analogue Scale (VAS) scores and postoperative wound infections. A total of six studies were included for analysis under inclusion and exclusion criteria. There were 798 patients, 476 was AL group and 322 was OL group. No statistical significance was found on the incidence of postoperative wound infection in the patients who underwent the Latarjet procedure (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.28-7.31; p = 0.67) and the VAS score after surgery (mean difference [MD], 0.70; 95% CI, -0.67 to 2.06; p = 0.32) for patients. However, it has now been demonstrated that arthroscopy is a safe and viable alternative. The only drawback of arthroscopic Latarjet surgery is probably that it has a long learning curve and requires a lot of practice from the surgeon.

Does previous arthroscopic Bankart repair influence coracoid graft osteolysis in Latarjet procedure? A case-control study with computed tomography scan data

Latarjet procedure is commonly performed in treatment of recurrent shoulder instability and also indicated as a salvage procedure for recurrence after failed arthroscopic Bankart repair. While this procedure has shown success, there is an increased awareness of complications in recent studies, especially for graft osteolysis. Most relevant research have focused on pathophysiology, incidence, location or risk factors of graft osteolysis; however, the data is limited to primary Latarjet procedures. This study aims to investigate the effect of previous arthroscopic Bankart repair surgery on corocaid bone graft osteolysis in Latarjet procedure. This retrospective case-control study analyzed data from patients who underwent primary Latarjet procedure or revision Latarjet procedure following failed arthroscopic Bankart repair. Clinical outcome measures included range of motion (ROM), subjective shoulder value (SSV) and Rowe score. Volumetric analysis of each transferred coracoid graft were performed using early postoperative and late postoperative computed tomography (CT) scan data and amount of graft osteolysis was then calculated as percentage of volume reduction of each graft. 32 patients who met the inclusion criteria, with 24 patients in the primary Latarjet group (group I) and 8 patients in revision Latarjet group (group II), were included to study. Mean age of patients was 32.5±7.7 years and mean follow-up duration was 52.1±8.9 months. Both study groups showed significant improvement in SSV compared to baseline (p<0.05). Comparison of postoperative clinical outcome measures showed no significant difference between two study groups in any outcome parameter (p>0.05). No recurrence was observed during follow-up period. There were 6 patients (25%) with positive apprehension sign in group I and 4 patients (50%) in group II (p>0.05). Analysis of radiological data revealed that all patients underwent some degree of graft osteolysis with varying osteolysis ratios between 12% to 98%. Mean osteolysis ratio of the coracoid graft was 67.3±22.6% in group I and 69.4±25.6% in group II, without significant difference between two groups (p>0.05). Findings of this study suggest that both primary and revision Latarjet procedures following failed arthroscopic Bankart repair underwent considerable amount of coracoid graft osteolysis. Previous arthroscopic Bankart repair did not seem to have significant influence on the amount of graft osteolysis and both primary and revision Latarjet procedures showed satisfactory clinical outcomes.

Cadaveric Biomechanical Study of Partial Glenoid Arthroplasty Versus the Latarjet Procedure for Anterior Glenoid Bone Loss

Background: For severe anterior glenoid bone loss due to recurrent shoulder instability, the Latarjet procedure offers a dynamic sling effect in addition to bone augmentation. Yet, it heavily alters the surrounding anatomy, while fixation and graft union issues are also common. Purpose/Hypothesis: The purpose of this study was to compare a novel printed 3-dimensional (3D) partial glenoid arthroplasty (PGA) implant with the classic Latarjet procedure. It was hypothesized that by replicating the original glenoid geometry and preserving soft tissue anatomy, PGA may better reproduce normal joint kinematics. In addition, the locking screw construct may offer stronger fixation. Study Design: Controlled laboratory study. Methods: A total of 14 matched cadaveric shoulders were tested. The PGA implant was 3D printed in titanium based on preoperative computed tomography. The intact, 25% anterior glenoid bone loss, and postoperative states were tested in the scapular and coronal planes. The following parameters were measured: articular surface area and stepoff, rotational range of motion and the humeral head apex position during rotation, and load and linear stiffness at 25% anterior translation and at 2-mm construct displacement. Results: The baseline dimensions of the glenoid articular surface were comparable between the groups. The articular surface area after PGA was significantly larger (P = .006) with less articular stepoff (P = .030). PGA better approximated the intact state’s external (P = .006) and total (P = .019) rotational range of motion in the scapular plane. The course of the humeral head apex after PGA better followed that of the intact state (P < .001). Resistance against anterior translation after PGA was not significantly different compared with after the Latarjet procedure. Greater linear stiffness (P = .031) and loading (P = .002) at 2-mm construct displacement were demonstrated in the PGA group. Conclusion: In addressing anterior glenoid bone loss, PGA better approximated intact glenohumeral joint kinematics compared with the Latarjet procedure with less articular stepoff in a cadaveric model. PGA was comparable in resisting anterior translation while being significantly stronger against loading at 2-mm construct displacement. Further clinical studies are warranted to validate this novel procedure. Clinical Relevance: A 3D-printed PGA implant may offer an alternative treatment option for severe glenoid bone loss due to shoulder instability, overcoming the previous drawbacks of the Latarjet procedure, including altered kinematics, fixation failure, and hardware issues.

Poster 175: ALPSA Lesions Associated with High Rate of Early Repair Failure

Objectives: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions occur in patients with recurrent shoulder instability and are associated with higher rates of failure after capsulolabral repair surgery compared to typical Bankart lesions. Despite recognition that these lesions can portend poor outcomes, there is relatively limited data to understand the associated injuries and postoperative course in a young, active population. The purpose of this study is to evaluate ALPSA lesions for associated pathology and outcomes. Methods: Methods: We reviewed the records of 312 patients who underwent arthroscopic shoulder stabilization by one of two fellowship trained sports surgeons at a single facility between 1 January 2010 and 31 December 2015. Inclusion criteria were a minimum follow-up of five years after index surgical repair and presence of an ALPSA lesion as identified on arthroscopic exam, leaving 46 patients available for review. Our primary outcome measures were failure and operative revision surgery. We considered failure as any recurrent shoulder instability events including subjective subluxation and dislocation, recurrence of pain consistent with instability, or functionally limiting apprehension. We performed survival analysis and a multivariate logistic regression analysis to identify factors associated with failure. Results: Results: In total, 46 patients with average age 21.2 years met inclusion and underwent surgery a median of 7.1 months after initial recalled injury event. 11/46 had concomitant posterior pathology in addition to anterior labral lesion. Six patients were found to have SLAP lesions. All patients experienced subjective instability, and 44/46 endorsed pain prior to surgery. 38/46 reported having experienced complete dislocation. The median number of dislocations before surgery was 3. Repairs were performed with average 3.7 anchors. Eight patients failed surgery at median 15.1 months post-index procedure, with 75% of failures occurring before two years with the remaining 25% occurring later in follow-up. Three of these failed revision repair. Conclusions: Conclusions: ALPSA lesions frequently occur in the presence of other intra-articular shoulder lesions and portend a high rate of recurrent shoulder instability despite repair. Notably, while failure occurs at a high rate, most repair failure for these lesions tends to occur early.

Bone loss in shoulder instability: putting it all together.

Glenohumeral bone loss is frequently observed in cases of recurrent anterior and posterior shoulder instability and represents a risk factor for failure of nonoperative treatment. Patients with suspected glenoid or humeral bone loss in the setting of recurrent instability should be evaluated with a thorough history and physical examination, as well as advanced imaging including computed tomography (CT) and/or magnetic resonance imaging (MRI). In cases of both anterior and posterior instability, the magnitude and location of bone loss should be determined, as well as the relationship between the glenoid track (GT) and any humeral defects. While the degree and pattern of osseous deficiency help guide treatment, patient-specific risk factors for recurrent instability must also be considered when determining patient management. Treatment options for subcritical anterior bone loss include labral repair and capsular plication, while more severe deficiency should prompt consideration of bony augmentation including coracoid transfer or free bone block procedures. Concomitant humeral lesions are treated according to the degree of engagement with the glenoid rim and may be addressed with soft tissue remplissage or bony augmentation procedures. While critical and subcritical thresholds of glenoid bone loss guide the management of anterior instability, such thresholds are less defined in the setting of posterior instability. Furthermore, current treatment algorithms are limited by a lack of long-term comparative studies. Future high-quality studies as well as possible modifications in indications and surgical technique are required to elucidate the optimal treatment of anterior, posterior, and bipolar glenohumeral bone loss in the setting of recurrent shoulder instability.

Paper 02: Distal Radius Allograft for Glenohumeral Instability: A Novel Osteochondral Allograft Reconstruction Option in the Setting of Glenoid Bone Loss

Objectives: Glenoid bone loss in the setting of recurrent shoulder instability remains a challenging surgical problem. The coracoid process and iliac crest currently serve as primary autograft options for glenoid reconstruction. With regards to allograft alternatives, the distal tibia, first described in 2007, has good midterm outcomes when used during an index surgery and in cases of failed prior Latarjet reconstruction. While the distal tibia performs well in reconstructing the glenoid bony defect, it is a nonanatomic reconstruction and does not match the glenoid radius of curvature (ROC) in the anterior to posterior (AP) plane. No prior work has evaluated and described the utilization of the dorsal articular portion of the distal radius as an allograft reconstruction option for recurrent instability with glenoid bony deficiency. The purpose of this study was to evaluate distal radius fresh frozen allograft as a potential match for glenoid reconstruction through assessment of graft ROC and bone mineral density (BMD). Distal tibia allograft was utilized as the primary comparison group with both cadaveric and Computerized Tomography (CT) analysis. Methods: Eighteen fresh-frozen human cadaveric specimens (6 shoulder, 6 wrist, and 6 tibia) were utilized for this study. Specimens without osteoarthritis or prior surgical procedures were included. CT scans were obtained of all specimens to confirm the absence of osteoarthritis, significant joint deformity, or evidence of prior surgical procedure. Specimens were dissected free of all soft tissues except for the glenoid labrum of the shoulder and dorsal wrist ligaments of the distal radius. The ROC for each specimen were independently measured by two fellowship trained shoulder surgeons in both the superior to inferior (SI) and AP planes. Graft length in the SI plane was also assessed. A thirty percent defect was then created in all glenoid specimens and both distal tibia and distal radius grafts were harvested to assess graft fit post-fixation [Figure 1]. CTs were also analyzed to assess bony ROC and BMD for each specimen. Results: On cadaveric analysis, the mean SI graft length of the glenoid was 39.7 mm compared to 36.8 mm for the distal radius and 30.0 mm for the distal tibia [Table 1A]. Average ROC in the SI plane was 29.0 +/- 5.3 for the glenoid, 37.8 +/- 4.9 for the distal radius and 24.0 +/- 3.7 for the distal tibia; in the AP plan average ROC was 39.6 +/- 6.6 for the glenoid, 30.4 +/- 18.6 for the distal radius and 126.3 +/- 9.5 for the distal tibia [Table 1B]. On CT analysis, average ROC in the SI plane was 30.4 +/- 1.5 for the glenoid, 30.3 +/- 5.6 for the distal radius and 24.5 +/- 9.4 for the distal tibia; in the AP plane average ROC was 30.8 +/- 2.0 for the glenoid, 19.1 +/- 2.3 for the distal radius and 46.7 +/- 21.7 for the distal tibia [Table 2A]. Mean BMD was 226.3 +/- 79.0 for the glenoid, 228.5 +/-94.7 for the distal radius, 235.0 +/- 96.2 for the coracoid process, and 235.1 +/- 84.6 for the distal tibia [Table 2B]. Conclusions: Given fresh frozen allograft supply and cost constraints, exploration of additional graft options is necessitated. This study presents distal radius allograft as a novel reconstruction option for patients with anterior glenoid bone loss in the setting of recurrent glenohumeral instability. Compared with the distal tibia allograft, the distal radius had greater graft length in the SI plane providing possible utilization in cases of larger bony defects. The distal radius also has a more acute ROC in the AP plane (closer to that of the glenoid) compared with the distal tibia allograft providing a greater potential buttress to anterior humeral translation. Furthermore, the distal radius also has potential to employ the dorsal radio-carpal ligaments to perform an anterior capsular repair following allograft fixation. Finally, compared to currently utilized grafts (coracoid process and distal tibia), the distal radius BMD was not significantly diminished on CT analysis. This study presents the distal radius as a novel allograft reconstruction option in the setting of glenoid bone loss; further biomechanical and clinical investigation is indicated. [Table: see text][Table: see text]

Current concepts in chronic traumatic anterior shoulder instability.

Chronic traumatic anterior shoulder instability can be defined as recurrent trauma-associated shoulder instability requiring the assessment of three anatomic lesions: a capsuloligamentous and/or labral lesion; anterior glenoid bone loss and a Hill-Sachs lesion. Surgical treatment is generally indicated. It remains controversial how risk factors should be evaluated to decide between a soft-tissue, free bone-block or Latarjet-type procedure. Patient risk factors for recurrence are age; hyperlaxity; competitive, contact and overhead sports. Trauma-related factors are soft tissue lesions and most importantly bone loss with implications for treatment. Different treatment options are discussed and compared for complications, return to sports parameters, short- and long-term outcomes and osteoarthritis. Arthroscopic Bankart and open Latarjet procedures have a serious learning curve. Osteoarthritis is associated with the number of previous dislocations as well as surgical techniques. Latarjet-type procedures have the lowest rate of dislocation recurrence and if performed correctly, do not seem to increase the risk of osteoarthritis.

Arthroscopic Subscapularis Augmentation With Xenograft Glenoid Bone Block in Patients With Recurrent Anterior Shoulder Instability

IntroductionThe purpose of this study was to investigate the clinical and radiographic outcomes at 2 years for patients who underwent an arthroscopic xenograft bone block procedure plus ASA for recurrent anteroinferior gleno-humeral instability.MethodsThis retrospective study was conducted on patients affected by chronic anteroinferior shoulder instability. The inclusion criteria were as follows: patients must be aged 18 years or older; have recurrent anteroinferior shoulder instability, a glenoid defect >10%, assessment by the Pico area measurement system, anterior capsular insufficiency, and an engaging Hill-Sachs lesion. The exclusion criteria were as follows: multidirectional instability, glenoid bone defect <10%, arthritis, and minimum follow-up less than 24 months. Clinical outcomes were evaluated according to Western Ontario Shoulder Instability Index (WOSI) and Rowe scale. Computed tomography (CT) results were evaluated to assess any signs of resorption or displacement of the xenograft at 24 months follow-up.ResultsTwenty patients that met all the inclusion criteria underwent arthroscopic xenograft bone block procedure and ASA. The mean preoperative Rowe score was 38.3 points, and it significantly improved (P < .001), increasing to 95.5 points. ROWE level at follow-up was excellent for 18 patients (90%), fair for 1 patient (5%), and poor for another patient (5%). The mean preoperative WOSI score was 1242 points, and it improved significantly (P <.0001), with a mean score of 120 points at follow-up. In all patients, the comparative study between CT scans performed postoperatively and at final follow-up did not reveal a volume reduction of the xenografts (P > .05) and absence areas affected by signs of resorption and breakage with 34.4% of postprocedural increase of the glenoid surface, were seen.ConclusionsThe combination of ASA and bone block procedure with a xenograft was effective in the glenoid reconstruction and restoration of shoulder stability. No radiographic evidence of graft resorption, graft displacement, or glenohumeral arthritis were observed at 24-month follow-up.Level of EvidenceLevel IV, therapeutic case series. The purpose of this study was to investigate the clinical and radiographic outcomes at 2 years for patients who underwent an arthroscopic xenograft bone block procedure plus ASA for recurrent anteroinferior gleno-humeral instability. This retrospective study was conducted on patients affected by chronic anteroinferior shoulder instability. The inclusion criteria were as follows: patients must be aged 18 years or older; have recurrent anteroinferior shoulder instability, a glenoid defect >10%, assessment by the Pico area measurement system, anterior capsular insufficiency, and an engaging Hill-Sachs lesion. The exclusion criteria were as follows: multidirectional instability, glenoid bone defect <10%, arthritis, and minimum follow-up less than 24 months. Clinical outcomes were evaluated according to Western Ontario Shoulder Instability Index (WOSI) and Rowe scale. Computed tomography (CT) results were evaluated to assess any signs of resorption or displacement of the xenograft at 24 months follow-up. Twenty patients that met all the inclusion criteria underwent arthroscopic xenograft bone block procedure and ASA. The mean preoperative Rowe score was 38.3 points, and it significantly improved (P < .001), increasing to 95.5 points. ROWE level at follow-up was excellent for 18 patients (90%), fair for 1 patient (5%), and poor for another patient (5%). The mean preoperative WOSI score was 1242 points, and it improved significantly (P <.0001), with a mean score of 120 points at follow-up. In all patients, the comparative study between CT scans performed postoperatively and at final follow-up did not reveal a volume reduction of the xenografts (P > .05) and absence areas affected by signs of resorption and breakage with 34.4% of postprocedural increase of the glenoid surface, were seen. The combination of ASA and bone block procedure with a xenograft was effective in the glenoid reconstruction and restoration of shoulder stability. No radiographic evidence of graft resorption, graft displacement, or glenohumeral arthritis were observed at 24-month follow-up.

Return to Preinjury-Level Sports After Arthroscopic Latarjet for Recurrent Anterior Shoulder Instability in Professional Athletes.

The Latarjet procedure is recommended to treat recurrent anterior shoulder instability with glenoid bone loss. Longer return-to-sport (RTS) times have been reported after the open Latarjet when compared with the arthroscopic Latarjet. To assess the clinical outcomes and RTS in athletes who underwent an arthroscopic Latarjet. Case series; Level of evidence, 4. This study included 46 professional athletes with recurrent anterior shoulder instability who underwent an arthroscopic Latarjet between 2010 and 2016. Patients were divided by type of sport: noncollision and nonoverhead (n = 22), collision and martial arts (n = 13), and overhead (n = 11). Sport activity was evaluated with the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, Subjective Patient Outcome for Return to Sports score, and RTS time. Clinical results were evaluated by Constant-Murley score, Walch-Duplay score, and range of external and internal rotation. Complication rates, recurrence of shoulder instability, and number of revision procedures were recorded. Correlation tests were used to assess the relationship between measured parameters. The mean ± SD patient age was 27.1 ± 7.3 years, and the mean follow-up was 50.7 ± 18 months. Overall, 44 patients (95.7%) returned to their previously practiced sports, and 40 (87%) returned to their preinjury levels. The RTS time was 5 ± 1.4 months, with no significant difference among sport types. KJOC and Subjective Patient Outcome for Return to Sports scores were 95.2 ± 5.6 and 9.5 ± 1, respectively. Significant pre- to postoperative improvement was seen on the Constant-Murley score (from 54.3 ± 9.4 to 87.9 ± 8.2; P = .001) and Walch-Duplay score (from 53.7 ± 7.3 to 88.1 ± 10.7; P = .001). Mean postoperative external and internal rotation was 72.8° ± 18.6° and 81.3° ± 11.3°. Procedure-related complications occurred in 10 patients (21.7%); recurrence of shoulder instability was observed in 4 (8.7%); and 4 (8.7%) underwent revision surgery. A worse Walch-Duplay score was significantly associated with longer RTS time (r = -0.39; P = .019) and lower KJOC score (r = 0.29; P = .03). There was a 95.7% RTS rate after the arthroscopic Latarjet procedure, although the procedure was not free from complications.