Recurrent Anterior Shoulder Instability Research Articles

Open Bankart repair plus inferior capsular shift versus isolated arthroscopic Bankart repair in collision athletes with recurrent anterior shoulder instability. A prospective study

BackgroundOpen Bankart repair plus inferior capsular shift and isolated arthroscopic Bankart repair have never been prospectively compared under the concept of glenoid track in collision athletes with recurrent anterior shoulder instability. The aim of this study was to compare the functional outcomes, range of motion and recurrence rate between these two surgical techniques. We hypothesized that open Bankart repair plus inferior capsular shift would provide similar functional outcomes to isolated arthroscopic Bankart repair but with a lower recurrence rate. MethodsA prospective cohort study was conducted with 86 collision athletes divided into two groups of 43 patients each. All patients had a subcritical glenoid bone loss ≤ 13.5% and an on-track Hill Sachs lesion. The average follow-up was 66 (60-93) months for the open group and 68 (60-97) months for the arthroscopic group. The primary functional outcomes of each group were evaluated at baseline, 6 months, 1 year and for a minimum of 5 years after surgery. The functional outcomes were also compared between the two groups. The assessment tools included the WOSI and ASES scores. In addition, recurrent instability and range of motion were also evaluated. ResultsIn each group, there were significant differences in WOSI and ASES scores between the pre and postoperative periods. There were no differences between the groups at the end of follow-up (P = 0.47 and 0.22). Three dislocations (6.9%) in the open group and 10 dislocations (23.2%) in the arthroscopic group were reported showing significant differences (P = .012). In addition, there were no differences in range of motion between pre and postoperative periods for each group as well as between them. ConclusionWe found no differences in functional outcomes and range of motion between the two groups. The recurrence rate was significantly higher in the arthroscopic group. We recommend performing open Bankart repair plus inferior capsular shift as a treatment alternative in collision athletes with recurrent anterior shoulder instability.

Bony Bankart Lesion: Diagnosis, Management, and Outcomes.

» Bony Bankart lesions are fractures of the anteroinferior glenoid rim, commonly associated with a traumatic anterior shoulder dislocation, and are diagnosed through radiological imaging and physical examination. Young male athletes playing contact sports are at highest risk of these injuries. Early diagnosis and treatment are crucial because, if left untreated, recurrent anterior shoulder instability and glenoid bone loss can occur. Both nonsurgical and surgical treatment options are available depending on the size of the lesion, with arthroscopic repair being the most common treatment method. After repair, patients typically have favorable outcomes with low rates of recurrent instability. This review aims to discuss the etiology, diagnosis, and treatment of bony Bankart lesions.» Bony Bankart lesions are fractures of the anteroinferior glenoid rim and occur in up to 22% of first-time anterior shoulder dislocations.» Young men involved in contact sports or combat training are at the highest risk of sustaining bony Bankart lesions.» Diagnosis and treatment of bony Bankart lesions are essential to prevent long-term shoulder instability.» Bony Bankart lesions can be treated either nonoperatively or operatively (arthroscopic vs open repair), with the size of the glenoid defect being the primary determinant of treatment.

Comparison of Return to Sports and Competition After the Arthroscopic Bristow-Latarjet Procedure Versus Arthroscopic Bankart Repair in Adolescents With Recurrent Anterior Shoulder Instability

Background: The use of isolated soft tissue repair versus bone block stabilization for the treatment of recurrent anterior shoulder instability in adolescents has no scientific evidence. Purpose: To compare the clinical outcomes of adolescent patients who underwent isolated arthroscopic Bankart (iB) repair with those who underwent the arthroscopic Bristow-Latarjet procedure in addition to Bankart (BLB) repair. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 60 shoulders in adolescents (aged 13-18 years) were reviewed with a minimum 2 years’ follow-up: iB repair (n = 36) and arthroscopic Bankart repair with an additional Bristow-Latarjet procedure (BLB; n = 24). The characteristics of the patients in each group in terms of age at the first instability episode, age at surgery, hyperlaxity, participation in at-risk sports, and Instability Severity Index Score were comparable. The mean follow-up was longer in the iB group (7.7 vs 4.1 years, respectively), whereas the rates of patients engaged in competition and those with glenoid lesions were higher in the BLB group. The primary outcome measures were failure, defined as the recurrence of instability (clinical dislocation or subluxation), and return to sports. The mean follow-up was 6.2 years (range, 2-16 years). Results: At the last follow-up, the rate of recurrence was significantly higher in the iB group, with 22% (8/36) failures, than in the BLB group, with 8% (2/24) instability recurrences (P < .05). The rate of return to sports at the same level was significantly higher after the BLB repair than after iB repair (79% vs 47%, respectively; P < .001). No statistical difference was found in patient-reported outcome scores between treatment groups (P > .05). Although failures occurred early after the BLB repair, 88% of failures after iB repair occurred after 2 years. On multivariate analysis, adolescents in the iB group with >3 episodes of preoperative dislocation and shoulder hyperlaxity (external rotation >90°) had a 60% recurrence rate (P < .005). Conclusion: Adolescent patients undergoing the BLB repair had a lower rate of recurrent instability and higher rates of return to sports and competition than those undergoing iB repair. Patients with shoulder hyperlaxity (external rotation >90°) and >3 dislocations had an unacceptable failure rate of 60% after iB repair.

Clinical outcomes of open Latarjet-Patte procedures performed for recurrent anterior shoulder instability with primary bone loss versus failed arthroscopic Bankart repair.

The purpose of this study is to compare the outcomes of Latarjet-Patte procedures (LPs) performed for primary glenohumeral instability surgery in the setting of critical bone loss (LP-BL) versus salvage surgery performed after a failed primary arthroscopic Bankart repair (LP-FB). Patients who underwent an LP from 2017 to 2021 were identified from the senior author's database and separated into cohorts by LP indication. Data abstracted from electronic medical records included demographic information, preoperative clinical scores, radiological imaging, and complications. Postoperative clinical outcome scores collected after a 2-year minimum follow-up included: patient-reported outcomes measurement information system (PROMIS) upper extremity (UE), PROMIS Pain interference, PROMIS pain intensity, American Shoulder and Elbow Surgeons (ASES), and Visual Analog Scale pain scores. A total of 47 patients (LP-BL: n=29, LP-FB: n=18) with a mean age of 29 years (range, 15-58 years) were included in this study. Both cohorts achieved good upper extremity functionality without significant differences as indicated by mean PROMIS UE (LP-BL: 52.6±10.0 vs. LP-FB: 54.6±7.6, P=0.442) and ASES scores (LP-BL: 89.9±15.7 vs. LP-FB: 91.5±14.4, P=0.712). However, the LP-FB cohort reported lower levels of pain (LP-FB: 0.5±1.1 vs. LP-BL: 1.9±2.7, P=0.020) at their latest follow-up. There were no significant differences in complication rates including re-dislocation between cohorts (LP-BL: 2/29 [6.9%] vs. LP-FB: 2/18 [11.1%], P=0.629). When performed after failed Bankart repair, the LP results in similar postoperative functional outcomes and similar rates of complications and re-dislocations when compared to the primary indication of recurrent glenohumeral instability in the setting of critical bone loss.

Clinical Outcomes and Graft Resorption After Metal-Free Bone Block Suture Tape Cerclage Fixation for Recurrent Anterior Shoulder Instability: A Computed Tomography Analysis

Background: Glenoid reconstruction with a bone block for anterior glenoid bone loss (GBL) has shown excellent outcomes. However, fixation techniques that require metal implants are associated with metal-related complications and bone graft resorption. Hypothesis: Arthroscopic glenoid reconstruction using a tricortical iliac crest bone graft (ICBG) and metal-free suture tape cerclage fixation can safely and effectively restore the glenoid surface area in patients with recurrent anterior shoulder instability and anterior GBL. Study Design: Case series; Level of evidence, 4. Methods: Adult patients (≥18 years) of both sexes with recurrent anterior shoulder instability and anterior GBL ≥15% were enrolled. These patients underwent arthroscopic glenoid reconstruction with ICBGs and metal-free suture tape cerclage fixation. The effectiveness and clinical outcomes with this technique were evaluated at 24 months using functional scores. Resorption of the graft articular surface was assessed by computed tomography, with the graft surface divided into 6 square areas aligned in 2 columns. Descriptive analysis was conducted. Results: A total of 23 consecutive patients met inclusion criteria (22 male, 1 female; mean age, 30.5 ± 7.9 years). The mean preoperative GBL was 19.7% ± 3.4%, and there were 15 allograft and 8 autograft ICBGs. All patients exhibited graft union at 3 months. The median follow-up was 38.5 months (interquartile range, 24-45 months). The Western Ontario Shoulder Instability Index, Rowe, Constant-Murley, and Subjective Shoulder Value scores improved from preoperatively (35.1%, 24.8, 83.1, and 30.9, respectively) to postoperatively (84.7%, 91.1, 96.0, and 90.9, respectively) (P < .001). No differences in clinical scores were observed between the graft types. One surgical wound infection was reported, and 2 patients (8.7% [95% CI, 2.4%-26.8%]) required a reoperation. The mean overall glenoid surface area increased from 80.3% ± 3.5% to 117.0% ± 8.3% immediately after surgery before subsequently reducing to 98.7% ± 6.2% and 95.0% ± 5.7% at 12 and 24 months, respectively (P < .001). The mean graft resorption rate was 18.1% ± 7.9% in the inner column and 80.3% ± 22.4% in the outer column. Additionally, 3 patients treated with an allograft (20.0% [95% CI, 7.1%-45.2%]), including the 2 with clinical failures, exhibited complete graft resorption at the last follow-up. Conclusion: Arthroscopic glenoid reconstruction using an ICBG and metal-free suture tape cerclage fixation was safe and effective, yielding excellent clinical outcomes. Resorption of the graft articular surface predominantly affected the nonloaded areas beyond the best-fit circle perimeter.

Arthroscopic suture bridge fixation for acute bony Bankart with anterior glenohumeral instability: a case report and narrative review.

Anterior shoulder dislocations can result in acute glenoid rim fractures that compromise the bony stability of the glenohumeral joint. Adequate fixation of these fractures is required to restore stability, decrease shoulder pain, and facilitate return to activity. The double-row suture bridge is a relatively novel fixation technique, first described in 2009, that accomplishes internal fixation with sufficient stability using an all-arthroscopic technique to restore the glenoid footprint. A 40-year-old female with recurrent anterior shoulder instability in the setting of seizure disorder was found to have a bony Bankart lesion of 25% to 30% with a concomitant superior labral tear. The patient was treated with a double-row bony Bankart bridge and labral repair. At six months follow-up, she has progressed to a full recovery with no recurrence. A search was conducted in May 2023 in PubMed, EMBASE, and CINAHL with the search terms bony Bankart, bone Bankart, osseous Bankart, acute, bridge, suture bridge, double row. Double-row suture bridge repairs result in improvement in shoulder function as determined by ASES (93.5), QuickDASH (4.5), SANE (95.9), and SF-12 (55.6). The overall recurrence rate of anterior instability after a bony Bankart bridge repair is 8%. When examining the return to prior level of function, 81.4% of patients were able to do so with only 7.9% of patients reporting significant modifications to their activity level. In mid-term results, double row suture bridge demonstrates similar outcomes to other all-arthroscopic fixation methods of bony Bankart injuries. Importantly, bony Bankart bridge remains a viable option for critical glenoid lesions over the 20% cutoff used in other all arthroscopic techniques. Biomechanically, the double-row suture bridge offers distinct benefits over its single-row counterpart including increased compression, reduced displacement, and reduced step-off. Although there is limited data, the studies discussed and the demonstrative case show the potential benefit of all-arthroscopic double-row suture bridge fixation including increased compression, decreased displacement, and a lower complication rate in patients with large bony Bankart lesions traditionally requiring bony augmentation. However, more robust studies are necessary to determine the long-term success of the double-row suture bridge.

The Functional Outcome Between Arthroscopic and Open Surgery for Recurrent Anterior Shoulder Instability: A Systematic Review

Background: It remains unknown if arthroscopic repair of recurrent anterior shoulder instability is as effective as open repair. The aim of this study was to compare the functional outcome between arthroscopic and open repair for recurrent Anterior Shoulder Instability. Methods: We searched the Cochrane Library, EMBASE, and PubMed extensively for studies comparing open versus arthroscopic repair for recurrent anterior shoulder dislocations until March 1, 2021. The PRISMA guidelines were utilised by two different researchers to assist them in selecting pertinent papers. Because there were few studies, there was no restriction on publication status, open and arthroscopic repair technique, or patient demographics. Results: For recurrent anterior shoulder dislocations, five randomised controlled trials assessed the use of open repair against arthroscopic surgery. According to these investigations, there is no discernible difference between the two operational strategies. At present, there are no known long-term follow-up data that describe the outcomes of either surgical method. Every inquiry had flaws in the way it was designed, which reduced the reliability of the results. Conclusion: There is insufficient data from randomised controlled trials to conclude that there is a statistically significant difference between the groups that underwent open repair and those that underwent arthroscopic surgery in terms of redislocation rates, return to activity, and functional outcomes. After arthroscopic surgery, range of motion is slightly better than after open repair. No recommendations regarding the best course of surgery can be given. Keywords: recurrent anterior shoulder instability; open; arthroscopic; repair.

Comparison of the Latarjet Procedure With the Modified Putti-Platt Surgery for Recurrent Anterior Shoulder Dislocation With Respect to Functional Outcome.

Introduction Shoulder dislocation is the most common injury encountered in orthopedic outpatient department. The choice of procedure depends on the expertise of surgeons.The objective of this study was tocompare the Latarjet procedure with the modified Putti-Platt surgery for recurrent anterior shoulder dislocation in terms of functional outcomes. Materials and methods A quasi-experimental study evaluated 60 patients with recurrent anterior shoulder instability. Patients were assigned to either Latarjet or modifiedPutti-Platt surgery. Functional outcomes were assessed at sixmonths using the Constant-Murley shoulder score. Results This study encompassed 60 patients (mean age:23.93±5.88 years) undergoing shoulder procedures.Functional outcomes exhibited a majority of 55% excellent, 35% good, 6.7% fair, and 3.3% poor outcomes. No significant differences in functional outcomes were found between the procedures. Conclusion Both procedures may be viable options for recurrent shoulder instability. The choice may depend on patient factors and surgeon preference. Further research is needed to refine techniques and identify ideal candidates.

Arthroscopic Bankart versus Open Latarjet; Short-to-Mid-Term Outcomes of Recurrence and Patient-Reported Outcomes in Patients with Recurrent Anterior Shoulder Dislocation

Objectives This retrospective comparative study compared the short to mid-term outcomes of arthroscopic Bankart repair and open Latarjet procedures in patients with recurrent anterior shoulder instability. Methods Patients who underwent either arthroscopic Bankart repair or open Latarjet procedures between 2008 and 2020, with at least one year of follow-up, were included. Arthroscopic Bankart repairs were performed on shoulders with minimal glenoid bone loss (&lt;15%), and the Latarjet procedure was performed if the preoperative computed tomography (CT) scan showed a 15% bone loss on the glenoid side or 30-40% humeral head bone loss. Their surgery results and patient-reported outcome measures (PROMs) were assessed using the Oxford Shoulder Score (OSS) and Shoulder Pain and Disability Index (SPADI). Results 133 patients were analyzed in Latarjet (n = 67) and Bankart groups (n = 66). Before surgery, the two groups of patients were similar regarding surgery side, hand dominance, education level, occupation difficulty level, and smoking (P&gt;0.05). However, Latarjet’s patients were younger (32 vs. 35, P=0.04), had a higher proportion of males (96% vs. 82%, P=0.01), and had a significantly shorter follow-up period (3.2 vs. 6.4 years, P&lt;0.001) than the Bankart group. There was no significant difference between the Latarjet and Bankart groups regarding the follow-up’s OSS score (37 vs. 36; P=0.94) and SPADI score (22 vs. 24, P=0.80). Dislocation was observed in only one patient (1.5%) in the Latarjet group (P=1.0). Subluxation was observed in 5 patients (7.5%) of the Latarjet group and three patients (4.5%) of the Bankart group (P=0.4). The overall instability rate was similar (P&gt;0.05). Conclusion Our findings suggest that both arthroscopic Bankart repair and open Latarjet are reliable techniques in short to mid-term follow-up based on the glenoid bone loss cut-off of 15%. Level of Evidence Therapeutic Level III

Revision Anterior Glenoid Reconstruction With Distal Tibia Allograft Combined With Open Capsular Shift

Background: Managing patients with recurrent anterior shoulder instability and glenoid bony deficiency remains a challenge. Multiple graft options, including iliac crest, distal clavicle, coracoid, and distal tibia allograft have been used. There is a growing body of evidence that supports distal tibia allograft for glenoid restoration in patients with shoulder instability due to its ability to restore the articular surface as well as the glenoid depth and curvature. Indications: Surgical indications for anterior glenoid reconstruction with distal tibia allograft combined with open capsular shift include patients with recurrent shoulder instability and glenoid bone loss. Technique Description: A deltopectoral interval is utilized and the subscapularis is split in lines with its fibers. The subscapularis and capsule are split together in a horizontal fashion and tagged together. Any prior hardware is then removed utilizing appropriate removal sets, a burr, and a broken screw set if necessary. The anterior glenoid is then prepared and the defect is measured. Bone marrow aspirate is then harvested from the proximal humerus using a vortex needle. The distal tibia allograft is then cut to size and prepared utilizing pulsed lavage, pressurized sterile carbon dioxide, and the bone marrow aspirate. The allograft is then fixed with solid stainless steel 3.5-mm cortical screws with washers. The medial, glenoid based capsular repair it completed by placing 1.8-mm knotless FiberTak anchor at the bottom of the distal tibia allograft. A free needle is utilized to place a horizontal mattress stitch from the anchor to the inferior capsule, which is then loaded onto a shuttling suture, to repair it to the anterior inferior glenoid. A knotless anchor is then placed right off the chondral margin of the humeral head, and this is used to repair both the capsule and subscapularis in the correct position by passing through both inferior and superior leaflets. This is then loaded onto the knotless anchor and reduced, which shifts the subscapularis and capsule laterally. The remainder of the subscapularis split is then closed. Patients are then placed in a sling with an abduction pillow with no shoulder range of motion for 6 weeks. They can then progress their therapy with a goal of returning to sport at 6 months. Results: Several large systemic reviews have shown that return to sport rates after anterior glenoid reconstruction range between 80% and 90%, with returning to the same level of play in the 70% range. Discussion: Anterior glenoid reconstruction utilizing distal tibia allograft combined with an open capsular shift is a durable surgical option for patients presenting with shoulder instability and glenoid bone loss. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

The Arthroscopic Subscapular Sling Procedure Results in Low Recurrent Anterior Shoulder Instability at 24 Months of Follow-Up

The purpose of this study was to analyze the results of the subscapular sling procedure developed for anterior shoulder instability in patients with less than 10 % anterior glenoid bone loss. The aim was to explore if this procedure would be successful in preventing recurrent shoulder dislocation. Patients were treated surgically with the arthroscopic subscapular sling procedure. A semitendinosus graft was used to reconstruct the anterior labrum and to establish a sling suspension around the upper part of the subscapularis tendon. The patients were followed by x-ray (12 and 24 months). Magnetic resonance imaging (MRI) of the shoulder region and clinical examinations were performed at 3, 12 and 24 months. Recurrent dislocation was the primary endpoint. The Western Ontario Shoulder Instability Index (WOSI) and MRI results were secondary outcome measures. An independent physiotherapist assessed residual instability and ROM. Fifteen patients were included with a dislocation rate of zero % after 24 months follow-up. There was a significant clinical improvement of the WOSI score from 57 % (904) at baseline to 88 % (241) at 24 months (p < 0.001). The proportion of patients with an improvement in the WOSI Total score larger than the estimated Minimal Clinically Important Difference (MCID) was 100% both at 12 and 24 months. MRI showed an intact sling in all patients. External rotation was not significantly reduced (52° at baseline vs 47° at 24 months, p = 0.211). Flexion and abduction were significantly improved from 152° to 174° (p=0.001) and 141° to 170° (p<0.001) after 24 months. The surgical procedures were completed without any intraoperative complications. The subscapular sling procedure resulted in low recurrent shoulder instability and improved patient-reported outcome measures at 24-months follow-up.

Distal Tibial Allograft for the Treatment of Anterior Shoulder Instability With Glenoid Bone Loss: A Systematic Review and Meta-analysis.

The use of a distal tibial allograft (DTA) for reconstruction of a glenoid defect in anterior shoulder instability has grown significantly over the past decade. However, few large-scale clinical studies have investigated the clinical and radiographic outcomes of the DTA procedure. To conduct a systematic review and meta-analysis of clinical studies with data on outcomes and complications in patients who underwent the DTA procedure for recurrent anterior shoulder instability with glenoid bone loss. Systematic review and meta-analysis; Level of evidence, 4. A comprehensive search of major bibliographic databases was conducted for articles pertaining to the use of a DTA for the management of anterior shoulder instability with associated glenoid bone loss. Postoperative complications and outcomes were extracted and compiled in a meta-analysis. Of the 8 included studies with 329 total participants, the mean patient age was 28.1 ± 10.8 years, 192 (83.8%) patients were male, and the mean follow-up was 38.4 ± 20.5 months. The overall complication rate was 7.1%, with hardware complications (3.8%) being the most common. Partial graft resorption was observed in 36.5% of the participants. Recurrent subluxation was reported in 1.2% of the participants, and recurrent dislocation prompting a reoperation was noted in 0.3% of the participants. There were significant improvements in clinical outcomes, including American Shoulder and Elbow Surgeons score (40.9-point increase; P < .01), Single Assessment Numeric Evaluation (47.2-point increase; P < .01), Western Ontario Shoulder Instability Index (49.4-point decrease; P < .01), Disabilities of the Arm, Shoulder and Hand (20.0-point decrease; P = .03), and visual analog scale (2.1-point decrease; P = .05). Additionally, postoperative shoulder range of motion significantly increased from baseline values. The DTA procedure was associated with a low complication rate, good clinical outcomes, and improved range of motion among patients with anterior shoulder instability and associated glenoid defects.

Validating the Glenoid Track Concept Using Dynamic Arthroscopic Assessment.

Failure after isolated Bankart repair has led surgeons to consider when to address the Hill-Sachs lesion, which is thought to be a contributor to recurrent instability. One approach utilizes the glenoid track concept to determine whether a Hill-Sachs lesion is classified as "off-track," suggesting that the addition of a remplissage procedure may aid stability. However, the accuracy and reliability of using this approach require validation using an appropriate reference. To determine the accuracy and reliability of using the glenoid track concept against dynamic arthroscopic assessment of Hill-Sachs lesion engagement. Cohort study (diagnosis); Level of evidence, 3. A total of 49 patients undergoing arthroscopic Bankart repair surgery for recurrent traumatic anterior shoulder instability were enrolled in this diagnostic validation study. Shoulders were classified as on-track or off-track using 3-dimensional computed tomography (3DCT) and static arthroscopic measurements. These classifications were compared with dynamic arthroscopic assessment (engagement of the Hill-Sachs lesion on the anterior glenoid rim in the 'athletic position') to determine their accuracy and reliability. The 3DCT-based measurements to determine glenoid track status had a higher positive predictive value (66% vs 42%), higher specificity (47% vs 42%), and higher accuracy (65% vs 59%) compared with static arthroscopic measurements. Static arthroscopic measurements to determine glenoid track status had a higher negative predictive value (96% vs 64%) and higher sensitivity (96% vs 81%) compared with 3DCT-based measurements. Interrater reliability (Krippendorff α) was 'fair' for determining the glenoid track status using 3DCT (0.368; 95% CI, 0.217-0.519) and 'moderate' for static arthroscopic measurements (0.523; 95% CI, 0.364-0.666). Intrarater reliability (intraclass correlation coefficient [ICC] 3,k) was 'moderate' for 3DCT measurements (0.660; 95% CI, 0.444-0.798) and 'good' for static arthroscopic measurements (0.769; 95% CI, 0.629-0.862). Determining glenoid track status using either 3DCT or static arthroscopic measurements yielded moderate accuracy and reliability. Surgeons using the glenoid track concept to aid surgical decision-making in traumatic recurrent anterior shoulder instability should utilize 3DCT or static arthroscopic measurements with caution.

Dynamic Anterior Stabilization with Hill-Sachs Remplissage Can be Employed in Skeletally Immature Patients-Operative Technique.

Numerous studies indicate that glenoid bony augmentation raises the risk of complications during and after surgery. On the other hand, repairing the labrum alone in cases with subcritical glenoid bone loss results in recurrent instability and persistent apprehension. As a result, recent advancements in shoulder instability surgery prioritize fully restoring the anterior shoulder restraint. A novel method for treating recurrent anterior shoulder instability with subcritical glenoid bone loss and off-track Hill-Sachs lesion in skeletally immature patients is suggested: the use of dynamic anterior stabilization technique incorporating the long head of the biceps tendon onto the anterior glenoid rim via trans-subscapular transfer, in conjunction with Hill-Sachs remplissage. A practical, step-by-step surgical technique for a complete reconstruction of the anterior capsule-labral-ligamentous complex is provided. This involves utilizing a soft-tissue dynamic anterior sling, achieved through the trans-subscapularis transfer of the long head of the biceps tendon at the glenoid level. The procedure concludes with a Hill-Sachs remplissage to further prevent off-track events and alleviate apprehension. Dynamic anterior stabilization is a suitable approach for addressing recurring anterior shoulder instability in skeletally immature patients who have subcritical glenoid bone loss and bipolar bone lesions.

Bipolar bone loss and distance to dislocation.

Studies have shown that glenoid- and humeral-sided bone loss may be present in up to 73-93% of individuals with recurrent anterior shoulder instability. As such, bone loss must be addressed appropriately, as the amount of bone loss drives surgical decision making and influences outcomes. Methods to describe and measure bone loss have changed over time. Originally, glenoid and humeral bone loss were viewed separately. However, the concepts of bipolar bone loss, the glenoid track (GT), and "on/off-track" lesions arose, highlighting the interplay between the two entities in contributing to recurrent instability. Classically, "off-track" lesions have been described as those Hill-Sachs interval (HSI) greater than the GT, and have been shown to result in higher rates of re-instability when addressed nonoperatively or with Bankart repair alone. More recently, further attention has been given to "on-track" lesions (HSI < GT). The new concept of "distance to dislocation" (DTD) has gained popularity. DTD is calculated as the difference between the GT and HSI, and literature evaluating DTD suggests that not all "on-track" lesions should be treated in the same manner. The purpose of this concept review article is twofold: (I) describe glenoid, humeral, and bipolar bone loss in the setting of anterior shoulder instability; and (II) elaborate on the new concept of "DTD" and its use in guidance of management.

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.

Traumatic avulsion of the subscapularis tendon in adolescents: Return to sport after surgical repair

IntroductionTraumatic complete rotator cuff tears are rare in the pediatric population. These injuries might be a result of shoulder dislocation or direct trauma experienced during contact sports (i.e., rugby, judo). The purpose of this study was to identify the epidemiologic and clinical characteristics of these injuries and assess the medium- and long-term outcomes following surgery, with return to sport as the primary endpoint. Materials and methodsAn electronic questionnaire was sent to all surgeons who were members of the French Shoulder and Elbow Society (SOFEC) and/or the French Society of Arthroscopy (SFA), asking if they ever had to surgically treat a traumatic complete tear of 1 or more rotator cuff tendons in a child or adolescent. Ninety (38.6%) of the 233 surgeons members of the SOFEC and/or the SFA responded to our questionnaire. We then contacted the 15 surgeons who answered affirmatively to collect the complete medical records of their patient(s). ResultsWe reviewed the records of 17 children and adolescents who underwent surgery for a traumatic complete rotator cuff tear. The mean age at surgery was 15.2 years (range, 12–17). Glenohumeral dislocation during contact sports (n=7/17) was a frequent mechanism of injury (41%). All of these cases involved at least the subscapularis muscle with an avulsed bony insertion. The injury involved other rotator cuff tendons in 29% of cases (5/17). The bone and tendon repair was either performed as open surgery (n=5/17) or arthroscopically (n=12/17). At a median follow-up of 24 months and a mean follow-up of 50 months, 82.4% of patients had returned to sport at their preinjury level. Three patients presented neurologic complications resulting from the traumatic event, but only 1 of them required nerve grafting with a favorable outcome. We also reported 3 cases of nonunion of the lesser tuberosity that required revision surgery with good outcomes. Only 1 patient out of all those with at least 1 episode of dislocation presented a recurrent anterior shoulder instability that required a bone block-type procedure 7 years after the initial surgery. ConclusionTraumatic complete rotator cuff tears are rare in children and adolescents. They often occur during contact sports. These types of injuries are diagnosed by clinical examination and confirmed by cross-sectional imaging, ideally magnetic resonance imaging. Tendon injuries mainly involve the subscapularis but can also affect other cuff tendons. Return to preinjury activity levels after surgical management was possible in more than 80% of cases. Level of evidenceIV.

Functional Outcomes of Arthroscopic Bankart Repair in Indian Population: A Systematic Review and a Meta-analysis

Abstract Introduction: The past two decades have witnessed significant development in arthroscopic management for recurrent anterior shoulder instability. Currently, arthroscopic Bankart repair (ABR) is popular in the treatment of anterior shoulder instability. There is a dramatic rise in the number of orthopedic surgeons in India specializing in shoulder surgery and is believed to be secondary to the advancement in arthroscopic techniques and implants. However, there is a paucity of Indian literature on functional outcomes of ABR. The purpose of the current review is to better understand the functional outcomes of ABR in the Indian population. Methods: A search of major databases (Embase, Ovid Medline, Google Scholar, and Cochrane Library) was performed in April 2020. Reference lists of selected research articles were further screened in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion and exclusion criteria for analysis were used to generate the final list of studies. Results: A total of ten research studies were included in the final analysis representing a pooled patient population set of 391 patients. The mean age for patients across the studies was 27 years (range: 24–29) of age and the average number of dislocations before surgery was five (range: 0–14). The average follow-up period post-surgery was 20 months (range: 6–27 months). Among the functional scores, the average UCLA score improved from 22 (range: 18–30) at preoperatively to 32 (range: 31–35), and the mean Rowe score improved from an average of 27 (range: 24–63) preoperatively to 91 (range: 90–94) during the follow up duration. The average postoperative re-dislocation rate was 7% (range: 0%–10%). Conclusion: In the Indian population, ABR provides consistently good functional outcomes with a low postoperative re-dislocation rate, which is at par with the global data. Further studies with larger sample sizes and longer follow-ups are needed to validate these results.

Outcomes of primary Latarjet vs. revision Latarjet after prior surgery for anterior shoulder instability: a systematic review and meta-analysis.

Latarjet has become an increasingly popular treatment option for recurrent anterior shoulder instability. With the reported complication rates for primary Latarjet surgery, there are concerns about the complications of Latarjet as a revision surgery. It remains unclear if poor results after previous surgical management can be improved with revision Latarjet as well as with primary Latarjet. The aim of this systematic review and meta-analysis is to compare the outcomes of primary Latarjet and revision Latarjet for the treatment of anterior shoulder instability. A systematic search was performed on 3 databases for studies that compared primary Latarjet with revision Latarjet used after failed arthroscopic stabilization or failed free bone block procedures. From the included studies, demographic data, clinical outcome scores, range of motion measurements, and postoperative complications were obtained. A total of 11 studies were included for data analysis. Compared with the primary Latarjet cohort, revision Latarjet cohorts had a higher infection rate (1.2% vs. 2.6%; RR 0.46, P=.039). The primary Latarjet group showed a greater rate of return to sport (89.7% vs. 80.5%; RR 1.12, P=.41) and less subjective feeling of instability (12.6% vs. 20.9%; RR 0.60, P=.085) compared with the revision Latarjet group; however, this was not statistically significant. There were no significant differences in complication rates, reoperation, recurrence, and range of motion between primary Latarjet and revision Latarjet groups. Clinical outcome scores such as visual analog scale and Rowe scores were not significantly different between the cohorts. Based on the current evidence, primary Latarjet presents reduced infection rates but similar clinical outcome measures, overall complication, and range of motion measurements than revision Latarjet performed after failed prior operative treatment.

Bone formation of the coracoid bone graft after the Bristow procedure assessed using three-dimensional computed tomography

BackgroundThe Bristow procedure has been shown to be a reliable method to prevent recurrent anterior shoulder instability by compensating for glenoid bone loss and producing the sling effect. The degree of postoperative morphological change in the coracoid bone graft is speculated to influence glenohumeral joint stability; however, the details of these changes after the Bristow procedure remain unknown. This study was performed to quantify the postoperative change in the coracoid bone graft volume as assessed by three-dimensional computed tomography (3D-CT). MethodsThe Bristow procedure was performed on 17 shoulders in 17 patients from August 2018 to January 2020. All patients were men, and their mean age at surgery was 17.9 years. The mean follow-up duration was 21.4 months. Within the first week after the operation (Time 0) and at the final follow-up, 3D-CT was used to determine the total coracoid bone graft volume. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) shoulder score, the University of California Los Angeles (UCLA) shoulder score, and the Western Ontario Shoulder Instability Index (WOSI). ResultsThe mean volume of the total coracoid bone graft was 1.26 ± 0.29 cm3 at Time 0 and 1.90 ± 0.36 cm3 at the final follow-up (p < 0.0001). The mean JOA score, UCLA score, and WOSI were significantly better at the final follow-up than preoperatively (p < 0.001). No postoperative infection, neurovascular injury, or recurrent instability of the glenohumeral joint occurred. ConclusionsIn the Bristow procedure, the volume of the total coracoid bone graft as shown by 3D-CT was significantly greater at the final follow-up than at Time 0, and bone formation of the coracoid bone graft was found after the Bristow procedure.