Recurrent Shoulder Instability Research Articles

Is Revision Arthroscopic Bankart Repair a Viable Option? A Systematic Review of Recurrent Instability following Bankart Repair

Background/Objectives: Recurrent shoulder instability following Bankart lesion repair often necessitates surgical revision. This systematic review aims to understand the failure rates of arthroscopic revision Bankart repair. Methods: Following the PRISMA guidelines and registered on PROSPERO, this systematic review examined twenty-five articles written between 2000 and 2024. Two independent reviewers assessed eligibility across three databases, focusing on recurrent instability as the primary endpoint, while also noting functional measures, adverse events, revision operations, and return-to-sport rates when available. Results: The key surgical techniques for recurrent instability post-Bankart repair were identified, with revision arthroscopic Bankart being the most common (685/1032). A comparative analysis revealed a significantly lower recurrence for open coracoid transfer compared to arthroscopic revision Bankart repair (9.67% vs. 17.14%; p < 0.001), while no significant difference was observed between remplissage plus Bankart repair and Bankart repair alone (23.75% vs. 17.14%; p = 0.24). The majority of studies did not include supracritical glenoid bone loss or engaging Hill–Sachs lesions, and neither subcritical nor non-engaging lesions significantly influenced recurrence rates (p = 0.85 and p = 0.80, respectively). Conclusions: Revision arthroscopic Bankart repair remains a viable option in the absence of bipolar bone loss; however, open coracoid transfer appears to have lower recurrence rates than arthroscopic Bankart repair, consistent with prior evidence. Further studies should define cutoffs and investigate the roles of critical glenoid bone loss and off-track Hill–Sachs lesions. Preoperative measurements of GBL on three-dimensional computed tomography and characterizing lesions based on glenoid track will help surgeons to choose ideal candidates for arthroscopic revision Bankart repair.

Case Report of Arthroscopic Anatomical Bone Glenoid Augmentation with Subscapularis Tendon Protection with A 24 Months Follow-Up and Literature Review of The Current Concepts of Glenoid Bone Augmentation

Recurrent shoulder instability is known to be a challenge in terms of the success rate of surgical stabilization of the shoulder joint. According to the latest literature the choice of the glenohumeral stabilization surgical treatment is guided by the degree of bone loss. Among the techniques dedicated to significant glenoid bone loss, one will find many already reported, but each has its drawbacks. As we observe currently popular techniques, we conclude that we should continue to look for techniques or some modifications to those already available that are laden with as few complications as possible. In 2019, a new technique called bone block cerclage has been described. It is a new approach, using when metal implants are not used while providing benefits such as maintenance and integrity and function of structures like coracobrachialis, short head of biceps, pectoralis minor and preservation of subscapularis tendon. Currently, there are not many reported cases in the literature after BBC with a longer follow-up time. In this paper, we present the case of our patient operated on 24 months ago with this technique with good results. The patient is still under our observation. Due to the relatively new technique and the small number of described follow- ups, we feel it is relevant to describe our case.

Instability Severity Index Score predicts recurrent shoulder instability after arthroscopic Bankart repair.

The Instability Severity Index (ISI) Score was developed to preoperatively assess the risk of recurrent shoulder instability after an arthroscopic Bankart repair. This study aims to validate the use of ISI Score for predicting the risk of recurrence after an arthroscopic Bankart repair in a heterogeneous population and proposes an appropriate cut-off point for treating patients with an arthroscopic Bankart repair or otherwise. This study analysed 99 shoulders after a traumatic dislocation that underwent arthroscopic Bankart repair with at least 3 years follow-up. Patients were divided into subcategories based on their respective ISI Score. Recurrence includes either a postoperative dislocation or perceived instability. The overall recurrence rate was found to be 26.3%. A significant correlation was identified between ISI Score and the recurrence rate (odds ratio [OR]: 1.545, 95% confidence interval [CI]: 1.231-1.939, p < 0.001). Furthermore, ISI Score 4-6 (OR: 4.498, 95% CI: 1.866-10.842, p < 0.001) and ISI Score > 6 (OR: 7.076, 95% CI: 2.393-20.924, p < 0.001) both had a significantly higher risk of recurrence compared to ISI Score 0-3. In ISI Score subcategories 0-3, 4-6 and >6, the recurrence rate was, respectively, 15.4%, 40.7% and 71.4%. ISI Score has predictive value in determining the recurrence risk of shoulder instability following an arthroscopic Bankart repair in a heterogeneous population. Based on the findings of this study, we recommend using arthroscopic Bankart repair in patients with ISI Score 0-3. Clinical and shared decision-making are essential in the group with ISI Score 4-6, since the recurrence rate is significantly higher than in patients with ISI Score 0-3. Arthroscopic Bankart repair is not suitable for patients with ISI Score > 6. Level III.

Quantitative Musculoskeletal Imaging of the Pediatric Shoulder.

Pediatric acquired and congenital conditions leading to shoulder pain and dysfunction are common. Objective, quantitative musculoskeletal imaging-based measures of shoulder health in children lag recent developments in adults. We review promising applications of quantitative imaging that tend to be available for common pediatric shoulder pathologies, especially brachial plexus birth palsy and recurrent shoulder instability, and imaging-related considerations of musculoskeletal growth and development of the shoulder. We highlight the status of quantitative imaging practices for the pediatric shoulder and highlight gaps where better care may be provided with advances in imaging technique and/or technology.

Long-term results of arthroscopic capsulolabral revision repair for failed anterior shoulder instability repair using suture anchors at a minimum of 10 years follow-up.

Arthroscopic revision anterior shoulder instability repair has been proposed, and early clinical results have been promising. However, long-term results after this procedure and the probable risk factors for failure have not been sufficiently discussed in the literature. Thirty-eight patients who were diagnosed with recurrent anteroinferior shoulder instability after failed Bankart repair, treated with ACRR between September 1998 and November 2003 and able to be contacted were included. Of these patients, 2 were excluded from the study due to the use of SureTak anchors for fixation, and 5 other patients refused to participate in the study due to lack of interest (3 patients) or lack of time (2 patients). The remaining shoulders were clinically examined at a minimum of ten years after surgery via the ASES, Constant, AAOS, Rowe, Dawson and VAS scores for pain and stability. Degenerative arthropathy was assessed with the modified Samilson-Prieto score. All 31 remaining shoulders were evaluated at a mean time of 11.86 years (142.4 months) after surgery. Six patients (19.35%) reported redisolcation after the revision procedure, 4 of whom were affected by a new significant shoulder trauma. The ROWE and Constant scores improved significantly. Moderate to severe dislocation arthropathy was observed in 19.4% of patients. Five patients (16.2%) were not satisfied with the procedure. Long-term follow-up after ACRR shows predictable results, with a high degree of patient satisfaction, good to excellent patient-reported outcome scores and minimal radiological degenerative changes. However, with an average recurrence rate of 19.3% after 11.86 years, the redislocation rate appears high. With careful patient selection, recurrence rates can be significantly reduced.

Arthroscopic Shoulder Stabilization in High School Football Players.

Destabilizing shoulder injuries are common in high school American football players; however, the rate of recurrent glenohumeral instability and return to play after arthroscopic labral stabilization surgery remains unknown. The purpose of this study was to determine the rate of recurrent instability on return to competitive high school football after arthroscopic shoulder labral stabilization and capsulorrhaphy procedures. It was hypothesized that the instability rate would be greater in players with more years of eligibility remaining (YER) to play at the high school level. Case series; Level of evidence, 4. Consecutive male high school football players with at least 1 YER who sustained at least 1 anterior traumatic inseason shoulder instability episode and underwent arthroscopic stabilization between 2012 and 2017 were identified. Patients and/or families were contacted by phone to discuss (1) recurrent instability episodes and (2) return to competitive sport and/or recreational athletic activity. Statistical analysis was conducted using chi-square tests to compare recurrent shoulder instability with return to play and YER. A total of 45 football players aged 14 to 17 years were included, with a mean follow-up of 4.1 years. Most patients (60%) chose not to return to competitive football, due mainly to fear of recurrent injury. Overall, the recurrent instability rate was 15.6% (7/45). The instability rate in players who returned to football was 16.7%, with 66.7% requiring revision surgery. The instability rate in patients who did not return to football was 14.8%, with no revision procedures required. In players who returned to football, the instability rate in YER group 4 was significantly higher than that in YER groups 1 to 3 (42% vs 10.5%, respectively, P = .03), with each year of play conferring an additional 10% risk of reinjury. There was a significant difference in the type of recurrent instability in players who returned to any sport versus those who did not (P = .029). High school football players who returned to competitive play after arthroscopic shoulder stabilization surgery experienced a higher rate of recurrent instability that was dependent on their YER. Over half of the players chose not to return to football, with fear of reinjury being the most common reason.

Glenoid augmentation for subcritical bone loss: a narrative review.

Anterior shoulder instability can be debilitating for young, active individuals, and increasing magnitudes of glenoid bone loss (GBL) predisposes patients to recurrent instability and increases the likelihood of failure of soft-tissue only repairs. It is widely accepted that GBL >25% should be treated with a glenoid bone grafting procedure. However, consensus is lacking on the optimal management in the setting of subcritical GBL, typically classified as >13.5%. This article reviews the pathoanatomy relevant to anterior shoulder instability and subcritical GBL, while highlighting existing evidence regarding open augmentation procedures in comparison to other treatment options for this subpopulation. A narrative review of the current literature was conducted focusing on subcritical GBL in anterior glenoid stabilization procedures, including review of forward citation and reference lists of selected articles. Computed tomography (CT) is the modality of choice for obtaining precise measurements of subcritical GBL, defined as <13.5%, using the best-fit circle method. There is debate surrounding the optimal surgical management of subcritical GBL. Arthroscopic Bankart repair (ABR) remains the predominate surgery performed for primary anterior shoulder instability, while glenoid augmentation and open Bankart repair continue to be used sparingly in the United States. Historically, the Latarjet procedure was considered for substantial glenoid defects, but the illumination of subcritical GBL has expanded its indications. Arthroscopic, soft tissue-only repairs with the addition of remplissage, has been shown to have similar 2-year outcomes to the Latarjet in patients with >15% GBL, which has been limited in the study of subcritical GBL. Additionally, utilization of distal tibial allograft and local autograft is becoming increasingly prevalent. However, again, with limited prospective studies in the subcritical GBL population. There is no consensus regarding the optimal treatment approach to recurrent shoulder instability in the setting of subcritical GBL. Conversely, there is a growing agreement that isolated ABR is likely inadequate and subcritical GBL should prompt consideration of a more robust operation. To this end, interest in glenoid bone augmentation continues to grow as a reliable technique for recreating the native architecture and restoring glenohumeral stability are developed.

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.

Risk of suprascapular nerve injury in open Trillat procedure: an anatomical study.

The open Trillat Procedure described to treat recurrent shoulder instability, has a renewed interest with the advent of arthroscopy. The suprascapular nerve (SSN) is theoretically at risk during the drilling of the scapula near the spinoglenoid notch. The purpose of this study was to assess the relationship between the screw securing the coracoid transfer and the SSN during open Trillat Procedure and define a safe zone for the SSN. In this anatomical study, an open Trillat Procedure was performed on ten shoulders specimens. The coracoid was fixed by a screw after partial osteotomy and antero-posterior drilling of the scapular neck. The SSN was dissected with identification of the screw. We measured the distances SSN-screw (distance 1) and SSN-glenoid rim (distance 2). In axial plane, we measured the angles between the glenoid plane and the screw (α angle) and between the glenoid plane and the SSN (β angle). The mean distance SSN-screw was 8.8mm +/-5.4 (0-15). Mean α angle was 11°+/-2.4 (8-15). Mean β angle was 22°+/-6.7 (12-30). No macroscopic lesion of the SSN was recorded but in 20% (2 cases), the screw was in contact with the nerve. In both cases, the β angle was measured at 12°. During the open Trillat Procedure, the SSN can be injured due to its anatomical location. Placement of the screw should be within 10° of the glenoid plane to minimize the risk of SSN injury and could require the use of a specific guide or arthroscopic-assisted surgery.

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.

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.

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.

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.

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.