Recurrent Traumatic Anterior Shoulder Instability Research Articles

Arthroscopic Bankart Repair With Remplissage in Anterior Shoulder Instability Results in Fewer Redislocations Than Bankart Repair Alone at Medium-term Follow-up of a Randomized Controlled Trial

Background: A multicenter, double-blinded randomized controlled trial comparing isolated Bankart repair (NO REMP) to Bankart repair with remplissage (REMP) reported benefits of remplissage in reducing recurrent instability at 2 years postoperative. The ongoing benefits beyond this time point are yet to be explored. Purpose: To (1) compare medium-term (3 to 9 years) outcomes of these previously randomized patients undergoing isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) to manage recurrent anterior glenohumeral instability; (2) examine the failure rate, overall recurrent instability, and reoperation rate. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Recruitment and randomization for the original randomized trial occurred between 2011 and 2017. Patients ≥14 years diagnosed with recurrent traumatic anterior shoulder instability with an engaging Hill-Sachs defect of any size were included. Those with a glenoid defect >15% were excluded. In 2020, participants were contacted by telephone and asked standardized questions regarding ensuing instances of subluxation, dislocation, or reoperation on their study shoulder. “Failure” was defined as a redislocation, and “overall recurrent instability” was described as a redislocation or ≥2 subluxations. Descriptive statistics, relative risk, and Kaplan-Meier survival curve analyses were performed. Results: A total of 108 participants were randomized, of whom 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to the final follow-up was 49.3 and 53.8 months for the NO REMP and REMP groups, respectively. Failure rates were 22% (11/50) in the NO REMP group versus 8% (4/52) in the REMP group. Rates of overall recurrent instability were 30% (15/50) in the NO REMP group versus 10% (5/52) in the REMP group. Survival curves were significantly different, favoring REMP in both scenarios. Conclusion: For the treatment of traumatic recurrent anterior shoulder instability with a Hill-Sachs lesion and subcritical glenoid bone loss (<15%), a significantly lower rate of overall postoperative recurrent instability was observed with arthroscopic Bankart repair and remplissage than with isolated Bankart repair at a medium-term follow-up (mean of 4 years). Patients who did not receive a remplissage experienced a failure (redislocated) earlier and had a higher rate of revision/reoperation than those who received a concomitant remplissage. Registration: NCT01324531 (ClinicalTrials.gov identifier).

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.

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.

Paper 02: Is There a Benefit of Sling Immobilization After Open Latarjet Surgery for Anterior Shoulder Instability™ A Randomized Control Trial

Objectives: Recurrent traumatic anterior shoulder instability occurs most commonly in young to middle-aged male athletes. The Latarjet procedure was reported to enable early return to sport compared to capsulolabral repair. Recent research has highlighted the negative effect of immobilization on shoulder rehabilitation. However, only few studies evaluated different rehabilitation programs after open Latarjet and their potential impact on complication rates, stiffness and time to return to sport. The reported immobilization periods ranged from zero to three weeks, and different types of mobilization protocols were used. The aim of this study was to evaluate the benefit of sling immobilization after open Latarjet procedure for anterior shoulder instability. The hypothesis was that immediate self-rehabilitation without sling immobilization would result in improved functional scores at 6 months compared to patient wearing a sling for 3 weeks postoperatively. Methods: We randomized 72 patients with anterior shoulder instability scheduled for open Latarjet procedure into sling and no-sling groups. Two partially 1 cm apart threaded 4.0-mm cancellous screws were used to secure the graft. Both groups started the same immediate self-rehabilitation protocol. Patients were evaluated clinically using Rowe score, the Single Assessment Numeric Evaluation (SANE) instability score as well as visual analogue pain scale (VAS) preoperatively and at 1.5, 3, and 6 months. A computed tomography was performed at 6 months to evaluate graft healing. Results: Both groups had similar preoperative patient characteristics. Both groups had a significant improvement in Rowe score (from 38.8 ± 20.4 to 81.6 ± 17.8, p &lt; 0.001), SANE instability score (from 42.5 ± 20.5 to 84.7 ± 13.2, p &lt; 0.001) and VAS (from 27.7 ± 21.8 to 13.9 ± 16.1, p &lt; 0.001) at 6 months postoperative. There was no difference in functional outcomes between the two groups at 6 months. Mean Rowe score was respectively 80.7 ± 15.9 and 82.6 ± 19.6 in the sling and no-sling group (p = 0.64). Mean SANE instability score was 83.7 ± 13.0 and 85.7 ± 13.6 (p = 0.53) and mean VAS 15.6 ± 14.8 versus 12.2 ± 17.5 (p = 0.38), for sling and no-sling group respectively. Finally, computed tomography evaluation revealed no significant differences regarding bone graft healing between both groups (p = 0.35). Conclusions: Both treatment groups resulted in excellent early functional outcomes. Absence of sling immobilization did not increase complication rates after open Latarjet. Sling immobilization seems therefore optional after open Latarjet procedure.

RECURRENT ANTERIOR SHOULDER DISLOCATION TREATED BY OPENINFERIOR GLENOHUMERAL LIGAMENT RECONSTRUCTION

The anterior capsulolabralcomplex repair with inferior glenohumeral ligament reconstruction has been encouraging predominantly in young active population, and heavy workers with traumatic anterior shoulder dislocation. The aim of this study was to assess the clinical outcome of patients who underwent inferior glenohumeral ligament reconstruction for recurrent traumatic anterior shoulder instability by the open method. A prospective study of 40 patients with a mean age of 30 years ( 20 – 50 years ) who underwent open reconstruction of the inferior glenohumeral ligament ( RIGHL) to treattraumatic recurrent anterior shoulder dislocation was conducted. All patients met the criteria for inclusion in the study. They had traumatic anterior shoulder dislocation with subsequent recurrent instability. All were males with no professional athletes among them. Detachment of the dominant shoulder from the glenoid marginwas found in all cases . No patient had surgical intervention before. Twenty patients had the right shoulder affected. All patients were evaluated by physical examination and followed for a minimum of 6 months (15-80 months). Rowe score was used for the clinical assessment of patients. The mean modified Rowe score was 93.3% (65% -100%) with 92.3% good and excellent results. There were 14 excellent, 10 good, 5 fair, and 3 poor results due to redislocation after major trauma ( RTA). There was no loss of range of motion compared to preoperative values. These observations point out that glenoid sided capsulolabral repair can reestablish shoulder stability in patients with recurrent traumatic anterior dislocation, and success rates comparable to those of other open anterior shoulder repair procedures can be achieved. Although arthroscopic repair for recurrent shoulder instability is a choice for most surgeons nowadays, open repair remains an excellent option and should not be forgotten especially with the lack of experience or arthroscopic availability.

Knotless PEEK and double-loaded biodegradable suture anchors ensure comparable clinical outcomes in the arthroscopic treatment of traumatic anterior shoulder instability: a prospective randomized study

PurposeTo compare the clinical outcome of arthroscopic capsulolabral repair for traumatic anterior shoulder instability with PEEK knotless and knotted biodegradable suture anchors.MethodsArthroscopic stabilization was performed in 78 patients with recurrent traumatic anterior shoulder instability. They were divided into 2 groups of 39 patients each, according to suture anchors used: knotless PEEK anchors in group 1, and biodegradable anchors in group 2. Exclusion criteria were: instability without dislocation, posterior or multidirectional instability, glenoid bone loss > 20%, off-track lesions, concomitant rotator cuff tears and previous surgery. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) self-administered questionnaire. Secondary outcomes were: Work-DASH, Sport-DASH, Rowe score, recurrent instability and subsequent surgery. The following independent variables were considered: age, gender, dominance, generalized ligamentous hyperlaxity, duration of symptoms, age at first dislocation, number of dislocations, type of work, type of sport, sports activity level, capsule-labral injury pattern, SLAP lesion and number of anchors. Differences between groups for numerical variables were analyzed by use of the Student’s t-test or Mann–Whitney U-test. Fisher’s exact test was used for analysis of categorical variables. Significance was set at p < 0.05.ResultsSeven patients (9%) were lost at follow-up, 5 from group 1 and 2 from group 2. Follow-up ranged from 36 to 60 months (median: 44; IQR: 13). Comparison between groups did not show significant differences for each independent variable considered. No differences could be found either for DASH (n.s.) or Rowe (p = n.s.) scores between the two groups. Overall recurrence rate was 7%. Three re-dislocations were reported in group 1 and two in group 2 (n.s.). Only one patient in each group underwent re-operation.ConclusionsThe study showed no significant differences in clinical outcomes after arthroscopic treatment of traumatic anterior shoulder instability using PEEK knotless or biodegradable knotted anchors at mid-term follow-up.Level of evidenceI.

Arthroscopic Bankart repair: modified transglenoid sutures versus suture anchors more than 5 years: a retrospective study

Introduction Arthroscopic Bankart repair is a common procedure for treatment of recurrent traumatic anterior shoulder dislocation all over the world. Different studies compared the outcome of transglenoid sutures after different modifications with the outcome of suture anchors and they found no significant difference between the two procedures. Objective The aim of this study was to compare the long-term results of the modified transglenoid sutures through two holes and the use of suture anchors . Patients and methods Seventy patients were included in this study (42 for the transglenoid group and 28 for the second group). The mean follow-up period for the first (transglenoid) group was 7.19 years (range 5–11) and for the second (anchor) group 6.93 years (range 5–12). Results There is a significant difference in both groups between the preoperative and postoperative Rowe scores (P=0.000), while there is insignificance when comparing the two groups. Six patients (14.3%) in the transglenoid group suffered from recurrence of instability (two dislocations and four subluxations). Two of them needed second operation (open Laterjet procedure). In the anchor group, four (14.2%) patients suffered recurrence of symptoms of instability (two dislocations and two subluxations). Two of them required second operation. One patient of the first group suffered infection related to the sutures and the knot that required removal of the suture material. Conclusion Modified transglenoid suture technique is quietly equal to the repair with suture anchors for treatment of recurrent traumatic anterior shoulder instability.

Arthroscopic Bankart repair with and without arthroscopic infraspinatus remplissage in anterior shoulder instability with a Hill-Sachs defect: a randomized controlled trial

The purpose of this study was to compare patient-reported and clinic outcomes between arthroscopic Bankart repair with (REMP) and without (NO REMP) arthroscopic infraspinatus remplissage in patients with recurrent anterior shoulder instability with a Hill-Sachs lesion and minimal glenoid bone loss. Patients 14 years or older with a recurrent anterior shoulder instability with the presence of an engaging Hill-Sachs defect (of any size) confirmed on computed tomography or magnetic resonance imaging were eligible to participate. Consented patients were randomized intraoperatively to NO REMP or REMP. Study visits were conducted preoperatively and 3, 6, 12, and 24 months postoperatively. The primary outcome was the Western Ontario Shoulder Instability score. Secondary outcomes included incidence of postoperative recurrent shoulder instability, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, range of motion, complications, and revision surgery. To compare groups, a mixed-effects linear model was used for continuous variables and a χ2 or Fisher's exact test for categorical data. A Kaplan-Meier survival analysis assessed survival distribution between groups. One hundred and eight patients were randomized to Bankart repair with (n = 54) or without (n = 54) remplissage. The mean follow-up was 26.5 months (21-53 months) and 24.3 months (23-64 months) for the REMP and NO REMP groups, respectively. Rates of postoperative recurrent instability were higher (P = .027) in the NO REMP group with 9 of 50 (18%) vs. 2 of 52 (4%) postoperative dislocations in the REMP group. There were no significant differences in patient-reported outcomes between groups at any time point. Survival curve distributions were also significantly different favoring REMP (χ2 = 5.255, P = .022). There was a significant difference in rate of revision surgery between groups with 6 in the NO REMP and none in the REMP groups (P = .029). Post hoc, patients were noted to have a higher risk for re-dislocation if their Hill-Sachs lesion was ≥20 mm in width or ≥15% of humeral head diameter. One intraoperative complication was reported in the REMP group. There is significantly greater risk of postoperative recurrent instability in patients who did not have a remplissage performed in conjunction with an arthroscopic Bankart repair for the treatment of traumatic recurrent anterior shoulder instability with Hill-Sachs lesions of any size and minimal glenoid bone loss (<15%) at 2 years postoperatively. Otherwise, there are no differences in patient-reported outcomes, complications, or shoulder function at 2 years postoperatively. In addition, the remplissage procedure has significantly lower rates of re-dislocation in high-risk patients with Hill-Sachs lesions ≥20 mm and/or ≥15% in size.

Peri-anchor cyst formation after arthroscopic bankart repair: comparison between biocomposite suture anchor and all-suture anchor.

BackgroundThe purpose of this study is to investigate clinical outcomes and radiological findings of cyst formation in the glenoid around suture anchors after arthroscopic Bankart repair with either biocomposite suture anchor or all-suture anchor in traumatic anterior shoulder instability. We hypothesized that there would be no significant difference in clinical and radiological outcomes between the two suture materials.MethodsThis retrospective study reviewed 162 patients (69 in group A, biocomposite anchor; 93 in group B, all-suture anchor) who underwent arthroscopic Bankart repair of traumatic recurrent anterior shoulder instability with less than 20% glenoid defect on preoperative en-face view three-dimensional computed tomography. Patient assignment was not randomized. ResultsAt final follow-up, the mean subjective shoulder value, Rowe score, and University of California, Los Angeles shoulder score improved significantly in both groups. However, there were no significant differences in functional shoulder scores and recurrence rate (6%, 4/69 in group A; 5%, 5/93 in group B) between the two groups. On follow-up magnetic resonance arthrography/computed tomography arthrography, the incidence of peri-anchor cyst formation was 5.7% (4/69) in group A and 3.2% (3/93) in group B, which was not a significant difference. ConclusionsConsidering the low incidence of peri-anchor cyst formation in the glenoid after Bankart repair with one of two anchor systems and the lack of association with recurrence instability, biocomposite and all-suture anchors in Bankart repair yield satisfactory outcomes with no significant difference.

Excellent Clinical and Radiological Midterm Outcomes for the Management of Recurrent Anterior Shoulder Instability by All-Arthroscopic Modified Eden-Hybinette Procedure Using Iliac Crest Autograft and Double-Pair Button Fixation System: 3-Year Clinical Case Series With No Loss to Follow-Up

PurposeTo evaluate the clinical, functional, and radiological midterm outcomes of the all-arthroscopic modified Eden-Hybinette procedure in patients with recurrent anterior shoulder instability. MethodsA retrospective, single-center case series with prospectively collected data was conducted. The inclusion criterion was traumatic recurrent anterior shoulder instability with significant glenoid bone loss; patients with atraumatic or multidirectional instability were excluded. An all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and double-pair button fixation was carried out. All patients were postoperatively assessed for recurrence and apprehension. Shoulder range of motion values and functional scores, including American Shoulder and Elbow Surgeons Score, Oxford instability, Rowe instability, and Walch-Dupplay, were recorded. Graft positions, healing, and absorption were evaluated with computed tomography. Comparisons of values were performed with paired t tests for normally distributed differences and with nonparametric Wilcoxon’s signed rank test otherwise. ResultsThe final study cohort included 28 patients, mean age 36 ± 10 years, and mean follow-up period 43 ± 6 months (range 36 to 53). Median glenoid bone loss was 12.4% (range 8% to 33%). No recurrence occurred, no subjective shoulder instability was reported, and no major complications were documented through the last follow-up. Postoperative shoulder range of motion had no significant differences compared with the healthy side. All final postoperative functional scores significantly increased to show excellent results compared with preoperative values. All grafts were positioned and healed optimally, and none was completely reabsorbed. ConclusionsThe all-arthroscopic modified Eden-Hybinette procedure is safe, leading to excellent clinical and radiological midterm outcomes in patients with recurrent anterior shoulder instability. This technique restores glenoid bone defects and preserves the normal shoulder anatomy. Level of EvidenceIV, therapeutic, retrospective case series

Is there a difference in outcome of arthroscopic iliac crest autograft and allograft in recurrent anterior shoulder instability?

The aim of this study was to compare outcomes of arthroscopic tricortical iliac crest autograft and allograft bone blocks for recurrent traumatic anterior shoulder instability in terms of bone resorption, union and recurrent instability and assess which one is a better graft choice. Twenty-two consecutive patients treated for recurrent traumatic anterior shoulder instability that required reconstruction with bone block were included in the study. Surgical reconstruction was carried out arthroscopically with contoured tricortical iliac crest autograft or allograft. At follow-up, patients were assessed for Oxford Shoulder Instability Score (OSIS), recurrent dislocation, apprehension testing, complications, and 3-dimensional computed tomography (CT) for resorption and union rate at a mean of 10.89 months. There were 10 patients in the allograft group with a median age of 27.7years and a mean follow-up of 26.6months. In the autograft group, there were 12 patients with a median age of 29years and a mean follow-up of 28.7months. The OSIS increased in both groups but was significantly higher in the autograft group (54.1 vs 48.2, p = 0.02). There were 2 failures in each group but no hardware complications. Allograft had higher resorption rate in comparison (75% in allograft vs 40% in autograft) and higher non-union rate (62.5% in allograft vs 16.5% in autograft). This study demonstrated that both tricortical iliac crest autograft and allograft can improve shoulder instability symptoms. However, the results suggest that autograft may lead to significantly improved instability score, higher union rate and less bone resorption. IV, retrospective study.

Management of bone loss in recurrent traumatic anterior shoulder instability: a survey of North American surgeons

BackgroundManagement of bone loss in recurrent traumatic anterior shoulder instability remains a topic of debate and controversy in the orthopedic community. The purpose of this study was to survey members of 4 North American orthopedic surgeon associations to assess management trends for bone loss in recurrent anterior shoulder instability. MethodsAn online survey was distributed to all members of the American Shoulder and Elbow Surgeons, American Orthopaedic Society for Sports Medicine, and Canadian Orthopaedic Association and to fellow members of the Arthroscopy Association of North America. The survey comprised 3 sections assessing the demographic characteristics of survey respondents, the influence of prognostic factors on surgical decision making, and the operative management of 12 clinical case scenarios of varying bone loss that may be encountered in clinical practice. ResultsA total of 150 survey responses were returned. The age of the patient and quantity of bone loss were consistently considered important prognostic criteria. However, little consensus was reached for critical thresholds of bone loss and how this affected the timing (ie, primary or revision surgery) and type of bony augmentation procedure to be performed once a critical threshold was reached, especially in the context of critical humeral and bipolar bone loss. ConclusionsConsistent trends were found for the management of recurrent anterior shoulder instability in cases in which no bone loss existed and when isolated critical glenoid bone loss was present. However, inconsistencies were observed when isolated critical humeral bone loss and bipolar bone loss were present.

Arthroscopic glenoid labral lesion repair using all-suture anchor for traumatic anterior shoulder instability: short-term results

This study presents the preliminary clinical results of arthroscopic glenoid labral lesion repairusing all-suture anchors in the treatment of recurrent traumatic anterior shoulder instability. Seventy patients who underwent arthroscopic shoulder stabilization for traumatic anterior shoulder instability were evaluated in this single center-based retrospective study. Patients with a glenoid defect greater than 20%, off-track engaging Hills-Sachs lesion, multidirectional instability, and generalized ligamentous laxity were excluded. The 62 included patients treated with arthroscopic glenoid labral lesion repair using all-suture anchors were evaluated. The Rowe and Constant scores were used to assess the results. We evaluated 62 patients with a mean age of 26.7 ± 12 years. The mean Rowe and Constant scores were 35 ± 7.2 and 65 ± 6.3, respectively, preoperatively and increased to 93.6 ± 5.3 and 92 ± 4.3, respectively, postoperatively at the mean follow-up of 28.8 months (range, 24-48 months)(P < .001). The redislocation rate was 8.1%. Of the patients, 91.9% had good to excellent clinical scores. Younger age and contact sports were associated with a higher risk of recurrent dislocation (P = .012 and P = .041, respectively). The postoperative functional results were not significantly correlated with the findings concerning the number of dislocations, time until surgery, degree of anterior translation, and number of anchors. The use of all-suture anchors for arthroscopic glenoid labral lesion repair for the treatment of recurrent traumatic anterior shoulder instability yields satisfactory clinical results and is a safe and effective option.

Recurrent Shoulder Instability: Do Morbidity and Treatment Differ Based on Insurance?

Background:Patients with public insurance often face barriers to obtaining prompt orthopaedic care. For patients with recurrent traumatic anterior shoulder instability, delayed care may be associated with increasing bone loss and subsequently more extensive surgical procedures.Purpose/Hypothesis:The purpose of this study was to evaluate whether differences exist in patients undergoing treatment for shoulder instability between those with Medicaid versus non-Medicaid insurance. We hypothesized that at the time of surgery, Medicaid patients would have experienced greater delays in care, would have a more extensive history of instability, would have more bone loss, and would require more extensive surgical procedures than other patients.Study Design:Cohort study; Level of evidence, 3.Methods:Patients were identified who underwent surgical stabilization for traumatic anterior shoulder instability between January 1, 2011, and December 1, 2015, at a single sports medicine practice. Clinic, billing, and operative records were reviewed for each patient to determine age, sex, insurance type, total number of instability episodes, time from first instability episode to surgery, intraoperative findings, and procedure performed. Glenoid bone loss was quantified by use of preoperative imaging studies.Results:During this time period, 206 patients (55 Medicaid, 131 private insurance, 11 Tricare, 9 workers’ compensation) underwent surgical stabilization for traumatic anterior shoulder instability. Average wait time from initial injury to surgery was 1640 days (95% CI, 1155-2125 days) for Medicaid patients compared with 1237 days (95% CI, 834-1639 days) for others (P = .005). Medicaid patients were more likely to have sustained 5 or more instability events at the time of surgery (OR, 3.3; 95% CI, 1.64-6.69; P = .001), had a higher risk of having 15% or more glenoid bone loss on preoperative imaging (OR, 3.5; 95% CI, 1.3-10.0; P = .01), and had a higher risk of requiring Latarjet or other open stabilization procedures as opposed to an arthroscopic repair (OR, 3.0; 95% CI, 1.5-6.2; P = .002) when compared with other patients.Conclusion:Among patients undergoing surgery for traumatic anterior shoulder instability, patients with Medicaid had significantly more delayed care. Correspondingly, they reported a more extensive history of instability, were more likely to have severe bone loss, and required more invasive stabilization procedures.

Coracoacromial morphology: a contributor to recurrent traumatic anterior glenohumeral instability?

Although scapular morphology contributes to glenohumeral osteoarthritis and rotator cuff disease, its role in traumatic glenohumeral instability remains unknown. We hypothesized that coracoacromial and glenoid morphology would differ between healthy subjects and patients with recurrent traumatic anterior shoulder instability. Computed tomography scans of 31 cadaveric control scapulae and 54 scapulae of patients with recurrent traumatic anterior shoulder instability and Hill-Sachs lesions were 3-dimensionally reconstructed. Statistical shape modeling identified the modes of variation between the scapulae of both groups. Corresponding measurements quantified these modes in relation to the glenoid center (linear offset measures), defined by the best-fit circle of the inferior glenoid, or the glenoid center plane (angles), which bisects the glenoid longitudinally. Distances were normalized for glenoid size. Compared with controls, the unstable coracoids were shorter (P = .004), with a more superior and medial offset of the tip (mean difference [MD], 7 and 3 mm, respectively; P < .001)and an origin closer to the 12-o'clock position (MD, 6°; P < .001). The unstable scapular spines originated closer to the 9-o'clock position (MD, 4°; P = .012), and the unstable acromions were more vertically oriented (MD, 6°; P < .001). The unstable glenoids had an increased height-width index (MD, 0.04; P=.021), had a flatter anterior-posterior radius of curvature (MD, 77 mm; P < .001), and were more anteriorly tilted (MD, 5°; P = .005). Coracoacromial and glenoid anatomy differs between individuals with and without recurrent traumatic anterior shoulder instability. This pathologic anatomy is not addressed by current soft-tissue stabilization procedures and may contribute to instability recurrence.

Outcomes of the Latarjet Procedure Compared With Bankart Repair for Recurrent Traumatic Anterior Shoulder Instability.

Are clinical and patient-reported outcomes different between the Latarjet and Bankart repair stabilization procedures when performed for recurrent traumatic anterior shoulder instability? Ovid MEDLINE, PubMed, Cochrane databases, American College of Physicians Journal Club, and Database of Abstracts of Review of Effectiveness were searched up to June 2015. The search terms used were Bankart AND Latarjet OR Bristow. Criteria used to include studies that (1) were written in English; (2) compared the outcomes of any Latarjet procedure (Bristow-Latarjet, coracoid transfer, or modified Bristow) with Bankart repair (anatomic); (3) reported a minimum of 1 outcome of recurrence, redislocation, revision, or patient-reported outcome measure; and (4) reported original data. Data presented in any format (text, table, figure) were extracted from all included studies. The quality of each study was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Summary statistics were reported as relative risks and weighted mean differences. Fixed-effects (the assumed treatment effect was the same across studies) and random-effects (variations in treatment effect were assumed among studies) models were tested. Heterogeneity between trials was assessed using the χ2 statistic, and the amount (percentage) of variation across studies due to heterogeneity was calculated using the I 2 statistic. Forest plots were used to present pooled results. After the initial search, 245 articles were identified. After we applied the inclusion criteria, a total of 8 studies reporting on 795 patients (Latarjet = 379, Bankart = 416) were included in this review. Using the National Health and Medical Research Council's level of evidence, the authors scored 7 of the studies at level III and 1 study at level II. All Latarjet procedures were performed using an open technique, whereas the Bankart procedure was performed open in 6 studies and arthroscopically in 2 studies. The demographics of the patients (age, proportion of males to females, proportion with surgery on the dominant side, and proportion of revisions) were similar between the 2 surgical procedures. Four groups reported that patients who underwent the Latarjet procedure had fewer recurrences than patients in the Bankart repair group (11.6% versus 21.1%, respectively), irrespective of whether the Bankart was performed open or arthroscopically. Similarly, 4 groups observed that the Latarjet procedure resulted in fewer postsurgical redislocations (5.0%) than the Bankart (9.5%) procedure, irrespective of whether the repair was open or arthroscopic. The authors of 7 studies noted no differences between the 2 procedures in revision rates (Latarjet: 3.4%, Bankart: 4.5%), and 8 studies demonstrated no differences in complications requiring reoperation (Latarjet: 5.0%, Bankart: 3.1%). Investigators in 7 studies used the Rowe score to measure patient-reported satisfaction and function; patients who underwent the Latarjet procedure reported better Rowe scores postsurgically than patients who underwent the Bankart repair (scores: 79.0 and 85.4, respectively). Researchers in 4 studies reported a loss of external-rotation range of motion, which was less in the Latarjet (11.5°) compared with the Bankart (20.9°) procedure. Of the 5 groups that reported return to function, a trend suggested that a greater proportion of patients who underwent the Latarjet procedure returned to work, sport, and throwing activities compared with those who underwent the Bankart repair. The Latarjet procedure produced fewer recurrences, better patient-reported outcomes, and less restricted external-rotation motion than the Bankart repair.

Conjoined Tendon Transfer for Traumatic Anterior Glenohumeral Instability in Patients With Large Bony Defects and Anterior Capsulolabral Deficiency

To report outcomes of a conjoined tendon transfer procedure in a small case series of young active patients of various activity levels with recurrent traumatic anterior shoulder instability. A retrospective chart review identified 10 consecutive patients who underwent conjoined tendon transfer (8 open and 2 arthroscopic) for anterior glenohumeral instability from January 2009 through December 2012. The indications were traumatic anterior shoulder instability with 25% or greater anterior glenoid bone loss, engaging Hill-Sachs lesion, or absent anterior-inferior labral tissue with anterior capsular tissue that did not readily hold sutures or a combination of these deficiencies. Patients did not undergo the procedure if they had healthy capsulolabral tissue and small bony defects or if they competed in high-level collision sports or were overhead throwers. The American Shoulder and Elbow Surgeons (ASES) questionnaire and a physical examination were completed preoperatively. Postoperatively, patients answered questions about shoulder stability and completed ASES and Western Ontario Shoulder Index questionnaires. A physical examination was performed postoperatively to assess range of motion. Of 10 patients, 9 were available for follow-up. The mean age was 33.0years (range, 18-51years) at the time of surgery. Eight of nine patients underwent a physical examination at 31.3±10.5months (range, 24-58months) postoperatively. There were no revisions or complications except for recurrent instability in 1 patient who underwent the arthroscopic procedure and reported gross deviation from the postoperative protocol. The ASES score improved significantly (62.8 ± 21.2 at baseline vs 89.2 ± 11.5 at final follow-up, P= .01). The postoperative Western Ontario Shoulder Index score was 74.5 ± 19.7. No significant change was found in external rotation in 90° of abduction (80.6° ± 12.9° at baseline vs 88.4° ± 6.1° at final follow-up, P= .11) or in flexion (145.6°±14.9° at baseline vs 153.1° ± 16.4° at final follow-up, P= .19). All patients returned to their previous activity level. Stability was restored and no significant range-of-motion loss was observed in noncollision athletes who underwent conjoined tendon transfer. Recurrent instability occurred in 1 patient who underwent the arthroscopic procedure. There were no other complications. Level IV, therapeutic case series.

The results of Bankart repair without capsular plication in patients with recurrent traumatic anterior shoulder dislocation.

The aim of this study was to evaluate the results of patients with recurrent anterior shoulder dislocation, who had been treated with repair of the Bankart lesion without capsuler plication. The study included 22 shoulders of 22 patients (16 males and 6 females) with a mean age of 28 years, who underwent Bankart repair between 2011 and 2014. Patients with bilateral shoulder instability, multiple instability, >25% glenoid bone loss, and those with a history of shoulder surgery were not included in the study. The average follow-up time was 21.2 months. Evaluation was made of the preoperative number of dislocations, postoperative recurrence, functional status, and daily activity performance of the patients. Shoulder range of motion was measured. The results were evaluated using the Rowe shoulder score and the Oxford shoulder instability score. Recurrence was observed in only one patient who had a shoulder dislocation after trauma, thus giving a recurrence rate of 4.5%. Shoulder range of motion was full in all except that one patient. The mean Rowe shoulder score was 95.5 (excellent) and Oxford shoulder stability score was 44.6 (excellent). No recurrent shoulder dislocation was observed in patients who underwent Bankart repair surgery. Plication was not performed with the Bankart repair. Close to full range of motion was obtained in all patients. In conclusion, Bankart repair alone can be considered to be sufficient for the treatment of traumatic recurrent anterior shoulder instability.

Comparison of Time to Recurrence of Instability After Open and Arthroscopic Bankart Repair Techniques.

Background:The results of open and arthroscopic instability repairs have been shown to be equivalent in recent literature.Purpose:To compare the time to recurrence (TTR) of instability and disease-specific outcome measures in patients undergoing open and arthroscopic Bankart repair.Study Design:Cohort study; Level of evidence, 3.Methods:Patients with recurrent traumatic anterior shoulder instability and a Bankart lesion on diagnostic arthroscopy underwent either open Bankart repair (OB) or arthroscopic Bankart and suture capsulorrhaphy (ABSC) using suture anchors. There was a minimum follow-up of 24 months. The primary outcome measures included Western Ontario Shoulder Instability Index (WOSI) score and time to recurrence of instability (dislocation or subluxation). Rowe score, Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons (ASES) score, and Short Form–12 (SF-12) score were also compared.Results:A total of 82 shoulders in 80 patients (ABSC, n = 58; OB, n = 24) were evaluated at a mean of 39 months postoperatively. There were 4 clinical failures in the OB group (4 dislocations) and 7 clinical failures in the ABSC group (2 dislocations and 5 subluxations; P = .72 vs OB). The mean time to recurrence of postoperative instability was significantly shorter in the ABSC group (12.6 ± 2.7 months) compared with the OB group (34.2 ± 12 months; P = .04). The WOSI score in the OB group (265 ± 48.1) was better but not statistically significantly compared with the ABSC group (449.8 ± 63.8; P = .06).Conclusion:The time to recurrence of instability after open Bankart repair is significantly longer compared with arthroscopic Bankart repair.Clinical Relevance:Delayed time to recurrence after open Bankart repair suggests that the open technique may be more suited to withstand the high stress and demands of a heavy-duty profession (contact athletes and heavy manual labor).

Is Open Stabilization Superior to Arthroscopic Stabilization for the Treatment of Recurrent Traumatic Anterior Shoulder Instability?

A recent analysis of data from the American Board of Orthopaedic Surgery (ABOS) Certification Examination revealed that the use of open Bankart repair for glenohumeral dislocation is declining1. Indeed, the authors of several recent reports have suggested that arthroscopic stabilization for recurrent traumatic anterior shoulder instability with use of modern techniques yields similar recurrence rates to that of open stabilization2-4. Mohtadi et al. called this idea into question and provided evidence to the contrary in a well-powered prospective randomized trial. These authors compared arthroscopic and open stabilization in a large group of patients with recurrent traumatic anterior glenohumeral instability. A particular strength of the study was the matching of surgeons according to …