Setting Of Anterior Shoulder Instability Research Articles

Arthroscopic Remplissage Before Bankart Repair With All-Suture Anchor Mattress Fixation in the Beach-Chair Position

A common procedure for treatment of Hill-Sachs lesions in the setting of anterior shoulder instability is arthroscopic remplissage. Remplissage consists of using the posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion and convert it into an extra-articular defect. Previous versions of this technique have not specified the timing in which remplissage and Bankart repair occur and have been performed with the patient in the lateral decubitus position. In this Technical Note, we describe our technique where we perform the remplissage before Bankart repair using all-suture anchor mattress fixation with the patient in the beach-chair position. By performing the remplissage before Bankart repair, the shoulder is reduced to allow for easier execution of the remplissage and reduce difficulties that might prevent its completion if done after Bankart repair. Further, by completing remplissage before Bankart repair in the beach-chair position, the humeral head is moved posteriorly with the cuff to allow for better access for the following labral repair and allows for the standardization between arthroscopic and open shoulder instability management.

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.

Poster 185: Arthroscopic Inferior to Superior Capsular Shift Results in Superior Clinical Outcomes Compared to Arthroscopic Bankart Repair For the Treatment of Anterior Capsulolabral Tears After Shoulder Dislocation

Objectives: In the setting of anterior shoulder instability, both boney and soft tissue structures are at risk of injury. Often, there is an injury to the anterior capsulolabral complex. This pathology is most often treated with a traditional arthroscopic Bankart repair. The open Bankart is regaining popularity as some surgeons report a lower re-dislocation rate as compared to its arthroscopic counterpart. Some believe that a better capsular shift is achieved with open surgery. We recently developed a technique for performing this capsular shift arthroscopically. The purpose of this study is to analyze and compare clinical outcomes of patients with traumatic anterior shoulder instability treated with two different arthroscopic techniques, arthroscopic capsular shift and arthroscopic Bankart repair (Figure 1). The primary objective of this study is to analyze and compare clinical outcomes, Western Ontario Shoulder Instability (WOSI) scores, complication, and re-dislocation rates. We hypothesize that patients treated with arthroscopic capsular shift will have similar clinical outcomes and a lower failure rate at one year compared with the other surgical cohort. Methods: This study included patients who underwent arthroscopic soft-tissue stabilization surgery for shoulder instability between 2012-2021. Patients were included if they had an isolated primary soft- tissue repair performed arthroscopically with one of the above-mentioned surgical techniques. Patients were excluded if they had concomitant glenoid fractures, less than one year of clinical follow-up, posterior instability, multidirectional instability, and presence of HAGL lesions Demographic information, WOSI scores, pre-operative glenoid and humeral head dimensions, and new dislocation events were recorded. Results: Sixty-three patients met the inclusion and exclusion criteria. There were 27 patients in the Bankart repair group and 36 in the capsular shift group. The two groups had similar demographics and baseline characteristics, except for the length of clinical follow-up (which is due to the capsular shift technique being developed more recently) (p&lt;0.001) (Table 1). Both groups had similar pre-operative glenoid AP and Hill-Sachs depth measurements (p=0.358 and 0.329, respectively) (Table 1). Patient- reported outcomes were similar at baseline (p=0.602) and post-operatively (p=0.621). Both groups showed improvements in WOSI post-operatively (p&lt;0.001), however more patients met MCID in the capsular shift group as compared to the Bankart repair group (93% vs 75%, respectively). In terms of clinical outcomes, patients who received a capsular shift had a lower rate of re-dislocation as compared to the Bankart group (6% vs 22%). Conclusions: The arthroscopic capsular shift technique results in better post-operative clinical outcomes as compared to arthroscopic Bankart repair with a lower recurrence rate, lower rate of post-operative apprehension, and an increased proportion of patients who meet MCID for WOSI. This technique could be a better alternative for Bankart repair in patients with soft-tissue pathologies following anterior shoulder dislocations, however longer-term studies are necessary to determine the longevity of these outcomes. [Table: see text]

AB120. SOH22ABS083. Clinical outcomes in patients with humeral avulsion glenohumeral ligament (HAGL) lesions in the setting of anterior shoulder instability—a retrospective comparative study

AB120. SOH22ABS083. Clinical outcomes in patients with humeral avulsion glenohumeral ligament (HAGL) lesions in the setting of anterior shoulder instability—a retrospective comparative study

Clinical Outcomes in Patients With Humeral Avulsion Glenohumeral Ligament Lesions in the Setting of Anterior Shoulder Instability: A Retrospective Comparative Study

Background: Humeral avulsion glenohumeral ligament (HAGL) lesions are often underreported but have been shown to occur in up to 10% of cases of anterior shoulder instability. Purpose: To compare clinical outcomes and recurrence rates of patients with HAGL lesions undergoing open stabilization for anterior shoulder instability versus a pair-matched control. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of all patients who underwent both arthroscopic and open stabilization procedures with a minimum 24-month follow-up was performed. Patients with HAGL lesions were pair-matched in a 1:6 ratio for age, sex, sport, level of preoperative play, and follow-up length with those without HAGL lesions who underwent arthroscopic Bankart repair alone. Return to play (RTP), the level of return, and the timing of return were assessed. In addition, recurrence, visual analog scale for pain (VAS), Subjective Shoulder Value (SSV), Rowe score, satisfaction, and whether they would undergo the same surgery again were compared. Results: A total of 15 patients with HAGL lesions who underwent shoulder stabilization procedures were included, with a mean age of 21.5 ± 4.1 years and mean follow-up of 53.5 ± 17.4 months, and were pair-matched to 90 patients without HAGL lesions. Overall, there was no significant difference in any of the clinical outcome scores (VAS, Rowe, SSV, satisfaction) used between the 2 groups (1.6 vs 1.7, P = .86; 83.4 vs 88.0, P = .06; 85.7 vs 87.2, P = .76; and 86.7% vs 94.5%, P = .26, respectively). In addition, there were no significant differences in terms of overall rates, levels, and timing of RTP between the 2 groups (93.3% vs 90.0%, P > .99; 80.0% vs 78.9%, P > .99; and 5.3 ± 2.2 vs 5.9 ± 2.9 months, P = .45, respectively). There was no significant difference in the rates of apprehension, subluxation, and recurrent instability between the HAGL and pair-matched control groups (26.7% vs 26.7%, P > .99; 6.7% vs 3.3%, P = .47; and 13.3% vs 6.7% months, P = .32, respectively). Conclusion: Patients with anterior shoulder instability undergoing surgical stabilization with open HAGL repair demonstrate excellent functional outcomes and high rates of RTP, with low rates of recurrence in the medium term compared with a control group without HAGL lesions who underwent arthroscopic Bankart repair alone.

Clinical outcomes of Gaelic Athletic Association athletes after surgical stabilization in the setting of anterior shoulder instability

BackgroundGaelic Athletic Association (GAA) games are collision sports played at an amateur level, which represent the most popular sports played on the island of Ireland. Each year, many GAA players in Ireland require surgical stabilization with either arthroscopic Bankart repair (ABR) or open Latarjet (OL) procedures in the setting of anterior shoulder instability. The purpose of this study was to evaluate the clinical outcomes, recurrence, and return to play (RTP) in athletes who play GAA games having undergone surgical stabilization with either ABR or OL procedures in the setting of anterior shoulder instability.MethodsA retrospective review of all patients with anterior shoulder instability whom had stabilization with either ABR or OL under a single surgeon between 2012 and 2018 was performed. Patients who were athletes partaking in GAA sports were followed up by chart review and telephone survey to assess their clinical outcomes including satisfaction, pain as measured on the visual analog scale score, the Subjective Shoulder Value, recurrence, complications, and revision surgeries. In addition, RTP rates, time to RTP, level of RTP, and Shoulder Instability–Return to Sport after Injury scores were evaluated.ResultsA total of 200 GAA athletes (194 males) with a mean age of 23.9 ± 6.1 years with mean follow-up of 50.4 ± 24 months were included in this study. A total of 98.1% patients were satisfied with their procedure at the latest follow-up, with an overall recurrence rate of 5%. A total of 6.5% of athletes required revision surgery, of whom 4% required revision stabilization (all of whom had recurrence). The overall rate of RTP was 88% at mean 6.0 ± 1.7 months postoperatively, with 75% of athletes returning at the same or higher levels than their preinjury level. There were no significant differences for all outcome measures analyzed between patients who had ABR or OL procedures.ConclusionGAA athletes with anterior shoulder instability treated with either ABR or OL procedures report excellent clinical outcomes at medium-term follow-up, with high satisfaction rates, excellent functional outcomes, and high rates of RTP. Furthermore, this cohort demonstrates low rates of recurrence after stabilization with few requiring revision surgery.

Surgeon Agreement on the Presence of Pathologic Anterior Instability on Shoulder Imaging Studies.

Background:In the setting of anterior shoulder instability, it is important to assess the reliability of orthopaedic surgeons to diagnose pathologic characteristics on the 2 most common imaging modalities used in clinical practice: standard plain radiographs and magnetic resonance imaging (MRI).Purpose:To assess the intra- and interrater reliability of diagnosing pathologic characteristics associated with anterior shoulder instability using standard plain radiographs and MRI.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:Patient charts at a single academic institution were reviewed for anterior shoulder instability injuries. The study included 40 sets of images (20 radiograph sets, 20 MRI series). The images, along with standardized evaluation forms, were distributed to 22 shoulder/sports medicine fellowship–trained orthopaedic surgeons over 2 points in time. Kappa values for inter- and intrarater reliability were calculated.Results:The overall response rate was 91%. For shoulder radiographs, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.49), estimate of glenoid lesion surface area (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.35), and estimate of Hill-Sachs surface area (κ = 0.50). Intrarater agreement was moderate for radiographs (κ = 0.48-0.57). For shoulder MRI, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.44), glenoid lesion surface area (κ = 0.35), Hill-Sachs lesion (κ = 0.33), Hill-Sachs surface area (κ = 0.28), humeral head edema (κ = 0.41), and presence of a capsulolabral injury (κ = 0.36). Fair agreement was found for specific type of capsulolabral injury (κ = 0.21). Intrarater agreement for shoulder MRI was moderate for the presence of glenoid lesion (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.52), estimate of Hill-Sachs surface area (κ = 0.50), humeral head edema (κ = 0.51), and presence of a capsulolabral injury (κ = 0.53), and agreement was substantial for glenoid lesion surface area (κ = 0.63). Intrarater agreement was fair for determining the specific type of capsulolabral injury (κ = 0.38).Conclusion:Fair to moderate agreement by surgeons was found when evaluating imaging studies for anterior shoulder instability. Agreement was similar for identifying pathologic characteristics on radiographs and MRI. There was a trend toward better agreement for the presence of glenoid-sided injury. The lowest agreement was observed for specific capsulolabral injuries.

Assessment of Bone Loss in the Shoulder

The accurate identification and quantification of both glenoid bone loss and the presence of a Hill-Sachs lesion is essential in the setting of anterior shoulder instability as it directly dictates patient outcomes. The ability to diagnose and address these potential osseous defects of the glenohumeral joint based on patient history, physical exam, and the findings of various imaging modalities in a clinical setting is fundamental to the overall success of a surgeon's treatment algorithm. Multiple methods exist to quantify bone loss based on diagnostic imaging or arthroscopy, and the surgeon should be mindful of the respective pearls and pitfalls of each imaging modality and their ability to accurately diagnose shoulder bone loss. Pertinent findings in a patient's history such as age, level of activity, enlistment status, and events of recurrent anterior glenohumeral instability can help one not only predict the presence of bone loss, but the location and size of the defect as well. Furthermore, symptoms and signs of chronic instability along with accurate quantification of glenoid bone loss are essential in the algorithm of selecting the correct surgical procedure to provide optimal stabilization and maximize clinical outcomes.

Radiographic sclerotic contour loss in the identification of glenoid bone loss.

Quantification of glenoid bone loss guides surgical management in the setting of anterior shoulder instability. Glenoid defects resulting in ≥20% articular area loss require bony reconstruction. The objective of this study was to evaluate the utility of sclerotic glenoid contour loss on true anteroposterior radiography in the detection of varying quantities of simulated glenoid bone loss using a cadaveric model. Eight cadaveric scapulae with full radiographic sclerotic contour were osteotomized to produce glenoid surface area reductions of 10-50%. Radiography was performed initially and following each osteotomy, and assessed by an orthopedic surgeon and radiologist twice. Quantity of glenoid loss was compared using Fisher's exact test. Sensitivity, specificity, and reliability analyses were performed. On the first radiographic review, sclerotic contour loss was detected in 6 out of 8 scapulae with 50% area loss, but only 1 out of 8 scapulae with 20% area loss. There was a significantly higher proportion of radiographs containing sclerotic contour loss for defects with 50% area loss compared to those with 0-25% loss (p≤0.02). In the detection of ≥20% area loss, sclerotic contour loss had a sensitivity of 33-43% and specificity of 88-100%. Moderate inter-observer reliability (Cohen's kappa value of 0.42-0.53) and intra-observer reliability (kappa value of 0.46-0.58) were found. Radiographic sclerotic contour loss is commonly observed in radiographs of scapulae with 40-50% glenoid area loss and less often with smaller lesions. However, this finding lacks utility in discerning specific quantifications of glenoid bone loss. In a clinical setting, sclerotic contour loss suggests the presence of a large glenoid defect that may require bony reconstruction. However, an intact sclerotic contour does not rule out significant bone loss.

Arthroscopic Bony Bankart Fixation Using a Modified Sugaya Technique

Arthroscopic fixation of bony Bankart lesions in the setting of anterior shoulder instability has had successful long-term results. Key factors such as patient positioning, portal placement, visualization, mobilization of bony/soft tissues, and anatomic reduction and fixation are crucial to yield such results. We present a modified Sugaya technique that is reproducible and based on such key principles. This technique facilitates ease of anchor and suture placement to allow for anatomic reduction and fixation.