Traumatic Anterior Shoulder Instability Research Articles

Risk factors of recurrence after an arthroscopic stabilisation procedure performed for traumatic anterior shoulder instability in pediatric population

Arthroscopic stabilisation of traumatic anterior shoulder instability is being performed also in pediatric age group, and reports associated with risks of recurrent instability have been presented. The aim of the current study was determining the risk factors of recurrence after the arthroscopic anatomic repair preformed in pediatric age group. 46 patients who underwent arthroscopic Bankart repair for traumatic anterior shoulder instability with the mean age of 17 ±0.8 (15-18) were included in this study. After an average follow-up time of 40.4± 22.7(24-155) months age, gender, dominant side, number of dislocations before surgery, participation in contact sports, Rowe and Oxford shoulder scores, labral lesion type, number of anchor used, and capsular laxity were assessed, and their correlation with recurrence were investigated. Recurrence was encountered in 9 (19,5%) patients, on average, 16.1 ±13.43 months after surgery. The only risk factor of recurrence was found to be the history of five or more times of dislocation before surgery (p=0,006). Although statistically insignificant, when evaluated separately, it was found that patients with contact sports history had double times of recurrence rate if they had ALPSA or SLAP lesion and triple times of recurrence rate if they had capsular laxity. The recurrence rate was found to be 38,4% when accompained by capsular laxity, 50% when accompained by both capsular laxity and ALPSA lesion, and 100% when accompanied by all capsular laxity, ALPSA lesion and contact sports history. Arthroscopic stabilisation of traumatic anterior shoulder instability in pediatric population is an appropriate technique, especially in those with less than five times of dislocation because of the low recurrence rate (3.4%). Surgical procedures that are non-anotomic, such as coracoid transfer or anterior glenoid bone block, should be considered in patients with high risk of recurrence rate after an arthroscopic anatomic repair because of the risk factors like history of five or more times of dislocation, being accompanied by an ALPSA, SLAP lesion, or a capsular laxity and participation in contact sports.

The Open Bankart Repair for Traumatic Anterior Shoulder Instability in Teenage Athletes.

Traumatic anterior shoulder instability from recurrent dislocations or subluxations is a debilitating problem for the teenage athlete. The risk of recurrent instability is high in this adolescent population. We performed a retrospective case series analysis of adolescent athletes with recurrent instability treated with open Bankart repair and evaluated functional outcomes as well as redislocation rates. The retrospective study included 21 teenage patients with Bankart lesions and recurrent anterior shoulder instability. There were 19 males (90%) and 2 females (10%) with an average age of 16 years (range, 14 to 18 y). Patients were evaluated based on Rowe and UCLA shoulder scores, return to previous level of sport, external rotation, and recurrence. The average number of anchors used to repair the Bankart lesion was 3 (range, 2 to 5). One patient was lost to follow-up at 6 months after surgery. The remaining 20 patients all had at least 2-year follow-up. The recurrent instability rate was zero. In total, 100% of patients had an excellent result based on an average Rowe score of 96.5 points of 100 points (a score of 90 to 100 is an excellent result). In total, 100% of patients had good/excellent result based on an average UCLA shoulder score of 34 of 35 (a score >27 is a good/excellent result). At final follow-up, 7 patients (34%) had lost an average of 11 degrees of external rotation (range, 5 to 20 degrees) on the injured shoulder with the arm at the side compared with the noninjured shoulder. Contact teenage athletes with recurrent anterior shoulder instability can be treated with open Bankart repair with a low recurrence, excellent functional shoulder outcomes, and return to sport. A small amount of external rotation may be lost with this technique. Care must be taken when considering this method with throwing athletes (ie, quarterback or pitcher). The open Bankart should remain a viable alternative for the adolescent population with recurrent anterior instability. Level IV.

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.

MR arthrography evaluation in patients with traumatic anterior shoulder instability

IntroductionTo evaluate retrospectively the diagnostic accuracy of MR arthrography, compared with arthroscopy, in research of the glenoid labrum tear in patients with a first episode of traumatic anterior shoulder instability (TUBS). Material and methodsWe retrospectively reviewed the MR arthrography shoulder images of 118 patients with a first episode of TUBS, between June 2014 and May 2016. ResultsThe overall accuracy of MR arthrography compared with arthroscopy of the glenoid labrum lesions was 94%, sensitivity 93%, and specificity 96%. The sensitivity of MR arthrography for Perthes lesion was 71.4%, and for ALPSA lesion, it was 91%. Slap lesion occurred in 11 out of 77 cases (9.3% of 118 cases). The Hill-Sachs lesion occurred in 48 out of 118 cases (40.7%), while the Hill-Sachs reverse lesion in 4 cases (3.4%). ConclusionsThe MR arthrography is accurate in detecting labral injuries. However, other studies are needed to assess the less frequent tear, as Perthes lesion. The presence of the Hill-Sachs lesion could provide useful information about the level of the 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).

Evaluation of Coracoid Graft Location and Clinical Results of a Modified Arthroscopic Bankart-Bristow Procedure for Collision and Contact Athletes with Traumatic Anterior Shoulder Instability

Evaluation of Coracoid Graft Location and Clinical Results of a Modified Arthroscopic Bankart-Bristow Procedure for Collision and Contact Athletes with Traumatic Anterior Shoulder Instability

Outcomes of Bankart Repairs Using Modern Arthroscopic Technique in an Athletic Population

To report a large number of highly active patients who underwent arthroscopic Bankart repair at our institution over the last decade. A retrospective analysis of patients who underwent primary and revision arthroscopic Bankart repairs using bioabsorbable anchors was performed. Outcome measures included recurrence of dislocation, American Shoulder and Elbow Scores (ASES), Rowe, visual analog scale (VAS), return to sports, and satisfaction scores. A total of 94 shoulders met the inclusion criteria. The recurrence rate was 6/94 (6.4%) atamean follow-up of 5 years (range, 3 to 8.3). The mean postoperative scores were as follows: ASES= 91.5/100; Rowe= 84.3/100; VAS= 0.8/10; satisfaction= 8.8/10. In those who attempted to return to sports, 82.5% were able to return to the same level of competition. Statistical analyses revealed a significant increase in risk of recurrence among high school and recreational athletes. No recurrences were observed among professional or college-level athletes. No significant difference in recurrence rates was observed in regards to age, time to surgery, type of athlete (collision v limited contact), repair of SLAP lesion, number of anchors, or revision surgery. Although several repair techniques exist for traumatic anterior shoulder instability, arthroscopic repair remains a viable option even in a highly active patient population. This study uniquely identified high school and recreational athletes at higher risk for recurrence. This is perhaps due to inferior shoulder development and technique as well as to limited access to postoperative physical therapy. Level IV, therapeutic case series.

Arthroscopic Bankart repair and subscapularis augmentation: an alternative technique treating anterior shoulder instability with bone loss

This study presents the preliminary results of a new arthroscopic technique consisting of the association of 2 procedures, capsulolabral repair and subscapularis augmentation tenodesis, in the treatment of traumatic anterior shoulder instability with both glenoid bone loss and a Hill-Sachs lesion. Eighty-nine patients engaged in sports were enrolled in this retrospective case-series study with 2 to 5years' follow-up. All patients underwent a computed tomography scan to assess the percentage of glenoid bone loss by the Pico method. A prior stabilization procedure had failed in 20 patients, who were then segregated into a different group. Visual analog scale (VAS), Rowe, and American Shoulder and Elbow Surgeons (ASES) scores were used to assess the results. Only 3 of 89 patients had a post-traumatic redislocation. The mean length of follow-up was 31.5months (range, 25-60months). The VAS, Rowe, and ASES scores showed significant improvements: The VAS score decreased from a mean of 3.1 to 0.5 (P=.0157), the Rowe score increased from 58.9 to 94.1 (P=.0215), and the ASES score increased from 68.5 to 95.5 (P=.0197). The mean deficit of external rotation was 6° with the arm at the side of the trunk, and the mean deficit was 3° with the arm in 90° of abduction. The described procedure is a reproducible and effective technique used to restore joint stability in patients engaged in sports who have incurred anterior recurrent shoulder dislocation associated with glenoid bone loss (<25%) and a Hill-Sachs lesion.

Predictors of functional outcomes and recurrent shoulder instability after arthroscopic anterior stabilization.

To investigate what factors might predict the results of arthroscopic stabilization for anterior shoulder instability. One hundred and forty-three patients averaging 25 (15-58) years with traumatic anterior shoulder instability who underwent arthroscopic stabilization were reviewed at a median follow-up of 81 (24-172) months. Sixty-two (56.4 %) individuals were involved in contact sport activities, and there were 40 (30 %) patients who had only one dislocation prior to having surgery. Rowe score was measured preoperatively and at follow-up. Thirty-three (23.1 %) patients experienced recurrent instability 12 (1-120) months after surgery, and 15 of those underwent further surgery. There was a statistically significant lower risk of failure (p = 0.027) for patients who had a surgical procedure after only one episode of shoulder dislocation. Patients treated after the second or further episode of shoulder dislocation exhibited a mean odds ratio for failure of 3.8 (95 % confidence interval 1.2-11.6, p = 0.044) with regard to first-time dislocators. The Rowe score significantly improved from a preoperative value of 25 (5-55) to a postoperative value of 100 (40-100) (p < 0.001). A significantly higher postoperative Rowe score was found in patients older than 24 years of age at the operation (p = 0.011) and in patients with less than eight dislocations prior to surgery (p = 0.05). These results suggest that better functional results following arthroscopic stabilization can be expected in patients over 24 years of age and in those with a fewer number of dislocations preoperatively. A lower rate of recurrence can be expected if the patient undergoes surgery after the first episode of dislocation. Prognostic study, Level II.

Operative Management Options for Traumatic Anterior Shoulder Instability in Patients Younger Than 30 Years.

Anterior instability of the glenohumeral joint is a relatively common problem in the young population. Identification and treatment is essential to reduce the risk of recurrent instability, whether that is re-dislocation or subluxation events. Non-operative treatment for first-time dislocations was the classic option; however, a relatively high rate of recurrent dislocations has led to earlier operative management in some cases. Surgical treatment through either an open or arthroscopic approach has continued to be an area of research and debate. The decision depends partly on the exact etiology of the instability and the extent of soft tissue or bony deficiency. As arthroscopic techniques and experience improve, surgical procedures for arthroscopic anterior shoulder instability continue to evolve. This review serves as an in-depth overview of the treatment options for traumatic anterior shoulder instability in the patient younger than 30 years, generally focusing on non-rotator cuff-associated etiologies for recurrent instability.

The Bankart Procedure: An Unrealized Expectation for Long-Term Shoulder Stability: Commentary on an article by Philipp Moroder, MD, et al.: "Open Bankart Repair for the Treatment of Anterior Shoulder Instability without Substantial Osseous Glenoid Defects: Results After a Minimum Follow-up of Twenty Years".

In 1978, Rowe et al.1 popularized the Bankart repair and set the stage for future surgeons to have an expectation for durable stability after the procedure. Sir Blundell Bankart2 was, of course, the father of this procedure, and he would be proud of the efforts of Moroder et al. in their attempt to determine the long-term outcome of the Bankart repair for traumatic anterior shoulder instability. Indeed, the authors are to be congratulated for their effort in analyzing forty of forty-seven individuals who underwent Bankart repair more than twenty years previously. While their methods are well thought out, there are several flaws of which they themselves make note. Moreover, their ultimate findings are not at all unexpected when one considers what we now understand about the outcome of shoulder stabilization procedures. Their follow-up rate of 85% of all patients seems to be quite good; however, I have a real concern that this study is underpowered for a retrospective Level-IV cohort analysis. Moreover, they make the assumption that the computed tomography arthrogram method they used to rule …

Expression analysis of genes involved in collagen cross-linking and its regulation in traumatic anterior shoulder instability.

The molecular alterations involved in the capsule deformation presented in shoulder instability patients are poorly understood. Increased TGFβ1 acts as a signal for production of matrix macromolecules by fibrogenic cells at joint injury sites. TGFβ1, through its receptor TGFβR1, regulates genes involved in collagen cross-linking, such as LOX, PLOD1, and PLOD2. We evaluated TGFβ1, TGFβR1, LOX, PLOD1, and PLOD2 gene expression in the antero-inferior (macroscopically injured region), antero-superior and posterior regions of the glenohumeral capsule of 29 shoulder instability patients and eight controls. We observed that PLOD2 expression was increased in the anterior-inferior capsule region of the patients compared to controls. LOX expression tended to be increased in the posterior portion of patients. Patients with recurrent shoulder dislocation presented upregulation of TGFβR1 in the antero-inferior capsule portion and of PLOD2 in the posterior region. Conversely, LOX was increased in the posterior portion of the capsule of patients with a single shoulder dislocation episode. In the antero-inferior, LOX expression was inversely correlated and TGFβR1 was directly correlated with the duration of symptoms. In the posterior region, PLOD2, TGFβ1, and TGFβR1 were directly correlated with the duration of symptoms. In conclusion, PLOD2 expression was increased in the macroscopically injured region of the capsule of patients. Upregulation of TGFβ1, TGFβR1, and PLOD2 seems to be related with the maintenance of disease symptoms, especially in the posterior region. LOX upregulation seems to occur only in the initial phase of the affection. Therefore, TGFβ1, TGFβR1, LOX, and PLOD2 may play a role in shoulder instability.

A feedback protocol improves the diagnostic performance of MR arthrography by experienced musculoskeletal radiologists in patients with traumatic anterior shoulder instability

PurposeTo prospectively evaluate the diagnostic performance of magnetic-resonance-arthrography (MRA) by experienced musculoskeletal radiologists in patients with traumatic-anterior-shoulder-instability (TASI), after feedback protocol execution. Materials and methodsForty-five surgically confirmed MRA’s were used to enhance personal feedback, to discuss differences in outcome between MRA assessment and surgical findings and to fine-tune definition interpretation agreement of 7 different TASI-related lesions, between experienced musculoskeletal radiologists and experienced orthopaedic shoulder surgeons. After execution of the feedback protocol 20 new, surgically confirmed, MRA’s were assessed by 2 experienced musculoskeletal radiologists using a seven-lesion standardized scoring form. Kappa coefficients, sensitivity, specificity, and differences in percentage agreement or correct diagnosis (p-value, McNemar’s test) were calculated per lesion and overall per 7 lesion types to assess whether diagnostic reproducibility and accuracy was improved. ResultsPer 7 lesion types, the overall kappa and percentage of agreement, between the 2 radiologists, were dramatically increased in comparison with our former study (k=0.81 versus k=0.48 and 90.7% versus 78.2%, respectively). The overall sensitivity of radiologist 1 increased from 45.9% to 87.8%, the overall sensitivity of radiologist 2 increased from 63.5% to 79.6% and the overall specificity of radiologist 2 increased from 80.1% to 85.7%. Furthermore, the overall percentage of correct diagnosis of both radiologist was also exceedingly higher (85.7% and 83.6%) compared to our former study (74.4% and 74.8%). ConclusionThe implementation of our feedback protocol dramatically improved the reproducibility and accuracy of high field MRA by experienced musculoskeletal radiologist in patients with traumatic anterior shoulder instability.

Are radiologists superior to orthopaedic surgeons in diagnosing instability-related shoulder lesions on magnetic resonance arthrography? A multicenter reproducibility and accuracy study

We compared the diagnostic reproducibility and accuracy of musculoskeletal radiologists with orthopaedic shoulder surgeons in 2 large medical centers in assessing magnetic resonance arthrograms (MRAs) of patients with traumatic anterior shoulder instability. Forty-five surgically confirmed MRAs were assessed by 4 radiologists, 4 orthopaedic surgeons, 2 radiologic teams, and 2 orthopaedic teams. During MRA assessment and surgery, the same 7-lesion scoring form was used. κ Coefficients, sensitivity, specificity, and differences in percentage of agreement or correct diagnosis (P<.05, McNemar test) were calculated per lesion and overall per the 7 lesion types. The overall κ between the individual radiologists (κ=0.51, κ=0.46) and orthopaedic surgeons (κ=0.46, κ=0.41) was moderate. Although the overall percentage of agreement between the radiologists was slightly higher than that between the orthopaedic surgeons in both centers (80.0% vs 77.5% and 75.2% vs 73.7%), there was no significant difference. In each medical center, however, the most experienced orthopaedic surgeon was exceedingly more accurate than both radiologists per the 7 lesion types (81.9% vs 72.4%/74.6% and 76.5% vs 67.3%/73.7%). In 3 of 4 cases, this difference was significant. Overall accuracy improvement through consensus assessment was merely established for the weakest member of each team. Experienced orthopaedic surgeons are more accurate than radiologists in assessing traumatic anterior shoulder instability-related lesions on MRA. In case of diagnosis disagreement, these orthopaedic surgeons should base their treatment decision on their own MRA interpretation.

Outcomes of Bankart Repairs Using Modern Arthroscopic Technique in an Athletic Population

Objectives:The ideal technique for management of traumatic anterior shoulder instability is yet to be determined. Although open Bankart repairs have remained the gold standard, arthroscopic indications and techniques for Bankart repairs have significantly evolved over the last decade. The purpose of this study was to report a large number of highly active patients who underwent arthroscopic Bankart repair at our institution over the last decade.Methods:A retrospective analysis of all patients with a history of trauma to their shoulder resulting in an anterior shoulder dislocation was performed. Both primary and revision arthroscopic Bankart repairs using bioabsorbable anchors with at least two-year follow-up were included. Exclusion criteria included: atraumatic or multidirectional instability; an associated rotator cuff tear; a humeral avulsion of the glenohumeral ligament; significant glenoid bone loss; isolated posterior instability. Outcome measures included recurrence of dislocation, ASES (American Shoulder and Elbow Scores), Rowe, VAS (Visual Analog Scale), Return to sports and satisfaction scores. Final shoulder ROM (range of motion) and any complications were also reported.Results:A total of 94 shoulders met inclusion criteria and had sufficient follow-up data to be included in the study. Of these, 24% were professional athletes (19% NFL, 3% MLB, 1% NBA, 1% NHL), 31% were college athletes, 33% were high school athletes and the remaining played recreationally. Of these, 61% were classified as “collision” and 29% as “limited contact” sports. 22% were overhead athletes. A total of 78 primary repairs and 16 revision repairs were performed using the same arthroscopic technique with an average of 5.6 anchors. The recurrence rate was 6/94 (6.4%) at a mean follow-up of 4.3 years (range 2.3 - 8.3). The mean postoperative scores were as follows: ASES=91.5/100; Rowe=84.3/100; VAS=0.8/10; satisfaction=8.8/10. Return to sports at the previous level for at least one season was possible in 88% of patients. Statistical analyses revealed a significant increase in risk of recurrence amongst high school and recreational athletes. No recurrences were observed amongst professional or college level athletes. No significant difference in recurrence rates were observed in regards to age, time to surgery, type of athlete (collision vs limited contact), repair of SLAP lesion, number of anchors, overhead athlete or revision surgery.Conclusion:Although several repair techniques exist for traumatic anterior shoulder instability, arthroscopic repair remains a viable option even in a highly active patient population. To our knowledge, this is the second largest series of arthroscopic Bankart repairs in a population consisting primarily of patients involved in collision and limited contact sports. This study uniquely identified high school and recreational athletes at higher risk for recurrence. This is perhaps due to inferior shoulder development and technique as well as limited access to postoperative physical therapy. Nonetheless, the recurrence rate reported in this study approaches that of other recently reported studies. In conclusion, arthroscopic Bankart repairs can yield excellent results in highly active patients. Particular attention should be paid to the younger, underdeveloped athletes as they may be at higher risk for recurrence.

Arthroscopic Findings After Traumatic Shoulder Instability in Patients Older Than 35 Years.

Background:Shoulder instability in the older patient traditionally has received less attention in the literature than in the younger patient population. However, when traumatic dislocation does occur, these patients often still have frequent pain, disability, and even continued instability.Purpose:To characterize the pathoanatomy of traumatic anterior shoulder instability in the older patient population and to discuss the correlating symptoms that ultimately led to operative treatment.Study Design:Case series; Level of evidence, 4.Methods:Patients with a history of an initial traumatic anterior shoulder instability event occurring after the age of 35 years who underwent arthroscopic surgical intervention were prospectively enrolled. Exclusion criteria included posterior instability, major fractures of the shoulder girdle, and multidirectional instability. All patients initially underwent a period of nonoperative rehabilitation. Operative treatment was performed if a patient continued to have pain and/or instability. Operative reports and arthroscopic pictures were reviewed for pathoanatomical findings.Results:A total of 27 patients (28 shoulders) met the inclusion criteria and were analyzed in this study (22 men and 5 women; mean age, 55 years; age range, 35-74 years). Surgical intervention was performed for recurrent instability in 7 patients, pain for 8 patients, and pain with instability for 13 patients. Arthroscopic findings demonstrated 18 rotator cuff tears (RCTs) (64.3%) and 18 Bankart lesions (64.3%). Nine patients had both an RCT combined with a Bankart lesion (32.1%). Three humeral avulsion of the glenohumeral ligament (HAGL) lesions (10.7%) and 2 anterior labral periosteal sleeve avulsion (ALPSA) lesions (7.1%) were found. All shoulders demonstrated Hill-Sachs lesions of various size and depth.Conclusion:Traumatic shoulder instability in the older patient may result in a wide array of pathologic findings as well as a diversity of clinical presentations. These findings suggest that the clinical diagnostician should maintain a high index of suspicion for RCT, Bankart lesions, and HAGL lesions in older patients who remain symptomatic after traumatic anterior shoulder instability.

Bone Fragment Union and Remodeling After Arthroscopic Bony Bankart Repair for Traumatic Anterior Shoulder Instability With a Glenoid Defect

Background: Although good clinical outcomes have been reported after arthroscopic bony Bankart repair, the extent of bone union is still unclear. Purpose: To investigate bone union after arthroscopic bony Bankart repair and its influence on postoperative recurrence of instability. Study Design: Cohort study; Level of evidence, 3. Methods: Among 113 consecutive shoulders that underwent arthroscopic bony Bankart repair, postoperative evaluation of bone union by computed tomography (CT) was performed at various times in 81 shoulders. Bone union was investigated during 3 periods: 3 to 6 months postoperatively (first period), 7 to 12 months postoperatively (second period), and 13 months or more postoperatively (third period). The influence of the size of the preoperative glenoid defect and the size of the bone fragment on bone union was investigated, as well as the influence of bone union on postoperative recurrence of instability. In shoulders with bone union, bone fragment remodeling and changes in the glenoid defect size were also investigated. Results: The bone union rate was 30.5% in the first period, 55.3% in the second period, and 84.6% in the third period. Among 53 shoulders with CT evaluation in the second period or later and follow-up for a minimum of 1 year, there was complete union in 33 shoulders (62.3%), partial union in 3 (5.7%), nonunion in 8 (15.1%), and no fragment on CT in 9 (17.0%). The complete union rate was 50% for 22 shoulders with small bone fragments (<5% of the glenoid diameter), 56.3% for 16 shoulders with medium fragments (5%-10%), and 86.7% for 15 shoulders with large fragments (>10%). The recurrence rate for postoperative instability was only 6.1% for shoulders with complete union, while it was 50% for shoulders with partial union, nonunion, no fragment, and no fragment on CT. The recurrence rate was significantly higher (36.4%) in shoulders with small fragments, but it was significantly lower in shoulders with bone union. In shoulders with bone union, the bone fragment frequently became larger over time, while the size of the glenoid defect decreased significantly from 18.6% preoperatively to 4.7% postoperatively. Conclusion: Bone union was not always achieved after arthroscopic bony Bankart repair, and union was often delayed. Recurrence of instability was significantly more frequent when bone union failed. The size of the glenoid defect decreased significantly in shoulders with bone union.

Minimally invasive modified latarjet procedure in patients with traumatic anterior shoulder instability.

Background:Despite recent advances in arthroscopic soft tissue repair and reconstruction for shoulder instability, Latarjet procedure is continuously a method of choice for many cases of unstable shoulders.Objectives:To evaluate the clinical results of minimally invasive modified Latarjet technique in recurrent, traumatic anterior shoulder instability associated with obvious Hill-Sachs and Bankart lesions.Patients and Methods:Between 2007 and 2013, 36 consequent patients with traumatic anterior shoulder instability who underwent modified Latarjet operation were enrolled in this prospective study. The MRI studies revealed labrum detachment and Hill-Sachs lesion in all shoulders. For all patients, demographic and injury data were obtained and Constant Shoulder score, Rowe score, and UCLA scores were completed by related surgeon. Stability of the shoulder was assessed with the Jobe’s relocation test preoperatively. The patients were followed up at two weeks, one month, three months, and six months from the date of the surgery and evaluated for probable complications. Above mentioned assessments were completed again at the time of the final follow-up.Results:The average age of the enrolled patients was 24.6 (ranging from 18 to 33 years) and 35 patients out of the total of 36 patients were males. Motor-vehicle accidents were the major cause of the injuries (52%) with the average interval between the injury and operation of 3.1 ± 1.2 years (Ranging from 1 to 5 years). The average number of incidents of dislocations between the injury date and the surgery was 7.2 ± 2.1 (Ranging from 4 to 20). The average follow-up period was 37 months (Ranging from 12 to 65 months). All patients had Jobe’s relocation test (Apprehension sign) pre-operatively and negative Jobe’s relocation test post-operation. Significant improvements in functional scores were demonstrated postoperatively compared to preoperational assessment in all cases. Final follow up radiographs showed union of all the grafts and patients reported no incidents of re-dislocation during the follow-up period. One incidence of a superficial infection 2 weeks post operation was the only complication in this study. The infection was resolved with antibiotic treatment.Conclusions:The Latarjet procedure demonstrated good or excellent short-term outcomes in management of patients with traumatic, recurrent anterior shoulder dislocation with a low level of post-operative complication risks.

Double-Barrel Remplissage: An Arthroscopic All–Intra-articular Technique Using the Double-Barrel Knot for Anterior Shoulder Instability

The arthroscopic remplissage procedure is an effective addition to a standard anterior repair in traumatic anterior shoulder instability associated with large humeral defects. The double-barrel remplissage is an all–intra-articular technique that uses a double-pulley, sliding, and self-retaining knot mechanism called the double-barrel knot. A 70° arthroscope (posterior portal) is necessary for adequate visualization of the humeral defect and the rotator cuff. Trans-tendon anchors (single or double loaded) are inserted into the superior and inferior aspects of the humeral defect through a cannula that is placed posterior to the infraspinatus. Placement of anchors is facilitated by insertion of a guidewire, as well as an anchor sleeve that is threaded over it. The double-barrel knot is formed using the anchors as a double-pulley system, and the knot is tensioned after the anterior repair is complete. Intra-articular visualization confirms adequate approximation and compression of the infraspinatus tendon and capsule into the defect. Advantages include an increased surface area (footprint) for healing and ease of knotting without the necessity for additional subacromial dissection.

Traumatic anterior instability of the pediatric shoulder: a comparison of arthroscopic and open bankart repairs.

Arthroscopic and open Bankart repairs have proven efficacy in adults with recurrent anterior shoulder instability. Although studies have included children in their analysis, none have previously compared functional outcomes or redislocation rates between these 2 methodologies for anteroinferior glenoid labrum repair in this young population. We hypothesize that open and arthroscopic Bankart repair in children will have similar functional outcomes and redislocation rates, but differing results from adults treated in a similar manner. A retrospective chart review was performed on all Bankart repairs performed between 2006 and 2010 at a tertiary care children's hospital. A shift in treatment modalities occurred in 2008 creating 2 cohorts, open and arthroscopic. Brachial plexus injury, congenital soft-tissue disorder, or incomplete charts were excluded. Demographics, age at surgery, follow-up length, and sport were recorded. Telephone interviews were then performed obtaining the most current QuickDASH (Disability Arm, Shoulder, or Hand), WOSI (Western Ontario Shoulder Instability Index), SF-12 (Short Form 12), SANE (Single Assessment Numeric Evaluation), and verbal pain scores; as well as, inquiring about recurrent dislocation and further surgery. Ninety-nine children (16.9±1.5 y) were included (28 open, 71 arthroscopic). There were no differences in preoperative demographics. Fifty-one patients completed the questionnaires (11 open, 40 arthroscopic). No significant differences in the outcomes scores were seen between the 2 groups. Of the 99 patients, 21 (21%) had redislocation or secondary surgery; there was no significant difference in failure rate between groups (4 open, 17 arthroscopic). A plotted survival curve demonstrated that the adolescent shoulder undergoing Bankart repair for recurrent traumatic anterior instability has a 2-year survival of 86% and a 5-year survival of only 49%, regardless of technique. In adolescents, there is no significant difference in functional outcomes or redislocation rates between open and arthroscopic Bankart repair, yet both demonstrate a very high risk of failure in this young, athletic population which contrasts the results in the historic adult population. Level III-retrospective comparative study.