Treatment Of Anterior Shoulder Instability Research Articles

Cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet reconstruction in anterior shoulder instability.

The ideal surgical treatment for anterior shoulder instability is still under debate. In the healthcare setting, both clinical and economic factors must be considered for optimal resource allocation. From the clinical perspective, the Instability Severity Index Score (ISIS) is a helpful and validated tool for surgeons, although a gray area between 4 and 6 exists. In fact, patients with an ISIS < 4 and > 6 can be treated effectively with arthroscopic Bankart repair and open Latarjet, respectively. The purpose of this study was to conduct a cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet in patients with an ISIS between 4 and 6. A decision-tree model was constructed to simulate the clinical scenario of an anterior shoulder dislocation patient with an ISIS between 4 and 6. Based on previously published literature, outcome probabilities and utility values in the form of Western Ontario Instability Score (WOSI) were assigned to each branch of the tree, alongside institutional cost. The primary outcome assessed was an Incremental cost-effectiveness ratio (ICER) of the two procedures. Eden-Hybbinette was also considered in the model as a salvage procedure for failed Latarjet. A two-way sensitivity analysis was performed to identify the most impactful parameters on the ICER upon their variation within a pre-determined interval. Base case cost was 1245.57 € (1220.48-1270.65 €) for arthroscopic Bankart repair, 1623.10 € (1580.82-1665.39 €) for open Latarjet and 2.373.95 € (1940.81-2807.10 €) for Eden-Hybbinette. Base-case ICER was 9570.23 €/WOSI. Sensitivity analysis showed that the most impactful parameters were the utility of arthroscopic Bankart repair, the probability of success of open Latarjet, the probability of undergoing surgery after post-operative recurrence of instability and the utility of Latarjet. Of these, utility of arthroscopic Bankart repair and Latarjet had the most significant impact on the ICER. From a hospital perspective, open Latarjet was more cost-effective than arthroscopic Bankart repair in preventing further shoulder instability in patients with an ISIS between 4 and 6. Despite its several limitations, this is the first study to analyze this subgroup of patients from a European hospital setting from both an economic and clinical perspective. This study can help surgeons and administrations in the decision-making process. Further clinical studies are needed to prospectively analyze both aspects to further delineate the best strategy.

Open Bankart Repair

Shoulder instability is one of the most common complaints seen by orthopaedic surgeons taking care of an athletic patient. The management of shoulder instability has varied over the years and significant controversy and debate about the proper management of this pathology. The surgical treatment of anterior shoulder instability can present a dilemma. Historically, an open Bankart repair was the benchmark solution. Over the last decade as surgeons became more arthroscopically safe, the pendulum swung and a paradigm shift occurred. However, more recent studies have challenged this trend and, subsequently, revived interest in open repair. Thus, we feel it is critical to provide a more contemporary stepwise description of a procedure that has become essentially abandoned. The goal is to provide tips and pearls to achieve optimal exposure and, ultimately, a robust repair for a notoriously challenging operation. Patient selection, risk factors, and pathology are crucialin makig the correct treatment decision. The benefits of open Bankart repair including the indication of open Bankart repair will be discussed. Additionally, a reliable surgical technique will be presented

Arthroscopic BANKART in the Treatment of Anterior Shoulder Instability: A Review of 5 Cases

The arthroscopic BANKART technique is part of the panel of surgical treatment of anterior shoulder instability, allowing reinsertion of the anterior-inferior labrum as well as the capsule at the level of the anterior glenoid rim. Its indication is based on a set of criteria gathered in the ISIS score, which must be less than or equal to 3 for an optimal result and a lower recurrence rate.

Arthroscopic Remplissage for the Treatment of Anterior Shoulder Instability

A Hill-Sachs lesion (HSL) is a compression fracture on the posterolateral humeral head that can increase the risk of recurrent shoulder instability after isolated arthroscopic Bankart repair. Remplissage involves capsulotenodesis of the infraspinatus tendon and posterior capsule into the HSL to prevent its engagement with the glenoid rim through extra-articular conversion and restraint against humeral head anterior translation. The glenoid track concept can be applied preoperatively and intraoperatively to evaluate risk of recurrence and help direct clinical management options for recurrent shoulder instability. Recent literature supports expanding indications for remplissage to include patients with on-track HSLs who are at increased risk of recurrence including collision athletes, military personal, and patients with joint hyperlaxity. New techniques and suture constructs have demonstrated improved biomechanical strength while avoiding the need to access the subacromial space.

Modified All-Arthroscopic Metal-Free Latarjet with Cerclage Tape for Recurrent Shoulder Dislocation with Critical Glenoid Bone Loss: Technical Note

Latarjet procedure involving coracoid bone transfer has been the preferred method of treatment for anterior shoulder instability with critical glenoid bone loss, failed Bankart repair, severe soft tissue insufficiency, bipolar bone lesions, and young patients involved in contact sports. Screw-related complications were the most common reason for revision surgery following the Latarjet procedure. We describe an all-arthroscopic method of Latarjet procedure with cerclage fiber tape (Arthrex) and a modified technique for performing the procedure in this technical note.

Arthroscopy with subscapularis upper one-third tenodesis for treatment of recurrent anterior shoulder instability independent of glenoid bone loss

BACKGROUNDRecurrent anterior shoulder instability is a common traumatic injury, the main clinical manifestation of which is recurrent anteroinferior dislocation of the humeral head. The current follow-up study showed that the effect of arthroscopic Bankart repair is unreliable.AIMTo evaluate the clinical efficacy of arthroscopy with subscapularis upper one-third tenodesis for treatment of anterior shoulder instability, and to develop a method to further improve anterior stability and reduce the recurrence rate.METHODSBetween January 2015 and December 2018, male patients with recurrent anterior shoulder instability were selected. One hundred and twenty patients had a glenoid defect < 20% and 80 patients had a glenoid defect > 20%. The average age was 25 years (range, 18–45 years). Patients with a glenoid defect < 20% underwent arthroscopic Bankart repair with a subscapularis upper one-third tenodesis. The patients with a glenoid defect > 20% underwent an arthroscopic iliac crest bone autograft with a subscapularis upper one-third tenodesis. All patients were assessed with Rowe and Constant scores.RESULTSThe average shoulder forward flexion angle was 163.6° ± 8.3° and 171.8° ± 3.6° preoperatively and at the last follow-up evaluation, respectively. The average external rotation angle when abduction was 90° was 68.4° ± 13.6° and 88.5° ± 6.2° preoperatively and at the last follow-up evaluation, respectively. The mean Rowe scores preoperatively and at the last follow-up evaluation were 32.6 ± 3.2 and 95.2 ± 2.2, respectively (P < 0.05). The mean Constant scores preoperatively and at the last follow-up evaluation were 75.4 ± 3.5 and 95.8 ± 3.3, respectively (P < 0.05). No postoperative dislocations were recorded by the end of the follow-up period.CONCLUSIONArthroscopy with subscapularis upper one-third tenodesis was effective for treatment of recurrent anterior shoulder instability independent of the size of the glenoid bone defect, enhanced anterior stability of the shoulder, and did not affect postoperative range of motion of the affected limb.

Patient perceptions after the operative and nonoperative treatment of shoulder instability: A qualitative focus group study.

Little evidence is available regarding patient perceptions of the treatment of shoulder instability. The aim of this study is to investigate patient perceptions regarding the operative and nonoperative treatment of anterior shoulder instability. Patients who presented to the emergency department or outpatient clinic between 2016 and 2020 were retrospectively selected using diagnosis and procedure codes. Online focus groups and semistructured interviews were conducted, systematically recorded and subsequently transcribed to MaxQDA 2007 for qualitative analysis. Coded transcripts of all focus groups were subjected to a grounded theory-based analysis. Six focus groups and two semistructured interviews were hosted with 35 included patients. The mean age of included patients was 34.1 years (±11.5). Eight patients were female (23%), and 27 patients were male (77%). Fear of (recurrent) dislocation, preoperative counseling, communication between surgeon and physiotherapists and need for a consistent postoperative rehab protocol turned out to be important patient perceptions. The most crucial factor for discontent was a lack of communication from the surgeon. This patient-centered focus group study revealed that fear of (recurrent) dislocation, preoperative counseling, communication between surgeons and physiotherapists and the need for a consistent postoperative rehabilitation protocol was the most frequently discussed themes.

Bankart Repair With Remplissage Restores Better Shoulder Stability Than Bankart Repair Alone, and Medial or Two Remplissage Anchors Increase Stability but Decrease Range of Motion: A Finite Element Analysis

To investigate the effects of the number and location of anchors for remplissage on postoperative glenohumeral biomechanics. A biomechanical study was conducted involving finite element model constructed based on data from the intact glenohumeral joint. Seven models were established, including a normal model, a model of Bankart lesion combined with "off-track" Hill-Sachs lesion, a model of Bankart repair alone, and 4 models of Bankart repair with remplissage based on different remplissage anchor numbers and locations. The effects of the number and location of the remplissage anchors on glenohumeral stability were studied through calculation and comparison of (1) the stress and its distribution on the joint capsule, cartilage, labrum and anchors as well as (2) the displacement of the humeral head. Finite element analysis demonstrated that contact stress on the glenohumeral cartilage decreased when medial or 2 anchors were used and was minimized in the combined repair model with 2 medial anchors. The stress on remplissage anchors was greater when the anchors were placed medially. The humeral head displacement was maximized in the combined lesion model. The combined repair models with 2 medially placed anchors showed the largest slope on the force-displacement curve, indicating the largest strain on the humeral head. Based on a finite element analysis, Bankart repair with remplissage restored better shoulder stability compared with Bankart repair alone in the treatment of anterior shoulder instability involving Bankart lesion combined with "off-track" Hill-Sachs lesion. When the anchor for remplissage was medially placed or 2 anchors were used, the stability of the glenohumeral joint increased but with a loss of range of motion. The results of this study will assist in choosing the number and location of anchors for remplissage during shoulder stabilization surgery although with some limitations.

Long-term results of arthroscopic Bankart repair with Hill-Sachs remplissage.

BackgroundArthroscopic Bankart repair with Hill-Sachs remplissage (BHSR) is suggested for the treatment of anterior shoulder instability in the presence of an engaging humeral lesion. The objective of this study is to report the long-term clinical and radiological results of this procedure.MethodsThis is a single-center retrospective study including 51 patients who underwent surgery by BHSR for anterior shoulder instability with engaging Hill-Sachs lesion and who were reviewed after a minimum follow-up of 5 years. The mean age was 26 years (16-49; ±8.4) and 70% of the patients practiced sports. The average for Instability Severity Index score was 3.3 points (3-7; ±1.7). At the last follow-up, active range of motion, Subjective Shoulder Value, Walch-Duplay and Rowe scores, and the incidence of osteoarthritis according to the Samilson classification were assessed.ResultsAt a mean follow-up of 87 months (60.0-124; ±17), 83% of the patients had resumed their sports activities. The mean Rowe, Walch-Duplay, and Subjective Shoulder Value scores were respectively 88 points (51-100; ±12), 82 points (50-100; ±16.4), and 89% (50-100; ±8). There was a recurrence of dislocation or subluxation for 8 patients (15.6%). In univariate analysis, patients who were unstable at follow-up had a deeper Hill-Sachs lesion (25% vs. 18% of the humeral head radius, P = .04) and were younger (19 vs. 27 years, P = .04). Radiographically, 17% of the patients showed signs of osteoarthritis (14% grade 1).ConclusionConsidering that at a follow-up of more than 5 years, the failure rate was more than 15% of the BHSR, this procedure should be recommended with caution in case of deep Hill-Sachs lesions in young patients. The incidence of osteoarthritis after this procedure was acceptable, with few severe forms.

Poster 151: Latarjet Treatment of Anterior Shoulder Instability: The Effect of Pre-Operative MRI Coracoid Dimensions on Post-Operative Outcomes

Objectives:While pre-operative coracoid dimensions have been previously evaluated utilizing CT, no studies have utilized MRI to evaluate coracoid dimensions before Latarjet surgery. Also, no studies have evaluated post-operative outcomes based on pre-operative coracoid dimensions in Latarjet patients. Therefore, the purpose is to determine the effect of coracoid length and width as measured on pre-operative imaging (MRI) on outcomes following Latarjet treatment of anterior shoulder instability. We hypothesized that patients with longer and wider coracoid dimensions would have improved post-operative outcomes after Latarjet treatment for anterior shoulder instability.Methods:Patients who underwent primary Latarjet surgery between 2009-2019 were identified. Inclusion criteria were an available pre-operative MRI and minimum of 2-year post-operative follow-up. Longitudinal coracoid length was measured on axial MRI sequences as the distance from the coracoclavicular ligament insertion to the distal tip. Width measurements were obtained perpendicular to length at three locations – the coracoid base, midpoint and tip – and then averaged. Inter-rater reliability was good for measuring both coracoid length (ICC=0.75) and coracoid width (ICC=0.76). The primary outcomes of interest were recurrent instability, re-operation, complications, rate of and time until return-to-sport (RTS), and American Shoulder and Elbow Surgeons (ASES) score. Comparisons were made between shorter vs. longer coracoid length, narrower vs. wider coracoid width, and male vs. female coracoid dimensions.Results:56 patients were included with an average age of 28.4 years and 16% were female. There were no statistically significant demographic differences between coracoid length and coracoid width groups. Coracoid length averaged 21.6 ± 2.4 mm (range: 16.7-26.9 mm), coracoid width 10.0 ± 1.0 mm (range: 8.3-13.2 mm), and glenoid bone loss 13.7% ± 8.2% (range: 0.0%-32.4%). There were 41 patients (73.2%) with harvestable coracoid length ≥ 20 mm. 55 patients received two coracoid screws for fixation, and only one patient was limited to one screw. Patients with a smaller coracoid length (<22 mm, n=30) had similar rate of recurrent instability (smaller length 6.7% vs. longer length 3.8%), complication (10.0% vs. 15.4%), re-operation (3.3% vs. 7.7%), rate of RTS (76.5% vs. 58.8%), and post-operative ASES scores (85.0 vs. 81.6) (all p>0.05), relative to patients with a larger coracoid length (>22 mm, n=26). Likewise, patients with a smaller coracoid width (<10 mm, n=29) had similar prevalence of recurrent instability (smaller width 6.9% vs. larger width 3.7%), complication (17.2% vs. 7.4%), re-operation (3.5% vs. 7.4%), rate of RTS (66.7% vs. 68.4%), and post-operative ASES scores (87.1 vs. 80.0) (all p>0.05), relative to patients with a larger coracoid length (>10 mm, n=27). Finally, male patients had a larger average coracoid width (10.1 ± 1.0 mm) than female patients (9.3 ± 0.5 mm) (p=0.001).Conclusions:This MRI protocol closely accounts for the specific landmarks utilized during the Latarjet osteotomy by focusing on identification of the CC ligament insertion. A minimum pre-operative coracoid length of 25 mm is not needed as previously stated, as anterior shoulder instability patients experience favorable post-operative outcomes after Latarjet surgery regardless of pre-operative coracoid dimensions based on our findings. Surgeons who are treating patients with significant glenoid bone loss may utilize this MRI protocol if they are concerned about the anatomy of the coracoid pre-operatively.Figure 1.Demonstration of coracoid width measurements. (Figure 2A) First, on the coronal T1 weighted oblique sequence the coracoclavicular ligaments were identified (between the red arrows), outlined by fat, including the more medial trapezoid ligament and lateral conoid ligament. (Figure 2B) Using scout localizers, the insertion of the coracoclavicular ligaments on the fluid sensitive axial sequence was identified (red arrow). A line from this point to the anterior margin of the glenoid was drawn (yellow dotted line) denoting the width of the coracoid base. Coracoid width measurements were then collected at three locations: 5 mm anteriorly from the coracoid base, midpoint, and 5 mm posteriorly from the coracoid tip. A straight line from the midpoint of the base to tip (not shown) was drawn to approximate coracoid length.Figure 2.Difference between mean pre-operative coracoid length (on left) and width (on right) between female (dark) and male (not dark) patients as measured on MRI. UPLOAD-https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/d06d5b2e-8ec8-40b2-a9b0-fd58358533b7/1/Table_2_Coracoid_Dimensions.doc Table 1.Comparison of post-operative complications, recurrent instability, and re-operation between smaller (<22 mm) and larger (≥22 mm) coracoid length, and between smaller (<10 mm) and larger (≥10 mm) coracoid width. Categorical data presented as n (%), continuous data presented as mean ± standard deviation.Table 2.Comparison of post-operative American Shoulder and Elbow Surgeons (ASES) scores, return to play (RTP) rates, and RTP time between smaller (<22 mm) and larger (≥22 mm) coracoid length, and between smaller (<10 mm) and larger (≥10 mm) coracoid width. Categorical data presented as n (%), continuous data presented as mean ± standard deviation.

Arthroscopic Treatment of Anterior Shoulder Instability Using Suture Anchors With Pre-Tied Knots in the Beach Chair Position

Background: Arthroscopic Bankart repair is routinely performed for treatment of anterior shoulder instability. Although an overall successful procedure, arthroscopic free-hand knot tying can be challenging and inconsistent, even for experienced surgeons. Knotless anchors, on the other hand, pose challenges in developing consistent good loop security prior to implantation, and, in the absence of a secure loop tissue tension on the glenoid face, might be inadequate. As an alternative, suture anchors with pre-tied knots offer the strength and security of knots without the need to perform complex and unreliable free-handed ties. Furthermore, loop security is consistent, reliable, and effective with each anchor. Indications: Patients with anterior labral tears and minimal bone loss are candidates for arthroscopic Bankart repair. The goal of surgery is to restore a robust tissue profile and statically keep the humeral head well-seated within the glenohumeral joint space. Technique Description: We demonstrate how to perform Bankart repair using suture anchors with pre-tied knots. The torn labrum is first mobilized and elevated, and suture anchors are placed along the glenoid rim from inferior to superior, treating the torn tissue as “rungs of a ladder.” The pre-tied sliding knot secures the restored labrum, along with glenohumeral ligaments and capsule, as necessary, using only a limited number of incrementally tensioned half hitch knots. Results: Of the 30 patients treated for anterior shoulder instability using this technique, the majority met the minimal clinically important improvement in the American Shoulder and Elbow Surgeons Shoulder Score, Western Ontario Shoulder Instability Index, and Marx activity scale by 2 years. Two patients reported experiencing subsequent minor subluxation events that improved following short courses of physical therapy, and no patients sustained subsequent frank dislocations. Discussion/Conclusion: Using suture anchors with pre-tied knots for arthroscopic Bankart repair allows for fast, easy, and consistently dependable reconstruction of the labrum and leads to reliable clinical outcomes.

Paper 70: "Distance to Dislocation" as a Predictor of Surgical Failure Following Primary Arthroscopic Anterior Labral Repair: Rethinking the Glenoid Track Concept

Objectives:Larger amounts of bipolar bone loss have a strong association with shoulder re-dislocation following arthroscopic labral repair. Development of the Glenoid Track (GT) concept has helped propose bone loss cut-offs for shoulders that should not be managed with arthroscopic labral repair alone. Recent literature has suggested the use of the glenoid track as a continuous variable rather than a binary “on-track/off-track” concept. The re-dislocation risk for “on-track” shoulders with smaller distances to dislocation (DTD), or “near-track” shoulders, has not been previously described. We hypothesized that decreasing DTD, or on-track lesions approaching an off-track lesion, would result in an increased risk of failure following arthroscopic Bankart repair alone.Methods:We performed a retrospective analysis of 197 patients who had undergone primary arthroscopic anterior labral repair between 2007 and 2019 with minimum 2-year follow-up. Glenoid bone loss using a perfect-circle method and Hills-Sachs (HS) interval, were measured from pre-operative MRIs. GT was calculated using previously described methods. Surgical failure was defined as a patient who re-dislocated their shoulder following surgery. DTD was calculated by subtracting the HS measurement from the GT calculation. Patients with “off-track” lesions (negative DTD), and those who had undergone a concomitant arthroscopic remplissage were excluded. We performed a logistical regression model to evaluate the relationship between surgical failure and DTD, glenoid bone loss, Hill-Sachs lesion size, number of anchors used, and patient age. We then created a risk estimator tool that calculates the risk of dislocation with DTD as a continuous variable.Results:Twenty-eight patients (14%) sustained recurrent shoulder dislocations following anterior shoulder labral repair. Average follow up was 7.8 years and there were no demographic differences between those with recurrence and those without (p>0.05). All patients had less than 25% glenoid bone loss (range 0-23%). Increased DTD (p < 0.0005) and glenoid bone loss (p < 0.0005) were independent predictors of surgical failure. After adjusting for glenoid bone loss and patient age, logistic regression modeling showed that for every 1mm decrease in DTD, there was an associated 13.6% increase in re-dislocation risk (p = 0.003). Patient age, Hill-Sachs length, participation in collision sports, and number of anchors used were not significantly associated with failure risk (p>0.05). A DTD <10mm had a 4.26 times greater odds of failure compared to those with DTD >10mm (OR 4.26; 95% CI 1.57-11.65; p = 0.005). The risk estimator tool developed using a logistic regression modeling demonstrated a 19% risk of failure for DTD 10mm, 26% risk for DTD 8mm, 36% risk for DTD 6mm, 49% risk for DTD 4mm, and 67% risk for DTD 2mm after adjusting for glenoid bone loss and patient age (Figure 1).Conclusions:The main finding of this study was that on-track lesions approaching off-track lesions, the so-called “near track” lesions, are associated with an exponentially increased risk of recurrent dislocation following primary arthroscopic anterior stabilization with labral repair alone. Furthermore, DTD values of <10mm were associated with the highest odds ratios for failure and were 4 times more likely to fail than for patients with DTD values >10mm. All of the patients included in this analysis had “on-track” shoulder lesions and <25% glenoid bone loss. Historically, these values have been identified as “cut-offs” used to identify patients who can be treated successfully with arthroscopic labral repair without a remplissage or other augmentation. DTD is a simple calculation for bipolar bone loss that can be used to predict risk of recurrent dislocation. Our results demonstrate potential pitfalls in making treatment decisions for bipolar bone loss using a binary “on-track, off-track” construct. Rather, the glenoid track concept applied as a continuum may be more useful for optimizing treatment.“On-track” shoulder lesions <10mm with diminishing DTD have a substantially higher risk of surgical failure with arthroscopic labral repair alone. As the DTD approaches 0mm (“off track lesion”), the risk of failure increases exponentially. When making treatment decisions for shoulder instability, bipolar bone loss should be viewed as a continuum rather than discreet “on-track, off-track” entities. For high-risk patients with a DTD approaching 0mm, additional augmentation with remplissage or open approaches should be considered.DTD can be used to estimate patient’s risk of recurrent dislocation following primary arthroscopic anterior labral repair for treatment of anterior shoulder instability. Application of this calculation would help surgeons decide the best surgical treatment for patients following anterior shoulder dislocation and can be particularly valuable for high risk patients. Understanding the association between lower DTD values and failure can also help inform the surgeon and patient regarding the risks and benefits of available treatment options.

Poster 156: Investigating Disparity in Follow-Up Rates of Non-Operative Treatment for Anterior Shoulder Instability

Objectives:Racial and ethnic disparities have been documented in numerous aspects of musculoskeletal care. Specifically, the Multicenter Orthopedic Outcomes Network (MOON) Shoulder Instability Group found that amongst patients undergoing surgery for anterior shoulder instability, minorities had a higher frequency of articular cartilage lesions, and increased frequencies of both glenoid bone loss >10% and Hill-Sachs lesions at the time of surgery. Loss to follow-up and failure to comply with initial non-operative management may play a role in the increased disease burden in this group. This study sought to investigate patient demographics associated with poor follow-up after initiation of nonoperative management regimens for anterior shoulder instability. We hypothesized that significant disparities would be observed with nonoperative follow-up rates. More specifically, we predicted that minority patients and those with state or federal dependent insurances such as Medicaid or Medicare will have lower rates of follow-up.Methods:After obtaining IRB approval, demographics and ambulatory care appointment data for new patient visits and subsequent follow-up encounters associated with a diagnosis of “shoulder instability” or/and “labral tear” were extracted from our electronic medical records from 01/01/2010 to 01/31/2020. National Institute of Health (NIH) guidelines were followed for race, ethnicity, and insurance type categorizations. With the standard of care for non-operative management of anterior shoulder instability ranging from 6-12 weeks of physical therapy, the optimal time window for follow-up used for analysis was defined as 4-12 weeks after the initial visit. Chi-squared tests, pairwise comparisons for multiple variables of interest, and parametric between-group comparison and analyses were performed.Results:A total of 10,854 patient visits were identified. After excluding patients that underwent surgical intervention, a total of 2,679 unique patients and their subsequent encounters were analyzed. These patients had a mean age of 31.4 ± 13.6 years, 77.9% were male and 43.9% were white (Table 1). Of these patients, 1,217 (45.4%) followed up at any point and 420 (34.5%) of this subset of patients followed up within 4-12 weeks of their first visit. There was no significant difference between the overall rates of follow up of white versus minority patients (50.6% versus 49.0%, p = 0.64), nor in the rates of follow up within the optimal time window (16.6% versus 16.9%, p = 0.85) (Table 2). There was no significant difference between rates of follow-up at any point based on insurance types (commercial/ managed care, Medicaid, Medicare, self-pay, and workers compensation) (p = 0.084). However, there was a significant difference between rates of optimally timed follow-up based upon insurance type (p = 0.002) (Table 3). 23.2% of patients with Medicare or Medicaid followed up within 4-12 weeks, as compared to 17.2% of patients who paid out-of-pocket and 14.5% of patients with commercial/ managed care insurance.Conclusions:There were no significant racial disparities seen between white and minority patients in regard to the rates of non-operative follow up for anterior shoulder instability in this study. Furthermore, patients with governmental insurance plans successfully followed up within the optimal 4-12 week time period at a higher rate when compared to patients with commercial or self-pay insurance. These findings suggest that a large, urban academic tertiary care center, can successfully employ strategies to retain patients of different minority status and insurance type for follow-up. The presence of satellite clinics minimizing the distance burden of access to care, use of interpreters to bridge language gaps, and systemic implementation of comprehensive discharge instructions used at our institution may be contributing factors to the findings of the investigation. This study may be enhanced by a multicenter investigation in the future in various geographic locations with a diverse patient population and payer mix. The investigation is limited by the large overall number of patients (54.6%) who never followed up. Further investigations are needed to determine what factors may have influenced these patients to not seek follow-up within our institution. In conclusion, this study found that a single tertiary care system equitably retains patients for follow-up for treatment of their anterior shoulder instability. Further work is needed to better understand if this equitable follow-up results in similar outcomes in different patient populations at our institution, and if disparities in follow-up quantity, quality, and timing are associated with the increased burden of disease for minorities with anterior shoulder instability seen at other institutions in previous studies.Table 1.Patient Demographics (2,679 patients)Table 2.Analysis of Follow-Up within 4-12 Week Window Stratified by Racial Groups Table 3.Analysis of Follow-Up within 4-12 Week Window Stratified by Insurance Type

Effect of Preoperative MRI Coracoid Dimensions on Postoperative Outcomes of Latarjet Treatment for Anterior Shoulder Instability.

Background:Preoperative coracoid dimensions may affect the size of the bone graft transferred to the glenoid rim and thus the postoperative outcomes of Latarjet coracoid transfer.Purpose:To determine the effect of coracoid length and width as measured on preoperative magnetic resonance imaging (MRI) on outcomes after Latarjet treatment of anterior shoulder instability.Study Design:Cohort study; Level of evidence, 3.Methods:Included were patients who underwent primary Latarjet surgery between 2009 and 2019 and had preoperative MRI scans and minimum 2-year postoperative outcomes. Longitudinal coracoid length was measured on axial MRI sequences as the distance from the coracoclavicular ligament insertion to the distal tip. Comparisons were made between shorter and longer coracoids and between narrower and wider coracoids. The outcomes of interest were recurrent instability, reoperation, complications, return to sport (RTS), and American Shoulder and Elbow Surgeons (ASES) score. Independent-samples t test, Mann-Whitney test, chi-square test, and Fisher exact test were used to compare outcomes between groups, and univariate correlation coefficients were calculated to evaluate the relationships between demographics and coracoid dimensions.Results:Overall, 56 patients were included (mean age, 28.4 years). The mean ± SD coracoid length was 21.6 ± 2.4 mm and width 10.0 ± 1.0 mm. Relative to patients with a longer coracoid (≥22 mm; n = 26), patients with a shorter coracoid (<22 mm; n = 30) had similar rates of recurrent instability (shorter vs longer; 6.7% vs 3.8%), complications (10.0% vs 15.4%), reoperation (3.3% vs 7.7%), and RTS (76.5% vs 58.8%) and similar postoperative ASES scores (85.0 vs 81.6) (P ≥ .05 for all). Likewise, relative to patients with a wider coracoid (≥10 mm; n = 27), patients with a narrower coracoid (<10 mm; n = 29) had similar prevalences of recurrent instability (narrower vs wider; 6.9% vs 3.7%), complications (17.2% vs 7.4%), reoperation (3.5% vs 7.4%), and RTS (66.7% vs 68.4%) and similar postoperative ASES scores (87.1 vs 80.0) (P ≥ .05 for all).Conclusion:Patients undergoing Latarjet coracoid transfer had similar postoperative outcomes regardless of preoperative coracoid dimensions. These findings should be confirmed in a larger cohort before further clinical recommendations are made.

The Cuistow: A Modified Arthroscopic Bristow Procedure for the Treatment of Recurrent Anterior Shoulder Instability.

Specific instruments have been designed to improve the safety and accuracy of the arthroscopic inlay Bristow procedure (Weigao, Shangdong, China). The posterior portal (A), superolateral portal (B), and 3 anterior portals (i.e., proximal [C], inferolateral [D], and inferomedial [E]) were utilized. General anesthesia and an interscalene block were administered with the patient in the beach-chair position. The surgical technique can be divided into 6 steps: (1) evaluation of the shoulder joint; (2) coracoid preparation, drilling, and osteotomy; (3) subscapularis splitting and labrum detachment; (4) glenoid preparation and drilling; (5) coracoid retrieval, trimming, transfer, and fixation; and (6) Bankart repair. Soft-tissue capsulolabral repairs or bone reconstruction procedures are commonly performed for the treatment of anterior glenohumeral instability2. The arthroscopic Bristow-Latarjet procedure is increasingly popular for the treatment of anterior shoulder instability with a substantial osseous defect of the glenoid3. Defects that are too large to be restored with the coracoid process can be treated with use of the Eden-Hybbinette procedure or a distal tibial allograft4,5. This procedure was inspired by the structure of mortise-tenon joints, resulting in a modified version of the Bristow-Latarjet technique in which the coracoid process is trimmed and placed into a trough (5 to 10 mm deep) in the glenoid neck. This procedure substantially increases the contact area between the fresh bone surface and the coracoid and glenoid neck. Another important advantage of this technique is that it can facilitate accurate positioning of the coracoid on the glenoid. This procedure resulted in a high rate of graft healing, excellent functional outcomes (Rowe and American Shoulder and Elbow Surgeons Shoulder scores), and a high rate of return to sport6. Currently, indications of this procedure are (1) participation in high-demand sports (i.e., collision and overhead) combined with the presence of a glenoid defect involving <25% of the glenoid, or (2) any glenoid defect involving 10% to 25% of the glenoid. Increased bone-contact area and accurate positioning of the graft helped to facilitate osseous union, with a union rate of 96.1% at 12 months postoperatively. The clinical outcomes were excellent, with a high rate of return to sport (87%) at a minimum of 3 years of follow-up6. When the coracoid is retrieved through portal D (the inferolateral portal), there is a risk of stretching the musculocutaneous nerve.Trimming the coracoid graft could lead to stretching of the graft and the surrounding soft tissue, resulting in overstretching of the musculocutaneous nerve.To minimize the risk of musculocutaneous nerve injury, (1) the graft should be gently retrieved through portal D, (2) the graft should be trimmed with caution without overstretching it and surrounding soft tissue, and (3) a cannula should be utilized when driving the screw to fix the graft in order to avoid the surrounding soft tissue. RHD = right-hand dominantMRA = magnetic resonance angiography3D-CT = 3-dimensional computed tomographyPDS = polydioxanone sutureMCN = musculocutaneous nerve.

The third era of surgical treatment for anterior shoulder instability

The third era of surgical treatment for anterior shoulder instability

Arthroscopic Cortical-Button Latarjet Procedure for Anterior Shoulder Instability With Glenoid Bone Loss

Background: The Latarjet procedure is a common treatment of anterior shoulder instability associated with glenoid bone loss. Advanced arthroscopic technique provided a safe cortical-button fixation of the coracoid process transferred onto the glenoid neck combined with a Bankart repair. Indications: This is an 18-year old woman, complaining of recurrent right shoulder dislocation and subluxation, which made her unable to play handball at competitive level. Physical examination confirmed anterior apprehension without hyperlaxity. Computed tomography (CT) scan identified a Hill-Sachs lesion and a glenoid bone loss of 11%. Instability Severity Index Score was calculated at 7 points. Technique Description: Patient was placed in a beach-chair position under general anesthesia combined with an interscalene nerve block. A 70° scope and specifically designed instruments were used. The technique required 5 steps: (1) coracoid preparation: pectoralis minor and coracoacromial ligament release, flattening of the undersurface, positioning of the peg button, and osteotomy of the coracoid; (2) glenoid preparation: flattening of the neck of the scapula, insertion of 2 anchors (3 and 6 o’clock), and glenoid drilling with a specific guide; (3) subscapularis split: use of an intra-articular and extra-articular spreader splitting the subscapularis muscle at the level of the glenoid wire (shoulder in neutral rotation) and opening of a “safe window”; (4) fixation step: transfer of the coracoid through the subscapularis split with shuttle suture and permanent fixation with a posterior cortical button (compression controlled at 100 Newtons with a dynamometer); and (5) Bankart repair. The shoulder was protected in a sling 4 weeks, and external rotation recovery was allowed at 6 weeks. Results: Favorable outcomes were reported at 6 months of follow-up without any complication. Full range of motion with limited external rotation deficit was obtained and a negative apprehension test. Radiologic assessment confirmed graft incorporation at 6 months, allowing return to overhead sports at a competitive level. Discussion/Conclusion: Arthroscopic cortical-button Latarjet procedure is a safe option to treat anterior shoulder instability associated with glenoid bone loss in patient with high demand sports. The procedure is safe and combine bone graft and Bankart repair. Using a cortical button fixation avoids screw related complications.

Surgical treatment of anterior shoulder instability with glenoid bone loss with the Latarjet procedure in active-duty military service members.

The arthroscopic Bankart repair in the setting of glenoid bone loss has high rates of failure. In patients with anterior glenoid bone loss, the Latarjet provides glenohumeral stability through restoration of the glenoid bone, the conjoint tendon acting as a sling on the subscapularis, and anterior capsulolabral repair. Active-duty military personnel are at high risk for glenohumeral instability and have been equated to the contact athlete; most are young, male, and engage in contact sports. The purpose of this study is to assess the return to full-duty rates in active-duty military personnel following the Latarjet for anterior glenohumeral instability with glenoid bone loss. A retrospective review of all glenohumeral instability procedures were reviewed at a tertiary training hospital from June 2014 to June 2019. The patient population consisted of active-duty military personnel with glenoid bone loss and anterior glenohumeral instability, who were treated with a Latarjet. The primary outcome was return to full-duty status. There were 50 patients identified for the study. Four patients were lost to follow-up, leaving 46 of 50 patients (92.0%) eligible for this study. The average age at the time of the index procedure was 23.1 years. The average percentage bone loss was 18.4%. Forty-one patients (89.1%) were able to return to full-duty status. Four patients (8.7%) sustained a recurrent dislocation following the Latarjet; all 4 dislocations occurred during a combat deployment. Four patients (8.7%) reported episodes of subluxation without dislocation. Forty-one patients (89.1%) reported that their shoulders felt stable, and we found an average return to full duty at 5.3 months CONCLUSION: In our active-duty military cohort, we found an 8.7% rate of recurrent instability after a Latarjet procedure, and 41 patients (89.1%) were able to return to full-duty status. In conclusion, the Latarjet procedure in the active-duty military population with anterior glenoid bone loss resulted in a high rate of return to duty, excellent functional outcomes, low rate of recurrent instability, and a low overall complication rate.

Arthroscopic Bone Block Cerclage Technique Using a Tricortical Scapular Spine Autograft for Glenoid Reconstruction in Patients With Anterior Shoulder Instability

In the treatment of anterior shoulder instability with glenoid bone loss, free bone graft transfers have proven to be a viable anatomic alternative to the commonly performed, nonanatomic Latarjet procedure. Implant-free fixation of the free bone grafts, in particular, has rendered excellent short- and long-term results. However, a drawback remains the source of the graft. We describe an arthroscopic bone block cerclage technique using a tricortical scapular spine autograft, which provides an anatomic arthroscopic glenoid reconstruction with the combined benefit of sparing the subscapularis, metal-free fixation, and intraregional donor site for autograft harvesting.

Nonoperative management of anterior shoulder instability can result in high rates of recurrent instability and pain at long-term follow-up.

Data on the long-term outcomes of nonoperative treatment of anterior shoulder instability are lacking, particularly for the US population. The purpose was to (1) describe the characteristics of patients with anterior shoulder instability treated nonoperatively, (2) assess the long-term outcomes of nonoperative management in a US population, and (3) identify risk factors for poor outcomes following nonoperative management. A geographic cohort of >500,000 subjects was used to identify patients treated nonoperatively for anterior shoulder instability. Only patients aged <40 years at the time of initial instability with minimum 10-year follow-up were included. Medical records were reviewed to obtain demographic characteristics, physical examination findings, clinical history data, imaging results, treatment details, and clinical and/or radiographic progression. Recurrent pain, recurrent instability, and the development of symptomatic osteoarthritis (OA) were the primary outcomes evaluated. The study included 254 patients (73% male) with a median age of 19 years (range, 16-26 years) at the time of initial instability. At median 17-year follow-up, 37.5% experienced recurrent instability, 58.4% had recurrent pain, and 12.2% had symptomatic OA development. Factors associated with recurrent pain at final follow-up were multiple instability events prior to presentation (hazard ratio [HR], 2.43; P < .01) and increased pain at the initial visit (HRs of 0.79 for mild, 1.74 for moderate, and 1.39 for severe; P < .01); patients with multiple instability events prior to presentation also had an increased risk of recurrence (P < .01). Factors increasing the risk of the development of symptomatic OA included increased pain at the initial visit (P = .05), seizure disorder (HR, 27.01; P< .01), and smoking (HR, 5.15; P < .01). At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability. Overall, 37.5% of patients experienced recurrent shoulder instability, 58.4% had recurrent shoulder pain, and 12.2% had symptomatic OA development. Risk factors associated with adverse clinical outcomes included increased pain at the initial visit, recurrent instability prior to presentation, seizure disorder, and smoking.