Treatment Of Anterior Shoulder Instability Research Articles

Responses From ChatGPT-4 Show Limited Correlation With Expert Consensus Statement on Anterior Shoulder Instability

PurposeThe purpose of this study was to compare the similarity of answers provided by GPT-4 to those of a consensus statement on diagnosis, nonoperative management, and Bankart repair in anterior shoulder instability (ASI). MethodsAn expert consensus statement on ASI published by Hurley et al. in 2022 was reviewed and questions laid out to the expert panel were extracted. GPT-4, the subscription version of ChatGPT, was queried using the same set of questions. Answers provided by GPT-4 were compared to those of the expert panel and subjectively rated for similarity by two experienced shoulder surgeons. GPT-4 was then used to rate the similarity of its own responses to the consensus statement, classifying them as low, medium, or high. Rates of similarity as classified by the shoulder surgeons and GPT-4 were then compared and interobserver reliability calculated using weighted κ scores. ResultsThe degree of similarity between responses of GPT-4 and the ASI consensus statement, as defined by shoulder surgeons, was high in 25.8%, medium in 45.2%, and low 29% of questions.GPT-4, assessed similarity as high in 48.3%, medium in 41.9%, and low 9.7% of questions.Surgeons and GPT-4 reached consensus on the classification of 18 questions (58.1%) and disagreement on 13 questions (41.9%). ConclusionThe responses generated by artificial intelligence exhibit limited correlation with an expert statement on the diagnosis and treatment of ASI.

Distal Tibial Allograft for the Treatment of Anterior Shoulder Instability With Glenoid Bone Loss: A Systematic Review and Meta-analysis.

The use of a distal tibial allograft (DTA) for reconstruction of a glenoid defect in anterior shoulder instability has grown significantly over the past decade. However, few large-scale clinical studies have investigated the clinical and radiographic outcomes of the DTA procedure. To conduct a systematic review and meta-analysis of clinical studies with data on outcomes and complications in patients who underwent the DTA procedure for recurrent anterior shoulder instability with glenoid bone loss. Systematic review and meta-analysis; Level of evidence, 4. A comprehensive search of major bibliographic databases was conducted for articles pertaining to the use of a DTA for the management of anterior shoulder instability with associated glenoid bone loss. Postoperative complications and outcomes were extracted and compiled in a meta-analysis. Of the 8 included studies with 329 total participants, the mean patient age was 28.1 ± 10.8 years, 192 (83.8%) patients were male, and the mean follow-up was 38.4 ± 20.5 months. The overall complication rate was 7.1%, with hardware complications (3.8%) being the most common. Partial graft resorption was observed in 36.5% of the participants. Recurrent subluxation was reported in 1.2% of the participants, and recurrent dislocation prompting a reoperation was noted in 0.3% of the participants. There were significant improvements in clinical outcomes, including American Shoulder and Elbow Surgeons score (40.9-point increase; P < .01), Single Assessment Numeric Evaluation (47.2-point increase; P < .01), Western Ontario Shoulder Instability Index (49.4-point decrease; P < .01), Disabilities of the Arm, Shoulder and Hand (20.0-point decrease; P = .03), and visual analog scale (2.1-point decrease; P = .05). Additionally, postoperative shoulder range of motion significantly increased from baseline values. The DTA procedure was associated with a low complication rate, good clinical outcomes, and improved range of motion among patients with anterior shoulder instability and associated glenoid defects.

Functional Outcomes of Arthroscopic Bankart Repair in Indian Population: A Systematic Review and a Meta-analysis

Abstract Introduction: The past two decades have witnessed significant development in arthroscopic management for recurrent anterior shoulder instability. Currently, arthroscopic Bankart repair (ABR) is popular in the treatment of anterior shoulder instability. There is a dramatic rise in the number of orthopedic surgeons in India specializing in shoulder surgery and is believed to be secondary to the advancement in arthroscopic techniques and implants. However, there is a paucity of Indian literature on functional outcomes of ABR. The purpose of the current review is to better understand the functional outcomes of ABR in the Indian population. Methods: A search of major databases (Embase, Ovid Medline, Google Scholar, and Cochrane Library) was performed in April 2020. Reference lists of selected research articles were further screened in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion and exclusion criteria for analysis were used to generate the final list of studies. Results: A total of ten research studies were included in the final analysis representing a pooled patient population set of 391 patients. The mean age for patients across the studies was 27 years (range: 24–29) of age and the average number of dislocations before surgery was five (range: 0–14). The average follow-up period post-surgery was 20 months (range: 6–27 months). Among the functional scores, the average UCLA score improved from 22 (range: 18–30) at preoperatively to 32 (range: 31–35), and the mean Rowe score improved from an average of 27 (range: 24–63) preoperatively to 91 (range: 90–94) during the follow up duration. The average postoperative re-dislocation rate was 7% (range: 0%–10%). Conclusion: In the Indian population, ABR provides consistently good functional outcomes with a low postoperative re-dislocation rate, which is at par with the global data. Further studies with larger sample sizes and longer follow-ups are needed to validate these results.

Outcomes of primary Latarjet vs. revision Latarjet after prior surgery for anterior shoulder instability: a systematic review and meta-analysis.

Latarjet has become an increasingly popular treatment option for recurrent anterior shoulder instability. With the reported complication rates for primary Latarjet surgery, there are concerns about the complications of Latarjet as a revision surgery. It remains unclear if poor results after previous surgical management can be improved with revision Latarjet as well as with primary Latarjet. The aim of this systematic review and meta-analysis is to compare the outcomes of primary Latarjet and revision Latarjet for the treatment of anterior shoulder instability. A systematic search was performed on 3 databases for studies that compared primary Latarjet with revision Latarjet used after failed arthroscopic stabilization or failed free bone block procedures. From the included studies, demographic data, clinical outcome scores, range of motion measurements, and postoperative complications were obtained. A total of 11 studies were included for data analysis. Compared with the primary Latarjet cohort, revision Latarjet cohorts had a higher infection rate (1.2% vs. 2.6%; RR 0.46, P=.039). The primary Latarjet group showed a greater rate of return to sport (89.7% vs. 80.5%; RR 1.12, P=.41) and less subjective feeling of instability (12.6% vs. 20.9%; RR 0.60, P=.085) compared with the revision Latarjet group; however, this was not statistically significant. There were no significant differences in complication rates, reoperation, recurrence, and range of motion between primary Latarjet and revision Latarjet groups. Clinical outcome scores such as visual analog scale and Rowe scores were not significantly different between the cohorts. Based on the current evidence, primary Latarjet presents reduced infection rates but similar clinical outcome measures, overall complication, and range of motion measurements than revision Latarjet performed after failed prior operative treatment.

Biomechanical comparison of open Bankart repair vs. conjoint tendon transfer in a 10% anterior glenoid bone loss shoulder instability model

The treatment of shoulder instability in patients with subcritical glenoid bone loss poses a difficult problem for surgeons as new evidence supports a higher failure rate when a standard arthroscopic Bankart repair is used. The purpose of this study was to compare a conjoint tendon transfer (soft-tissue Bristow) to an open Bankart repair in a cadaveric instability model of 10% glenoid bone loss. Eight cadaveric shoulders were tested using a custom testing system that allows for a 6-degree-of-freedom positioning of the glenohumeral joint. The rotator cuff muscles were loaded to simulate physiologic muscle conditions. Four conditions were tested: (1) intact, (2) Bankart lesion with 10% bone loss, (3) conjoint tendon transfer, and (4) open Bankart repair. Range of motion, glenohumeral kinematics, and anterior-inferior translation at 60° of external rotation with 20 N, 30 N, and 40 N were measured in the scapular and coronal planes. Glenohumeral joint translational stiffness was calculated as the linear fit of the translational force-displacement curve. Force to anterior-inferior dislocation was also measured in the coronal plane. Repeated measures analysis of variance with a Bonferroni correction was used for statistical analysis. A Bankart lesion with 10% bone loss increased the range of motion in both the scapular (P=.001) and coronal planes (P=.001). The conjoint tendon transfer had a minimal effect on the range of motion (vs. intact P=.019, .002), but the Bankart repair decreased the range of motion to intact (P=.9, .4). There was a significant decrease in glenohumeral joint translational stiffness for the Bankart lesion compared with intact in the coronal plane (P=.021). The conjoint tendon transfer significantly increased stiffness in the scapular plane (P=.034), and the Bankart repair increased stiffness in the coronal plane (P=.037) compared with the Bankart lesion. The conjoint tendon transfer shifted the humeral head posteriorly at 60° and 90° of external rotation in the scapular plane. The Bankart repair shifted the head posteriorly in maximum external rotation in the coronal plane. There was no significant difference in force to dislocation between the Bankart repair (75.8±6.6 N) and the conjoint tendon transfer (66.5±4.4 N) (P=.151). In the setting of subcritical bone loss, both the open Bankart repair and conjoint tendon transfer are biomechanically viable options for the treatment of anterior shoulder instability; further studies are needed to extrapolate these data to the clinical setting.

A Systematic Review of Screw and Suture Button Glenoid Augmentation Constructs.

Glenohumeral dislocations often lead to glenoid bone loss and recurrent instability, warranting bony augmentation. While numerous biomechanical studies have investigated fixation methods to secure a graft to the glenoid, a review of available constructs has yet to be performed. To synthesize the literature and compare the biomechanics of screw and suture button constructs for anterior glenoid bony augmentation. Systematic review. A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. There were 2 independent reviewers who performed a literature search using the PubMed, Embase, and Google Scholar databases of studies published between 1950 and 2020. Studies were included that compared the biomechanical outcomes of fixation for the treatment of anterior shoulder instability with glenoid bone loss. Overall, 13 of the 363 studies screened met the inclusion criteria. The included studies measured the biomechanical strength of screws or suture buttons on a cadaveric or synthetic Latarjet construct. Screws and suture buttons were biomechanically similar, as both constructs exhibited comparable loads at failure and final displacement. Screw type (diameter, threading, or composition) did not significantly affect construct strength, and double-screw fixation was superior to single-screw fixation. Additionally, 2 screws augmented with a small plate had a higher load at failure than screws that were not augmented. Unicortical double-screw fixation was inferior to bicortical double-screw fixation, although construct strength did not significantly decrease if 1 of these screws was unicortical. Further, 2 screws inserted at 15° off axis experienced significantly higher graft displacement and lower ultimate failure loads than those inserted at 0° parallel to the glenoid. Suture buttons provided comparable strength to screws and offer an effective alternative to reduce screw-related complications. Augmentation with a small plate may clinically enhance construct strength and decrease complications through the dispersion of force loads over a greater surface area. Differences in screw type did not appear to alter construct strength, provided that screws were placed parallel to the articular surface and were bicortical.

Effect of open versus minimally invasive surgery on postoperative wound site complications in patients with recurrent shoulder instability: A meta-analysis.

The Latarjet procedure is the accepted method of operation for patients with anterior shoulder instability. However, as arthroscopy becomes more and more popular, more and more patients are being treated with minimally invasive techniques for the treatment of anteriorly unstable shoulder. This research aims to compare the curative effects of arthroscopic Latarjet (AL) and open Latarjet (OL) on postoperative anterior shoulder instability. Our hypothesis is that arthroscopy will produce better results than open surgery. During the study, a review was conducted on four main databases, including EMBASE and Cochrane Library. Six cohort studies comparing AL with OL in the treatment of anterior shoulder instability were included. Patients who were operated by open technique up to 2023 were referred to as OL and those who underwent arthroscopic surgery were referred to as AL. Comparison was made between the two methods of operation. The statistical analysis was done with RevMan 5.3. The analysis included Visual Analogue Scale (VAS) scores and postoperative wound infections. A total of six studies were included for analysis under inclusion and exclusion criteria. There were 798 patients, 476 was AL group and 322 was OL group. No statistical significance was found on the incidence of postoperative wound infection in the patients who underwent the Latarjet procedure (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.28-7.31; p = 0.67) and the VAS score after surgery (mean difference [MD], 0.70; 95% CI, -0.67 to 2.06; p = 0.32) for patients. However, it has now been demonstrated that arthroscopy is a safe and viable alternative. The only drawback of arthroscopic Latarjet surgery is probably that it has a long learning curve and requires a lot of practice from the surgeon.

The open Latarjet-Patte procedure for the treatment of anterior shoulder instability in professional handball players at a mean follow-up of 6.6 years

The popularity of team handball is increasing with over 10 million children playing this overhead, throwing and collision sport with highest demands on the shoulder joint. Due to the risk for recurrent instability, the Latarjet-Patte (LP) procedure has been recommended to treat young competitive players. This is the first LP outcome study in professional handball. We included 20 shoulders retrospectively (18 players/17 males/mean age 22.9 years, range 17-35 years; minimum/mean follow-up: 2/6.6 years) operated on by three expert surgeons (2011-2020) with Walch's LP-technique. Preoperative hyperlaxity (25%/n=5), affected throwing arm (55%/n=11), position (backcourt, winger, goalkeeper: 22% each; full back, pivot: 17% each), >2 dislocations prior (20%/n=4), >10 dislocations (5%/n=1), previous failed Bankart/HAGL repair (10%/n=2) and large Hill-Sachs lesions (HSL: 20%/n=4) were documented. Clinical and radiographic outcomes, visual analogue scale (VAS), subjective shoulder value (SSV), Walch-Duplay (WDS), Rowe score (RS) and return to sports (RTS) parameter were recorded. RTS was 85% (n=17/20), RTS to same-level 80% (n=16/20), RTS with no throwing pain 73% (n=8/11), time to training with ball: 3.2/12 and to competition 4.9/12. The mean RS, WDS and SSV were 90, 88, 89 % respectively. Shoulder symptoms lead to giving up handball in 2 cases (10%). One player (5%) stopped for other reasons. One recurrent dislocation (5%) was recorded (non-throwing arm, winger, no recurrence after rehabilitation). Persistent apprehension occurred in one goalkeeper (5%). Four shoulders showed residual pain (20%) relieved in one by screw removal. Resistant pain (throwing shoulder) was seen in 2 backcourt players (10%/one large HSL) and one goal keeper (5%/large HSL; >10 dislocations prior), all three >30years of age. Bone block positioning was correct (no lateral overhang) in all shoulders. One shoulder (5%) showed mild arthritic changes at final follow-up (>10 dislocations, large HSL). The open Latarjet-Patte is consistent in providing shoulder stability combined with return to throwing performance in professional handball players with a short time to RTS and high same-level RTS rate without increasing the risk of arthritic changes. Throwing shoulders of backcourt players, with large HSL or shoulders at age >30 years may have an increased risk for persistent symptoms.

Poster 158: Remplissage Reduces Recurrent Instability in High-Risk Patients with “On-Track” Hill-Sachs Lesions

Objectives: The objective of this study was to compare recurrent instability rates and patient reported outcomes (PROs) between patients with “on-track” Hill-Sachs lesions who underwent ALR alone versus patients who had received ALR with remplissage (ALR+R). Our hypothesis was that performing a remplissage in addition to ALR would decrease the recurrence rate, especially among high-risk subjects such as contact athletes. Methods: We performed a retrospective analysis of patients age 12-40 years old with “on-track” shoulders who underwent ALR+R between Jan 2014 and Dec 2019 at a single institution, with minimum 2-year follow-up. Exclusion criteria included: prior ipsilateral shoulder surgery, &gt;20% glenoid bone loss (GBL), concomitant rotator cuff repair, and connective-tissue disorder. We then identified a cohort of patients meeting the same inclusion and exclusion criteria who had undergone ALR alone. Patient age, gender, follow-up time, first-time dislocation vs. multiple dislocations, and contact sport participation were recorded. GBL, Hills-Sachs Interval (HSI), glenoid track (GT), and DTD were measured from pre-operative MRIs. The patients were then contacted to determine if they had had recurrent instability and/or revision surgery. We also obtained current Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) scores. Subgroup analysis was performed on “high-risk” patients (DTD &lt;10mm and contact sport participation) from each cohort. Results: The ALR+R cohort had 17 subjects and the ALR cohort had 51 subjects. There were no differences in demographic variables or GBL between cohorts (P&gt;0.05). The ALR+R subjects had larger HSI (14.7mm ± 2.4 vs 5.7mm ± 5.0; P&lt;0.001) and smaller DTD (8.2mm ± 3.2 vs 16.2mm ± 5.7; P&lt;0.001). There were no difference in WOSI (304.2 ± 213 vs 302.4mm ± 344.2; P=0.98) or SANE (84.3 ± 16.6 vs 87.3 ± 8.9; P=0.94) scores between groups. Only 1 (5.9%) subject in the ALR+R cohort had a recurrent subluxation, and there were no dislocations or revision surgeries. The ALR cohort had 7 (13.7%) recurrent dislocations, 3 (5.8%) recurrent subluxations, and 6 (11.8%) revision surgeries. Multivariate analysis indicated that smaller DTD (OR 0.71; 95% CI (0.56 – 0.87); P=0.001) and contact sport participation (OR 8.67; 95% CI (1.19 – 63.35); P=0.033) were associated with increased risk of recurrent instability. After adjusting for contact sport participation and DTD value, the ALR+R cohort had a 98.8% lower risk of recurrent instability compared to the ALR cohort (OR 0.012; 95% CI (0.0001 – 0.22); P=0.003). Among “high risk” subjects, there was only 1 (11.1%) instability event in the ALR+R group and 4 (80%) in the ALR alone group (P=0.023) Conclusions: DTD calculations can be used as an independent predictor of recurrent shoulder dislocation following ALR for treatment of anterior shoulder instability. For patients with “on- track” shoulder lesions, but small DTD measurements (“near-track” lesions), remplissage is protective against recurrent instability events and need for revision surgery. This may be especially true for “high- risk” patients, such as those who participate in contact sports.

Paper 43: Defining and Predicting the “Optimal Observed Outcome” Following Surgical Treatment of Anterior Shoulder Instability: A Machine Learning Clustering Analysis of 200 patients with 11-year mean follow up.

Objectives: Desirable outcomes following surgery for anterior shoulder instability (ASI) include a multitude of functional and clinical functions, yet it remains uncertain if all of these outcomes are simultaneously achievable (i.e. can patients have full motion and no instability; does excellent stability coincide with stiffness?). The purpose of this study was to employ unsupervised machine learning techniques to define the actual "optimal observed outcome” for patients undergoing surgical treatment for ASI and to identify predictors of obtaining this outcome. Methods: Patients &lt;40 years with an initial diagnosis of ASI from 1994 -2016 were included. Four unsupervised machine learning clustering algorithms were evaluated to partition subjects into “optimal observed outcome” or “suboptimal outcome” based on combinations of actually observed outcomes. Demographic, clinical, and treatment variables were compared between groups using descriptive statistics and Kaplan-Meier survival curves; multivariate stepwise logistic regression evaluated variable prognostic value. Results: 200 patients with a mean follow-up of 11 years were included. 146 (64%) obtained the “optimal observed outcome”, characterized by significantly (P &lt;0.001) lower rates of: recurrent postoperative pain (23% vs 52%), recurrent instability (12% vs 41%), revision surgery (10% vs 24%), progression to osteoarthritis (OA) (5% vs. 19%), and mildly restricted motion (161° vs. 168°). Stepwise multivariate logistic regression identified time from initial instability to presentation (OR: 0.96, 95% CI: 0.92-0.98) and habitual instability (OR: 0.17, 95%CI: 0.04-0.77) as negative predictors of “observed optimal outcome”. Increased rate of subluxation over frank dislocation pre-operatively (OR: 1.30, 95% CI: 1.02-1.65) was a positive predictor. Type of surgery performed was not a significant predictor. Conclusions: Following surgical treatment for ASI, an appropriate “optimal observed outcome” can be defined as: minimal postoperative pain, absence of recurrent instability, low rates of revision surgery, absence of OA, and increased ROM. This “optimal observed outcome” was achieved in over 2/3rds of the cohort and this work demonstrated the synergistic relationship of these. The most significant predictors included shorter time to presentation and history of subluxations over frank dislocations pre-operatively. This definition of the “optimal observed outcome” may be more appropriate for surgical decision making and setting appropriate expectations. [Table: see text][Table: see text]

Outcomes of Shoulder Instability Repair - Latarjet vs Arthroscopic Bankart Repair: A Retrospective Study

This retrospective study aimed to compare the outcomes of two surgical procedures, Latarjet repair and arthroscopic Bankart repair, for the treatment of anterior shoulder instability. The study included 31 patients between the ages of 16 and 40 years who underwent either Latarjet repair or arthroscopic Bankart repair. The patients were evaluated using the Constant Murley Shoulder Score (CMS) and the American Shoulder and Elbow Surgeons Score (ASES) at 3, 6, and 12 months postoperatively. The results showed a gradual improvement in functional outcomes for both groups during the follow-up period. At one year postoperative, the Bankart repair group exhibited a CMS score of 89.3 and an ASES score of 94.1, while the Latarjet repair group showed a CMS score of 87.8 and an ASES score of 91.3. Statistical analysis revealed no significant differences in the CMS scores at any follow-up time point. However, the ASES score at 12 months postoperative was significantly higher in the Bankart repair group compared to the Latarjet repair group. The findings of this study suggest that both Latarjet repair and arthroscopic Bankart repair yield favorable clinical outcomes in terms of functional improvement for patients with anterior shoulder instability. Although arthroscopic techniques are minimally invasive and preferred by surgeons, the Latarjet procedure offers comparable results with less expenditure. The choice of surgical approach should be based on factors such as the patient's age, level of activity, and the presence of significant bone defects or soft tissue deficiencies. Further comparative studies with long-term follow-ups are recommended to validate these findings and provide more comprehensive insights into the outcomes of these procedures.

Research progress of the diagnosis and treatment of anterior shoulder instability

The shoulder joint is the most prone to dislocation in the whole body, and more than 95% of them are anterior dislocation. Improper treatment after the initial dislocation is easy to lead to recurrent anterior dislocation or anterior shoulder instability, and the outcomes following conservative treatment is poor. Anterior shoulder instability can damage the soft tissue structure and bone structure that maintain the stability of shoulder joint, among which bone structure is the most important factor affecting the stability of shoulder joint. Diagnosis should be combined with medical history, physical examination, and auxiliary examination. Currently, three-dimensional CT is the most commonly used auxiliary examination means. However, various bone defect measurement and preoperative evaluation methods based on three-dimensional CT and the glenoid track theory have their own advantages and disadvantages, and there is still a lack of gold standard. Currently, the mainstream treatment methods mainly include Bankart procedure, coracoid process transposition, glenoid reconstruction with free bone graft, Bankart combined with Remplissage procedure, and subscapular tendon binding tamponade, etc. Each of these procedures has its own advantages and disadvantages. For the diagnosis and treatment of anterior shoulder instability, there are still too many unknown, further research and exploration need to be studied.

Anterior shoulder instability: comparison between Latarjet open procedure and arthroscopic capsuloplasty.

Latarjet surgery and capsuloplasty are both valid alternatives for the treatment of anterior shoulder instability with limited glenoid bone loss, although in literature there is extensive discussion on it. The purpose of this study was to compare the outcomes of these procedures in patients with similar lesions. Between January 2000 to October 2020, 59 nonconsecutive patients suffering from anterior shoulder instability were treated, 33 had arthroscopic capsuloplasty (Group 1) and 26 had open Latarjet procedure (Group 2). The Group 1 was composed by 12% of female and 88% of males with the mean age at surgery 25.6 +/- 9.07 (15-49 years). In the Group 2, the 100% of patients were males with mean age 32.42 +/- 10.74 (16-56).Rowe Score, UCLA score and WOSI score were used to test patients. Only UCLA (average was 22.18 ± 6.13 for the Capsuloplasty and 26.76 ± 6.57 in the Latarjet, p = 0.01) and ROWE scores (average was 70.15 ± 24.75 in Latarjet and 50.15 ± 24.70 in Capsuloplasty, p = 0.002) showed a statistically significant difference between the two procedures, while the WOSI (mean results of Latarjet 0.31 ± 0.16 against 0.24 ± 0.09 of the capsuloplasty, p = 0.069) there was no significant difference between the two groups in question. Apparently, the Latarjet surgery is better in terms of instability recurrence compared to capsuloplasty but has higher rate of shoulder joint osteoarthtritis. However, there are no significant differences that could decree which procedure is better. (www.actabiomedica.it).

Surgical treatment of shoulder instability in active-duty service members with subcritical glenoid bone loss: Bankart vs. Latarjet.

Subcritical bone loss has been identified as a risk factor for potentially inferior outcomes following typical arthroscopic soft tissue repair. One alternative that has been presented as an option for patients with bone loss is the Latarjet, an ipsilateral coracoid transfer to the anteroinferior glenoid. The purpose of this study is to compare the outcomes between the arthroscopic Bankart repair and the open Latarjet for the treatment of anterior shoulder instability in patients with subcritical bone loss. We hypothesize that the open Latarjet will provide higher patient-reported outcome measure scores and lower rates of dislocation. A retrospective cohort comparison of patients with anterior glenohumeral instability procedures was performed. Inclusion criteria included symptomatic anterior shoulder instability, subcritical glenoid bone loss (13.5%-24%), surgical treatment with arthroscopic Bankart repair or open Latarjet, and minimum follow-up of 2 years. Outcomes included recurrent instability (defined as postoperative dislocation or subjective subluxation), permanent physical restrictions, Western Ontario Shoulder Index (WOSI), and Single Assessment Numeric Evaluation (SANE) scores. Forty-seven patients were included, 25 of whom underwent an arthroscopic Bankart repair and 23 patients an open Latarjet. The average bone loss was 17.8% and 19.3%, respectively. Overall, 8 patients experienced recurrent instability, 6 in the arthroscopic Bankart group and 2 in the open Latarjet group (P=.162). The average postoperative SANE score for arthroscopic Bankart group was 48% and for the open Latarjet group, 84% (P<.001). The average postoperative WOSI score for the arthroscopic Bankart group was 53.6% and for the open Latarjet group, 67.9% (P=.069). There were significantly more patients placed on permanent physical restrictions in the arthroscopic Bankart repair group (16) compared with open Latarjet (3) (P<.001). In patients with subcritical glenoid bone loss (defined as 13.5%-24%), patients treated with an open Latarjet have insignificantly higher SANE and WOSI scores and lower permanent physical restrictions than patients treated with an arthroscopic Bankart repair. We found no statistically significant difference in recurrent instability rates between the open Latarjet and arthroscopic Bankart repair (P=.162).

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.

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.