Treatment Of Recurrent Shoulder Instability Research Articles

Female Patients Undergoing Latarjet Surgery Show Similar 2-Year Secondary Surgery Rates but Greater Risk of Emergency Department Visits Compared With a Matched Cohort of Male Patients

To evaluate sex-based differences in 30-day postoperative emergency department (ED) visits, 90-day complication rates, and 2-year secondary surgery rates after the Latarjet procedure for the treatment of recurrent shoulder instability. A national administrative claims database was used to identify patients with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for shoulder subluxation or dislocation on the day of first-time stabilization with the Latarjet technique between 2015 and 2021. Male patients were matched 4:1 to female patients based on age, Elixhauser Comorbidity Index (ECI) score, and body mass index class. Rates of 30-day ED visits and 90-day complications were compared between cohorts, and risk factors for ED visits were identified by multivariate regression. The incidence of secondary surgery within 2 years was compared by Kaplan-Meier analysis. Prior to matching, 1,059 male and 360 female patients met the inclusion and exclusion criteria. Subsequent 4:1 (male-to-female) matching controlling for age, ECI score, and body mass index yielded 694 male and 185 female patients who underwent the Latarjet procedure. The overall incidence of 30-day ED visits was 9.3%, with an incidence of 8.2% for male patients and 13.5% for female patients. On the basis of multivariate logistic regression, these 30-day ED visits were associated with female sex (odds ratio, 1.79; P= .029) and incrementally higher ECI scores; relative to an ECI score of 0, ECI scores of 1 to 2, 3 to 4, and 5 or greater were associated with odds ratios of 5.31 (P= .006), 8.12 (P < .001), and 12.84 (P < .001), respectively. Ninety-day complications occurred in 1.5% of the total cohort, and the incidence was not statistically different between sexes. Overall, 2-year secondary surgery rates were similar between male and female patients (5.1% and 6.7%, respectively; P= .4). Female patients undergoing the Latarjet procedure for recurrent shoulder instability showed similar 90-day complication and 2-year secondary surgery rates to a matched cohort of male patients. Female sex, along with ECI score, however, was associated with a greater rate of 30-day ED visits. Level III, retrospective comparative case series.

Does previous arthroscopic Bankart repair influence coracoid graft osteolysis in Latarjet procedure? A case-control study with computed tomography scan data

Latarjet procedure is commonly performed in treatment of recurrent shoulder instability and also indicated as a salvage procedure for recurrence after failed arthroscopic Bankart repair. While this procedure has shown success, there is an increased awareness of complications in recent studies, especially for graft osteolysis. Most relevant research have focused on pathophysiology, incidence, location or risk factors of graft osteolysis; however, the data is limited to primary Latarjet procedures. This study aims to investigate the effect of previous arthroscopic Bankart repair surgery on corocaid bone graft osteolysis in Latarjet procedure. This retrospective case-control study analyzed data from patients who underwent primary Latarjet procedure or revision Latarjet procedure following failed arthroscopic Bankart repair. Clinical outcome measures included range of motion (ROM), subjective shoulder value (SSV) and Rowe score. Volumetric analysis of each transferred coracoid graft were performed using early postoperative and late postoperative computed tomography (CT) scan data and amount of graft osteolysis was then calculated as percentage of volume reduction of each graft. 32 patients who met the inclusion criteria, with 24 patients in the primary Latarjet group (group I) and 8 patients in revision Latarjet group (group II), were included to study. Mean age of patients was 32.5±7.7 years and mean follow-up duration was 52.1±8.9 months. Both study groups showed significant improvement in SSV compared to baseline (p<0.05). Comparison of postoperative clinical outcome measures showed no significant difference between two study groups in any outcome parameter (p>0.05). No recurrence was observed during follow-up period. There were 6 patients (25%) with positive apprehension sign in group I and 4 patients (50%) in group II (p>0.05). Analysis of radiological data revealed that all patients underwent some degree of graft osteolysis with varying osteolysis ratios between 12% to 98%. Mean osteolysis ratio of the coracoid graft was 67.3±22.6% in group I and 69.4±25.6% in group II, without significant difference between two groups (p>0.05). Findings of this study suggest that both primary and revision Latarjet procedures following failed arthroscopic Bankart repair underwent considerable amount of coracoid graft osteolysis. Previous arthroscopic Bankart repair did not seem to have significant influence on the amount of graft osteolysis and both primary and revision Latarjet procedures showed satisfactory clinical outcomes.

Anchorless Labral Repair for Recurrent Shoulder Instability in the Skeletally Immature

The optimal treatment of recurrent shoulder instability in skeletally immature athletes remains controversial, especially if there is significant growth remaining. Some investigators advocate conservative treatment until patients are close to skeletal maturity, whereas others push for earlier surgery to avoid further damage. The objective of this technical note is to describe a technique for labral repair using an anchorless approach to avoid potential damage to the glenoid physis.

No Differences in 90-Day Complications and Admissions After Latarjet Procedure for Primary Bone Loss Versus Latarjet Procedure for Failed Arthroscopic Instability Repair

PurposeTo investigate the variance in 90-day complication, emergency department (ED) visit, revision, and readmission rates between the Latarjet procedure (LP) performed as a primary procedure for the treatment of recurrent shoulder instability associated with critical levels of glenohumeral bone loss and the LP performed as a salvage surgical procedure after failed arthroscopic instability repair (FAIR).MethodsPatients who underwent a primary LP from 2016-2021 in a single surgeon’s practice were identified and divided into 2 cohorts based on the indication for surgery: primary LP for critical bone loss (unipolar or bipolar) (LP-PBL) or LP as salvage surgery for FAIR (LP-FAIR). Patients without a minimum follow-up period of 90 days were excluded. Chart review was conducted to analyze the prevalence of complications, ED visits and/or admissions, and secondary procedures in the 90-day postoperative period. Radiographic images were reviewed to evaluate for graft and/or hardware failure. An unpaired t test and the Fisher exact test were used to compare the 2 groups regarding continuous and categorical data, respectively, and the significance level was set at P < .05.ResultsThe final sample sizes consisted of 54 patients in the LP-PBL group and 23 patients in the LP-FAIR group. In the postoperative period, 4 complications were observed in the first 90 days. These included complex regional pain syndrome (n = 1) and superficial wound dehiscence (n = 1) in the LP-PBL cohort. Superficial suture abscess (n = 1) and audible crepitation (n = 1) were observed in the LP-FAIR cohort. There was 1 secondary intervention (arthroscopic debridement) in the LP-FAIR cohort. No statistically significant difference in complication rates, ED visits or admissions, or secondary procedures was found between the LP-PBL and LP-FAIR groups.ConclusionsThe results of this study indicate that the 90-day complication, ED visit, revision, and readmission rates after open LP are low irrespective of the extent of glenoid or bipolar bone loss and history of arthroscopic instability repair.Level of EvidenceLevel III, retrospective cohort study.

Arthroscopic Anatomic Glenoid Reconstruction With Distal Tibial Allograft and Hybrid Fixation

Glenoid grafting is the standard surgical treatment for recurrent shoulder instability with significant glenoid bone loss. Arthroscopic anatomic glenoid reconstruction using a distal tibial allograft for anatomic glenoid reconstruction has recently been gaining attention. This article describes the use of a hybrid graft fixation technique with 1 suture-EndoButton device and 1 compression screw in arthroscopic anatomic glenoid reconstruction using distal tibial allograft.

The “BioHumi” Humeral Head Elliptical Osteochondral Allograft Transplantation

Cartilage defects of the humeral head in young, active patients provide a challenge to treating surgeons. The causes of humeral head osteochondral lesions are variable, but these lesions most commonly result from trauma and recurrent glenohumeral instability. Palliative and reparative techniques such as arthroscopic debridement and microfracture have traditionally been used as surgical treatment but have high failure rates. Similarly to surgical trends in the knee, cartilage restoration in the shoulder is becoming more prevalent in younger patients. Osteochondral allograft transplantation (OAT) has been used as a joint-preserving surgical option to restore hyaline cartilage in multiple joints for decades. Although OAT is more commonly used to re-establish the subchondral bony architecture in the treatment of recurrent shoulder instability, the procedure may also be indicated in young, active patients with focal humeral head chondral defects. OAT has been shown in early studies to provide improvement in functional outcome scores and good long-term graft survival with relatively low rates of complications. This report describes our straightforward, reproducible technique for the treatment of large, oblong chondral defects of the humeral head using OAT.

Modified Mason–Allen Knot for Arthroscopic Complex Bankart Lesion Repair in Recurrent Anterior Shoulder Instability

The arthroscopic Bankart repair is a safe and reliable procedure for the treatment of recurrent shoulder instability for the well-indicated patient. Many repair techniques have been described to restore both labral height and width and recreate a dynamic concavity–compression effect. The modified Mason–Allen knot was first described for rotator cuff tear repair and consists of a horizontal mattress knot with a simple vertical stitch on the same anchor. The purpose of this work is to present the use of the modified Masen–Allen knot for the repair of the capsular labral complex during an arthroscopic Bankart procedure.

Clinical outcome and return to sports activity after surgical treatment for recurrent shoulder instability with a modified Latarjet procedure

IntroductionThe Latarjet procedure is an attractive surgical option for the management of chronic anterior shoulder instability. The original surgical approach involves the vertical tenotomy of the subscapularis tendon. Alternatively, the subscapularis muscle is split longitudinally and the tendon left attached at the lesser tuberosity. HypothesisThe hypothesis is that the longitudinal split is of functional advantage and may lead to better functional results and earlier return to sports activities compared to the vertical tenotomy. Material and methodsThirty-two patients were included in this retrospective cohort study. In 14 patients, the subscapularis tendon was vertically incised (group A), whereas in 18 patients, the subscapularis muscle was split longitudinally (group B). Patients were evaluated at 1 year (FU1) and 2 years (FU2) after the Latarjet procedure. Results at follow-up were correlated with patient-specific data and compared with the preoperative status. Primary outcomes were the functional assessment based on Western Ontario Shoulder Instability (WOSI) index and Constant Score (CS) and the assessment of the return to sports activity. Patients’ demographics, duration of surgery, and the rate of recurrent dislocations were recorded as secondary variables. ResultsAll patients started their sports activities with a mean±SD of 12.41±1.24 weeks. Interestingly, the time from surgery to full recovery of sports activities was significantly longer for group A (mean±SD of 30.17±10.36 weeks) compared to group B (mean±SD of 20.71±3.67 weeks). There is a statistically significant decrease of the WOSI score from the preoperative level compared to FU1 and FU2, indicating a decrease in instability related symptoms during the entire follow up period with no statistically significant difference between group A and B. There is an increase in shoulder function during the entire follow up period based on the CS. Most interestingly, there is a statistically significant difference between group A and B at FU1, indicating a significantly better shoulder function for group B at the early follow up timepoint (FU1). At the later follow up timepoint (FU2), no difference exists in the individual items. However, a significantly better total CS remains in group B, indicating an overall improved function compared to group A. Discussion/ConclusionThe longitudinal split of subscapularis muscle is a safe approach which leads to quicker functional recovery and return to sports activity compared to the vertical tenotomy, which is a benefit especially for active individuals. It is therefore recommended as the standard surgical approach. Level of evidenceIII; Retrospective cohort study.

Return to sport following Latarjet glenoid reconstruction for anterior shoulder instability.

Latarjet coracoid transfer reconstruction is the gold standard for the treatment of recurrent shoulder instability with anterior-inferior glenoid bone loss, and return to sport is often a primary outcome of interest in this patient population. The purpose of this study was to determine the rate of return to sport in patients undergoing the Latarjet procedure and variables that are associated with a higher likelihood of a successful return to sport. A prospectively maintained institutional registry was retrospectively queried between August 2012 and August 2016 for all patients who underwent the Latarjet procedure. Patients were contacted electronically and via telephone to administer a previously validated and standardized return-to-sport survey. Patients self-reported return to sport, varying sports participation, recurrence of instability, and time to return to sport. Multivariate analysis was performed to determine variables associated with each outcome. Of 83 patients, 66 (75.3%) were available for final follow-up, of whom 60 participated in sports prior to surgery and were eligible for inclusion. The average follow-up period was 53.8 ± 11.8 months. The average age at surgery was 26.7 ± 11.3 years, and the average body mass index was 26.2 ± 4.0 kg/m2. There were 54 patients (90%) who were able to return to sport at an average of 8.6 ± 4.1 months following surgery. In total, 36 patients (60%) were able to return to sport at the same level or a better level of intensity, 19 of 28 patients (67.9%) were able to return to throwing sports without difficulty, and 31 of 60 patients (51.7%) reported that their shoulder was a hindrance to some activity. An increased likelihood of returning to sport was associated with increased body mass index (P = .016), male sex (P = .028), and decreased humeral bone loss volume (P = .034). An increased likelihood of returning to sport at the same level or a better level of intensity was associated with reduced humeral bone loss volume (P = .026). Recurrent instability was associated with humeral bone loss (P = .038). Although a large majority of patients were able to return to sport following the Latarjet procedure, some patients experienced limitation with throwing and return to sport at the preinjury level. Greater humeral bone loss was associated with inferior outcomes. These findings should be discussed with patients in the preoperative setting to manage expectations appropriately.

11% complications rate after Latarjet procedure at up to 14years follow-up.

Evaluate complications in correlation with radiological findings after an open Latarjet procedure performed on 140 shoulders with recurrent anterior instability with follow-up from 8 to 174months. Retrospectively, 140 shoulders, diagnosed with recurrent anterior glenohumeral instability, which were surgically treated with the open Latarjet procedure in our hospital, between January 2004 and November 2017, had been analysed. Mean age of operated patients was 29.5years. One hundred and twenty-three patients were male (88.5%) and 16 were female (11.5%). Average length of follow-up was 110months. Radiographs and CT scans of 16 patients with complications had been evaluated and correlations between radiological findings and observed complications had been analysed. Complications occurred in 16 shoulders (11%). Rates of individual complications were: 1. persistent pain (9%), 2. limited ROM (7%), 3. recurrent instability (6%), 4. neurologic injury (2%), 5. persistent apprehension (2%), 6. reduced strength (2%), 7. hematoma (1%) and 8. intraoperative coracoid graft fracture (0.8%). Mean postoperative ASES score and ROWE score were statistically significantly lower in the group with complications, compared to the group without complications. Good or excellent results were reported by 87.9% patients. Open Latarjet procedure is an effective and safe method for the treatment of recurrent shoulder instability, resulting in good to excellent outcomes in 87.9% of our cases. However, it is related to a higher postoperative complication rate compared to some other treatment options. Overall, very good results with high level of patient satisfaction have been demonstrated.

A New Guide for the Arthroscopically Assisted Latarjet Procedure.

Background:The Latarjet procedure is a commonly used treatment for recurrent shoulder instability. However, its neurological complication rate has been reported to be as high as 10%. During the Latarjet procedure, the neurovascular structures are relocated inferiorly and medially. I hypothesized that the risk of nerve injury would be reduced by assisting the inferior-medial relocation of the neurovascular structures intraoperatively.Methods:Seventeen consecutive patients with shoulder instability accompanied by glenoid bone loss were treated with an all-arthroscopic Latarjet procedure assisted by the novel low-profile SaSumata (SS) guide. The SS guide is inserted through a portal made above the coracoid process and is attached to the coracoid process by 2 pre-fix screws (i.e., temporary pre-fixation screws). Unlike previous techniques, the SS guide is not shuttled from 1 portal to the other to redirect the bone graft from the donor site to the recipient site; instead, it remains attached to the graft throughout the procedure. The SS guide brings the coracoid graft along an inferior-medial trajectory, pushing aside the neurovascular structures with the help of a switching stick. Owing to its semicircular pronged head, the SS guide holds the graft until the pre-fix screws are exchanged with permanent screws. All patients were clinically assessed and underwent computed tomography (CT) scans.Results:This maneuver was performed arthroscopically in 17 patients, with no conversion to open surgery and no neurological injuries. No patient had recurrence of dislocation after follow-up for a minimum of 24 months. The mean Subjective Shoulder Value was 87.5% ± 11.7%. The mean Rowe score was 88 ± 15.7. The bone block was optimally positioned between 3 o’clock and 5 o’clock and was flush with the glenoid facet in 16 of the 17 patients. There was 1 fracture of the bone block. The mean operation time after the first 5 patients was 125 ± 23 minutes.Conclusions:The SS guide was a useful tool for performing the arthroscopically assisted Latarjet procedure for recurrent anterior shoulder instability, with good functional results.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcome of biceps suspensionplasty for recurrent multidirectional shoulder instability

IntroductionRecurrent multidirectional shoulder instability after failed capsular repair/plication, is a challenging treatment problem. The long head of the biceps has been identified as a structure that may be utilized as a checkrein to stop abnormal anterior and inferior translation of the humeral head. The purpose of this study is to analyse the outcomes of biceps suspensionplasty (BS) in the treatment of recurrent shoulder instability. MethodsA retrospective review identified patients with recurrent multidirectional instability that underwent BS as part of a revision shoulder stabilization procedure. Clinical records were reviewed for demographics, pain, complications, recurrent instability, reoperations, and range of motion. Patients were also administered ASES/SST/SANE/Rowe and Oxford instability questionnaire at minimum of 2-year clinical follow-up. ResultsFive patients (7 shoulders) were included with a mean follow-up of 3.2 years (2–7 years). Patients had an average of 1.6 prior procedures (1–3). Average patient age was 24.2 years (18.7–32.4 years) and all were female. Four shoulders were treated open while 3 were treated arthroscopically with a capsular shift and biceps suspension. Four shoulders also underwent capsular reconstruction with allograft. At final follow-up three shoulders had recurrent inferior subluxation, although all patients considered their shoulders to be much better (4) or somewhat better (3) and none have undergone repeat surgery. ConclusionIn our series of patients, we found BS may be useful as an adjunct to a revision capsular shift or reconstruction. While 42.8% of patients experienced recurrent subluxations, this high-risk population demonstrated encouraging subjective results and avoiding joint arthrodesis in the short-term.

Surgical treatment for recurrent shoulder instability: factors influencing surgeon decision making

The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability. A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included(1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures. Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48% <10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure. The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

Are the Classic and the Congruent Arc Latarjet Procedures Equally Effective for the Treatment of Recurrent Shoulder Instability in Athletes?

Background: There is a lack of evidence in the literature comparing outcomes between the classic and the congruent arc Latarjet procedures in athletes. Purpose: To compare return to sports, functional outcomes, and complications between the classic and the congruent arc Latarjet procedures in athletes with recurrent glenohumeral instability. Study Design: Cohort study; Level of evidence, 3. Methods: Between June 2009 and June 2017, 145 athletes with recurrent anterior glenohumeral instability underwent surgery with the Latarjet as a primary procedure in our institution. The classic procedure was used in 66 patients, and the congruent arc method was used in 79 patients. Return to sports, range of motion (ROM), the Rowe score, a visual analog scale (VAS) for pain in sports activity, and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Recurrences were also evaluated. The postoperative bone block position and consolidation were assessed with computed tomography. Results: In the total population, the mean follow-up was 41.3 months (range, 24-90 months) and the mean age was 25.3 years (range, 18-45 years). In total, 90% of patients were able to return to sports; of these, 91% returned at their preinjury level of play. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe, VAS, and ASOSS scores showed statistical improvement after operation (P < .001). The Rowe score increased from a preoperative mean of 42.8 points to a postoperative mean of 95.2 points (P < .01). Subjective pain during sports improved from 3.2 points preoperatively to 0.7 points at last follow-up (P < .01). The ASOSS score improved significantly from a preoperative mean of 46.4 points to a postoperative mean of 88.4 points (P < .01). No significant differences in shoulder ROM and functional scores were found between patients who received the classic vs congruent arc procedures. There were 5 recurrences (3.5%): 3 dislocations (2%) and 2 subluxations (1%). No significant difference in the recurrence rate was noted between groups. The bone block healed in 134 cases (92%). Conclusion: In athletes with recurrent anterior glenohumeral instability, the Latarjet procedure produced excellent functional outcomes. Most athletes returned to sports at their preinjury level, and the rate of recurrence was very low, regardless of whether the patients received surgery with the classic or congruent arc technique.

Open Distal Tibial Allograft Augmentation

Isolated soft tissue stabilization procedures for treatment of recurrent shoulder instability are often not appropriate when the patient demonstrates bone loss of greater than 15% and in situations where there is recurrent instability after multiple attempts at arthroscopic stabilization. Current techniques for glenoid reconstruction include autografts with coracoid transfers, both Latarjet and Bristow techniques, autografts from the iliac crest, and allografts. Recent focus is on the use of distal tibial allografts for glenoid reconstruction. Distal tibial allografts provide a nearly identical radius of curvature to the glenoid with the addition of a thick cartilaginous surface that helps to restore the natural arc of the glenoid, ultimately leading to improved contact pressures by increasing the contact area. Additionally, these grafts are readily available and offer exceptional bone strength for fixation with a screw. This article discusses the surgical technique of distal tibial allograft augmentation for recurrent shoulder instability as well as the pre- and postoperative management of these patients.

It’s Not All About Redislocation: A Systematic Review of Complications After Anterior Shoulder Stabilization Surgery

Background: The surgical treatment of recurrent shoulder instability has evolved in recent years to include a variety of soft tissue and bone block procedures, undertaken with either an open or arthroscopic approach. Although the utilization of such techniques has rapidly expanded, the associated risk of complications remains poorly defined. This information is vital for clinical decision making and patient counseling. Purpose: To quantify the complication rate associated with all types of surgery for anterior glenohumeral joint dislocation. Study Design: Systematic review. Methods: A systematic search was undertaken of studies reporting complications from anterior shoulder stabilization surgery. Inclusion criteria were studies published in English between 2000 and 2017 with a minimum 2-year follow-up. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies criteria. Complication rates for all undesirable events contributing to the patient outcome were extracted and cumulative rates calculated. Results: Out of 1942 references, 56 studies were included, totaling 4362 procedures among 4336 patients. Arthroscopic soft tissue repair had a complication rate of 1.6% (n = 2805). When repair was combined with arthroscopic remplissage, the rate was 0.5% (n = 219). Open soft tissue repair had a complication rate of 6.2% (n = 219) and open labral repair with remplissage, a rate of 2.3% (n = 79). An open bone block procedure had a complication rate of 7.2% (n = 573) and an arthroscopic bone block procedure, a rate of 13.6% (n = 163). Conclusion: This large systematic review demonstrates the overall complication rates (not purely recurrence rates) in modern shoulder stabilization surgery. With the growing interest in bone block stabilization procedures, including those performed arthroscopically, surgeons should be aware of the 10-fold increase in complications for these procedures over soft tissue arthroscopic surgery and counsel their patients accordingly.

Return to Play After Shoulder Instability Surgery in National Collegiate Athletic Association Division I Intercollegiate Football Athletes

Background: Recent attention has focused on the optimal surgical treatment for recurrent shoulder instability in young athletes. Collision athletes are at a higher risk for recurrent instability after surgery. Purpose: To evaluate variables affecting return-to-play (RTP) rates in Division I intercollegiate football athletes after shoulder instability surgery. Study Design: Case series; Level of evidence, 4. Methods: Invitations to participate were made to select sports medicine programs that care for athletes in Division I football conferences (Pac-12 Conference, Southeastern Conference [SEC], Atlantic Coast Conference [ACC]). After gaining institutional review board approval, 7 programs qualified and participated. Data on direction of instability, type of surgery, time to resume participation, and quality and level of play before and after surgery were collected. Results: There were 168 of 177 procedures that were arthroscopic surgery, with a mean 3.3-year follow-up. Overall, 85.4% of players who underwent arthroscopic surgery without concomitant procedures returned to play. Moreover, 15.6% of athletes who returned to play sustained subsequent shoulder injuries, and 10.3% sustained recurrent instability, resulting in reduction/revision surgery. No differences were noted in RTP rates in athletes who underwent anterior labral repair (82.4%), posterior labral repair (92.9%), combined anterior-posterior repair (84.8%; P = .2945), or open repair (88.9%; P = .9362). Also, 93.3% of starters, 95.4% of utilized players, and 75.7% of rarely used players returned to play. The percentage of games played before the injury was 49.9% and rose to 71.5% after surgery (P < .0001). Athletes who played in a higher percentage of games before the injury were more likely to return to play; 91% of athletes who were starters before the injury returned as starters after surgery. Scholarship status significantly correlated with RTP after surgery (P = .0003). Conclusion: The majority of surgical interventions were isolated arthroscopic stabilization procedures, with no statistically significant difference in RTP rates when concomitant arthroscopic procedures or open stabilization procedures were performed. Athletes who returned to play often played in a higher percentage of games after surgery than before the injury, and many played at the same or a higher level after surgery.

Shoulder instability: State of the Art

The mobility of the glenohumeral joint in multiple anatomic planes is not without consequence as recurrent instability is common, particularly among young, active individuals. Throughout midranges of shoulder motion, stability is conferred primarily by the compression-cavity effect of the rotator cuff as muscular contractions maintain the humeral head centred in the glenoid cavity. At extremes of shoulder motion (flexion and abduction), derangements of capsule-ligamentous complex, glenoid and glenoid labrum drive a pathophysiological cascade that manifests clinically as recurrent anterior, unidirectional instability. In the setting of bone loss <25% of the inferior glenoid diameter, arthroscopic Bankart repair using proper technique yields reliable clinical results. Additionally, much is now known about the extent to which attritional glenoid bone loss, related commonly to repeated dislocation events, affects the predicted success of certain treatment approaches. The preponderance of existing literature supports performing a bone grafting procedure for cases in which the osseous defect comprises >25% of the glenoid width, with the Latarjet procedure being favoured among recent authors. A growing body of evidence has elucidated the consequence of humeral head defects (the Hill-Sachs lesion) as a predictor of recurrent instability. Thus, the concept of ‘bipolar bone loss’ has emerged as a critical concept in the surgical treatment of recurrent shoulder instability. Surgeons should adopt a treatment paradigm that focuses on the relationship between both osseous defects—glenoid and humeral head—and incorporates a surgical tactic to appropriately address each lesion.

The J-Shaped Bone Graft for Anatomic Glenoid Reconstruction

Background: The J-shaped bone graft procedure is one of the recommended methods to reconstruct significant glenoid rim defects. Purpose: To evaluate long-term (minimum 10-year) clinical outcomes and show further details of the remodeling effects on the articular cavity of the glenoid after J-shaped bone grafting. Study Design: Case series; Level of evidence, 4. Methods: A total of 14 patients treated with a J-shaped bone graft procedure were observed clinically. Additionally, bilateral preoperative and postoperative follow-up computed tomography (CT) scans were used for CT-osteoabsorptiometry (OAM) to evaluate the bony remodeling processes. Results: The follow-up rate was 93% at a mean follow-up time of 10.7 years (range, 10.08-11.75 years). Patients exhibited a mean Constant score of 92.5 (range, 80-100) on the clinical evaluation. All patients had free range of motion and were pain free without any recurrence of instability. Based on CT-OAM, comparable and almost anatomically reconstructed, bilaterally equal glenoid cavities were found postoperatively. The distribution patterns of glenoid subchondral mineralization were bilaterally equal in 85.7% of the patients. Conclusion: The surgical treatment of recurrent shoulder instability with a significant bony Bankart lesion using the J-shaped bone graft procedure provided excellent long-term results. This study lends evidence to support the capability of the J-shaped bone graft procedure to restore the normal glenoid shape due to physiological remodeling processes.

Constrained fixed-fulcrum reverse shoulder arthroplasty improves functional outcome in epileptic patients with recurrent shoulder instability.

To report the results of fixed-fulcrum fully constrained reverse shoulder arthroplasty for the treatment of recurrent shoulder instability in patients with epilepsy. A retrospective review was conducted at a single facility. Cases were identified using a computerized database and all clinic notes and operative reports were reviewed. All patients with epilepsy and recurrent shoulder instability were included for study. Between July 2003 and August 2011 five shoulders in five consecutive patients with epilepsy underwent fixed-fulcrum fully constrained reverse shoulder arthroplasty for recurrent anterior shoulder instability. The mean duration of epilepsy in the cohort was 21 years (range, 5-51) and all patients suffered from grand mal seizures. Mean age at the time of surgery was 47 years (range, 32-64). The cohort consisted of four males and one female. Mean follow-up was 4.7 years (range, 4.3-5 years). There were no further episodes of instability, and no further stabilisation or revision procedures were performed. The mean Oxford shoulder instability score improved from 8 preoperatively (range, 5-15) to 30 postoperatively (range, 16-37) (P = 0.015) and the mean subjective shoulder value improved from 20 (range, 0-50) preoperatively to 60 (range, 50-70) postoperatively (P = 0.016). Mean active forward elevation improved from 71° preoperatively (range, 45°-130°) to 100° postoperatively (range, 80°-90°) and mean active external rotation improved from 15° preoperatively (range, 0°-30°) to 40° (20°-70°) postoperatively. No cases of scapular notching or loosening were noted. Fixed-fulcrum fully constrained reverse shoulder arthroplasty should be considered for the treatment of recurrent shoulder instability in patients with epilepsy.