Treatment Of Shoulder Instability Research Articles

The Shoulder Instability: An Overview

AbstractInstability of the shoulder joint is common but most of the time it is unrecognized by the treating surgeon. The symptoms can vary from subtle pain to shoulder dislocation. In many cases, there is no history of trauma. The shoulder joint is stabilized by both static and dynamic factors, and treatment is complex, with recurrence more common in young athletic individuals. Open and arthroscopic techniques of stabilization are available with specific indications for each of these methods. In this narrative review of shoulder instability, we describe the pathological anatomy, evaluation, natural history, classification, and treatment of shoulder instability.

Recurrence and return to sport after surgery for shoulder instability: arthroscopic Bankart versus Latarjet procedure.

BackgroundSurgeons differ in their preferences concerning the best surgical technique for treating shoulder instability in sportspeople. The purpose was to evaluate the risk of recurrence and the likelihood of return to sport for the 2 principal shoulder stabilization techniques used to treat shoulder instability in sportspeople.MethodsWe screened sportspeople who had undergone shoulder stabilization for inclusion in this cohort study. For eligibility, patients had to have undergone surgery by one of the 2 techniques: Latarjet or arthroscopic Bankart between 2005 and 2011, and aged from 18 to 35 years. We excluded acromioclavicular dislocation, tendinous lesion, global or posterior instability, bone fracture or severe glenoid bone loss, neurological lesion, other surgical technique, and orthopedic treatment. Patients were contacted by telephone between 2009 and 2012 and asked to participate in follow-up after surgery. The primary endpoint was recurrence, evaluated by determining frequency and time to recurrence (or censoring) with Cox models. The secondary endpoint was the return to sport (training and competition).ResultsFollow-up telephone interviews were conducted with 120 sportspeople (response rate of 61.5%), one of whom was excluded due to the occurrence of a new contralateral dislocation before returning to sport after surgery (Latarjet n = 80, Bankart n = 39). The risk of recurrence was significantly higher (P < .001) for Bankart (n = 7, 17.9%) than for Latarjet (n = 2, 2.5%) interventions. Being under the age of 20 years was a significant risk factor for recurrence (P = .007). Return to sport was significantly more frequent among sportspeople undergoing Latarjet procedures, for both training (P = .031) and competition (P = .038), and was also significantly more rapid for training (P = .034) with a mean time to return to training of 5.1 months for Latarjet procedures, versus 6.4 months for Bankart procedures.ConclusionThe Latarjet surgical technique results in fewer recurrences than the Bankart technique, with a higher rate of return to sport (training, competition) and a faster return to training for sportspeople practicing potentially risky sports in competition. Age was also identified as an additional risk factor for recurrence. It is important to take these factors into account when considering the indications for surgery.

Glenoid concavity has a higher impact on shoulder stability than the size of a bony defect

PurposeSurgical treatment of shoulder instability caused by anterior glenoid bone loss is based on a critical threshold of the defect size. Recent studies indicate that the glenoid concavity is essential for glenohumeral stability. However, biomechanical proof of this principle is lacking. The aim of this study was to evaluate whether glenoid concavity allows a more precise assessment of glenohumeral stability than the defect size alone.MethodsThe stability ratio (SR) is a biomechanical estimate of glenohumeral stability. It is defined as the maximum dislocating force the joint can resist related to a medial compression force. This ratio was determined for 17 human cadaveric glenoids in a robotic test setup depending on osteochondral concavity and anterior defect size. Bony defects were created gradually, and a 3D measuring arm was used for morphometric measurements. The influence of defect size and concavity on the SR was examined using linear models. In addition, the morphometrical-based bony shoulder stability ratio (BSSR) was evaluated to prove its suitability for estimation of glenohumeral stability independent of defect size.ResultsGlenoid concavity is a significant predictor for the SR, while the defect size provides minor informative value. The linear model featured a high goodness of fit with a determination coefficient of R2 = 0.98, indicating that 98% of the SR is predictable by concavity and defect size. The low mean squared error (MSE) of 4.2% proved a precise estimation of the SR. Defect size as an exclusive predictor in the linear model reduced R2 to 0.9 and increased the MSE to 25.7%. Furthermore, the loss of SR with increasing defect size was shown to be significantly dependent on the initial concavity. The BSSR as a single predictor for glenohumeral stability led to highest precision with MSE = 3.4%.ConclusionGlenoid concavity is a crucial factor for the SR. Independent of the defect size, the computable BSSR is a precise biomechanical estimate of the measured SR. The inclusion of glenoid concavity has the potential to influence clinical decision-making for an improved and personalised treatment of glenohumeral instability with anterior glenoid bone loss.

Open Trillat Procedure for Recurrent Anterior Instability of the Shoulder in Elderly Patients

Among the many different procedures available in the treatment of shoulder instability, the Trillat procedure remains indicated in case of recurrent shoulder instability in elderly patient with an irreparable cuff tear or in case of hyperlaxity. Despite the constantly increasing number of arthroscopic assisted techniques, the open procedure remains a simple, reliable and fast surgical procedure with a shorter learning curve than the arthroscopic techniques. It consists in a partial osteotomy of the anterior cortical of the coracoid process which is then tilted and fixed with a screw into the anterior part of the scapula downwards and medially to obtain a re-centering effect due to the conjoint tendon on the humeral head when rotational movement are applied. This article aims to present a stepwise approach for the open surgical technique.

Evolving Concepts in the Management of Shoulder Instability.

Shoulder instability exists on a spectrum ranging from subtle subluxation and pain to dislocation and can be the result of a traumatic event or repetitive microtrauma. Shoulder instability can result in significant disability and often requires surgical intervention, especially amongst younger, active patient populations. The optimal treatment of shoulder instability depends on the degree of instability and concomitant pathology involving the labrum, capsule, and bony anatomy of the glenoid and humeral head. Even with surgical intervention, recurrent instability remains a relatively common and difficult problem to address. With a focus on anterior instability, the purpose of this review article is to discuss the current assessment and treatment of shoulder instability, and highlight current and future treatment modalities, as well as to identify current trends and deficiencies in our current management. We also provide an algorithm for the surgical treatment of anterior shoulder instability. Literature databases were extensively searched for recent articles related to the mechanism, diagnosis, and treatment of shoulder instability to comprise a comprehensive review. Although there are multiple treatment modalities available for shoulder instability, such as nonoperative management, open and arthroscopic Bankart repair, Latarjet procedures, and remplissage, orthopaedic surgeons continue to learn about the most appropriate method of management as increasing long-term outcomes become available.

State of the art for treatment of bony defects around anterior shoulder instability—the American perspective

AbstractWhile arthroscopic Bankart repair yields high success rates, bone loss on the glenoid or humeral head can portend a poor outcome. The authors recommend a thorough evaluation including computed tomography (CT) scanning to best evaluate the amount of bone loss. Multiple studies have shown that the outcomes of revision stabilization procedures are inferior to the respective primary procedure; thus, it is of paramount importance to select the correct index procedure to optimize patient outcome. The authors present the American perspective on treating shoulder instability. For patients with a small on-track Hill Sachs lesion and less than 10 % glenoid bone loss, an isolated arthroscopic Bankart repair is appropriate. This procedure is also recommended for bony Bankart lesions, as well as in overhead throwing athletes. With an engaging Hill Sachs lesion and less than 15 % glenoid bone loss, the authors recommend the addition of a remplissage to the arthroscopic Bankart repair. For patients with up to 15 % bone loss or following a failed previous arthroscopic repair, the authors advocate for open Bankart repair. They recommend Latarjet in patients with a non-engaging Hill Sachs lesion greater than 15 % bone loss. Patients with bone loss over 30 % would benefit from bone grafting with iliac crest autograft or distal tibia allograft for stabilization. In summary, the authors believe that the index procedure provides an opportunity to optimize patient outcome and careful consideration of the treatment options is warranted.

Postoperative Rehabilitation and Return to Play Criteria After Anterior Shoulder Stabilization Procedures

Anterior shoulder stabilization surgery is the preferred method to treat shoulder instability in athletes; however, a variety of surgical techniques exist. The rehabilitation specialist needs to have a basic understanding of each procedure to properly protect healing structures while restoring range of motion, strength, and functional abilities. Few evidence-based guidelines exist for rehabilitation after anterior shoulder stabilization, and those that are available are specific to the standard arthroscopic approach. Further, even less guidance is available for the later stages of rehabilitation and return to sports preparation and decision making. In this review article, rehabilitation considerations and alterations for variations of anterior shoulder stabilization surgery are presented. The importance of individualizing late-stage rehabilitation and incorporating core and lower extremity exercises as appropriate is also discussed. Lastly, rationale for criteria-based return to sports assessments to aid clinical decision making is presented.

Shoulder instability: review of current concepts of diagnosis and treatment

To conduct a systematic review of modern literature data on the modern approaches in diagnosis and treatment of shoulder instability. Searching for literature data was performed using the Pubmed and Google Scholar databases. The authors analyzed the results of conservative treatment of patients with shoulder instability and emphasized higher risk of instability recurrence, degeneration of anatomical structures and functional impairment in these patients. Surgery is advisable to restore shoulder stability and normalize its function. Several methods for stabilizing the shoulder have been proposed. Successful treatment of shoulder instability is based on qualitative and complete assessment of soft tissues and bone structures. An individual approach considering bone tissue deficiency and individual needs of the patient is required.

Arthroscopic Treatment for Shoulder Instability with Posterior Glenoid Bone Loss Using Allograft

Several anatomical features contribute to posterior shoulder instability. Isolated soft tissue procedures in the presence of a significant glenoid bony pathology can result in high recurrence rates. The recognition of glenoid bone loss is essential for the success of the chosen treatment. The primary objective is to generate a safety profile for posterior anatomic glenoid reconstruction. The secondary objective is to evaluate the clinical trends and radiological outcomes of patients who underwent this procedure. To our knowledge, there are no clinical papers on this topic to this date. This study is a retrospective review of medical charts and diagnostic images of subjects who had posterior shoulder instability with glenoid bone loss and underwent posterior anatomic glenoid reconstruction by one surgeon (IW). Data was collected from pre and post-operative evaluations. This included an assessment by the Western Ontario Shoulder Instability (WOSI) index, as well as the pre-operative and post-operative imaging. This cohort of patients consisted of nine subjects with a mean age of 33.26 ± 9.94 years at a minimum follow-up of two years. There were no intra-operative or post-operative complications. All subjects had a stable shoulder at the latest follow-up. The overall mean pre-operative and post-operative WOSI scores (± SD) at the most recent follow-up were 72.60 ± 14.98 and 18.86 ± 16.77, respectively (p<0.05). The average AP dimension of the glenoid with graft at the most recent CT follow-up was 29.78 ± 3.49 mm. All patients demonstrated graft healing, and the grafts were shown to be placed in an excellent position. Of the nine patients, two did not demonstrate resorption, six demonstrated grade 1 resorption, and one demonstrated grade 2 resorption. The average screw alpha angle was 15.8 ± 4.6. Arthroscopic posterior shoulder stabilization with distal tibia allograft reconstruction demonstrates promising clinical, functional and radiographic results with an excellent safety profile. However, further investigations are required to obtain the longevity of the positive outcomes.

Are there racial differences between patients undergoing surgery for shoulder instability? Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Group

The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability. Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient's home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery. Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%. We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.

Comprehensive Arthroscopic Shoulder Stabilization in the Lateral Decubitus Position

Arthroscopic shoulder stabilization offers a safe and effective means for restoring glenohumeral mechanics in the setting of shoulder instability. Modern arthroscopic techniques have allowed improved access and efficiency when treating patients with shoulder instability. However, access to certain areas of the labrum and the creation of safe accessory portals can still prove difficult for the arthroscopic surgeon. Currently, there is debate as to the ideal patient position, portal location, equipment, and technique for addressing anterior–inferior labral pathology. The following article presents a safe and effective approach to accessing the labrum for treatment of shoulder instability in the lateral decubitus position. In addition, this paper highlights the use of accessory portals, including a percutaneous “7-o’clock” portal for suture anchor placement, along with multiple types of suture anchor and suture shuttling techniques.

Incidence and Risk Factors of the Complications Related to the Latarjet Surgery.

Objective The Latarjet procedure is a well-accepted treatment of shoulder instability. This technique is associated with a unique set of complications with overall rates of up to 30%. The purpose of the present study was to investigate the incidence and risk factors associated with complications after open Latarjet procedure. Methods We retrospectively reviewed 102 patients submitted to open Latarjet procedure. Complications were divided into three types: clinical; graft-related; and screw-related. All of the patients were submitted to radiography and computed tomography (CT). The risk factors analyzed were gender, age, previous surgery, epilepsy, experience of the surgeon. Results A total of 102 consecutive patients (108 cases) underwent the Latarjet procedure. The mean age was 33.7 years old (18 to 61 years old), with 88 males and 14 females. The overall complication rate was 21.2%, being 12% clinical-related, 7.4% graft-related, and 2.7% screw-related. The most frequent were anterior apprehension (eight cases) and lateral overhang of the graft in six patients. Computed tomography scan at a minimum of 6 months was performed in 79 cases (73%), and graft union occurred in 75 patients (94.9%). There were no cases of instability in the remaining four cases of nonunion. Ten patients (9.2%) required revision surgery. The risk factors associated with complications were epilepsy ( p = 0.0325), experience of the surgeon ( p = 0.0499) and patients ≥ 40 years old at the time of the surgery ( p = 0.0151). There was no correlation with gender and previous surgery. Conclusion The complication rate following the Latarjet procedure was 21.2%, with 9% requiring revision surgery. Epilepsy, age > 40 years old and experience of the surgeon were risk factors.

Arthroscopic Bankart Repair With Remplissage: Indications and Technique

Summary: Recurrent anterior shoulder instability can be challenging to treat especially in young active patients. The full spectrum of pathology present should be addressed during surgical stabilization and includes soft tissue and bone defects of both the glenoid and humeral head when present. Remplissage is an additional procedure, along with arthroscopic Bankart repair, that may be performed in the presence of a Hill Sachs defect to prevent humeral head engagement on the glenoid during abduction and external rotation. Our objective was to present the indications for and our preferred technique of arthroscopic bankart repair with remplissage for the treatment of shoulder instability with the presence of a Hill Sachs defect. In conclusion, arthroscopic Bankart repair combined with remplissage is a viable treatment option for anterior shoulder instability associated with a large engaging Hill Sachs defect and minimal to no glenoid bone loss.

Arthroscopic Reduction and Stable Fixation of an Anterior Glenoid Fracture With 4 Buttons

An arthroscopic technique for the reduction and stable fixation of an articular glenoid fracture with a 2-button compression system, originally designed for the treatment of shoulder instability with bone deficiency in the anterior glenoid, is presented. This technique allows direct visualization of the joint, reduction of the fracture, precise placement of the buttons according to the fracture line, and stable fixation. It is a safe and reproducible technique, using the standard shoulder arthroscopy portals.

Single Assessment Numeric Evaluation for instability as an alternative to the Rowe score

Several functional outcome scores have been proposed for the evaluation of shoulder instability. Most are multiple-item questionnaires, which can be time-consuming and difficult for patients to understand, as well as leading to lack of compliance. The Single Assessment Numeric Evaluation (SANE) score is a single question that has recently gained widespread acceptance based on its simplicity and correlation with more complex scoring systems. The purpose of this study was to assess the correlation of a new modified version of the SANE score, the SANE-instability score, with the Rowe score after treatment for shoulder instability. We prospectively evaluated a consecutive series of 253 patients (268 shoulders) treated surgically or nonoperatively for shoulder instability between November 2017 and November 2019, for whom the Rowe and SANE-instability scores were collected before treatment and/or after treatment. The SANE-instability score was assessed with the following question: "What is the overall percent value of your shoulder if a completely stable shoulder represents 100%?"Correlations were tested using the Pearsoncoefficient (r) and interpreted as very high (r = 0.90-1.00), high (r = 0.70-0.89), moderate (r = 0.50-0.69), low (r = 0.30-0.49), or negligible (r = 0.00-0.29). Subgroup analyses were also performed to observe correlation variations according to follow-up length (before treatment and at 6, 12, 26, 52, and 104 weeks after treatment), patient age (<20, 20-29, 30-39, or ≥40 years), and type of treatment (nonoperative or surgical). The overall correlation between the SANE-instability and Rowe scores was high (r = 0.85, P < .001). Subgroup analyses revealed that the correlation between the 2 scores was high before treatment (r = 0.74); moderate at 6 and 12 weeks after treatment (r = 0.66 and r = 0.57, respectively); and then high at 26, 52, and 104 weeks after treatment (r = 0.75, r = 0.75, and r = 0.78, respectively) (P < .001). The correlation was high across all types of treatment (r = 0.76-0.85), high for patients aged ≥ 20 years (r = 0.80-0.86), and very high for patients aged < 20 years (r = 0.93) (P < .001). This study demonstrated a significant correlation between the SANE-instability and Rowe scores before and after treatment, as well as across all patient age groups and treatments. Owing to its high simplicity, the SANE-instability score could be used as an alternative to the Rowe score for patient follow-up at various time points.

Reconstruction of the Coracoacromial Ligament during a Modified Latarjet Procedure for the Treatment of Shoulder Instability: Clinical Outcome at Minimum 5 Years Follow-Up.

The function of the coracoacromial ligament (CAL) in superior shoulder stability has been well established, and the release of the CAL with the Latarjet procedure leads to increased superior humeral translation. A surgical technique was developed recently to reconstruct the CAL during a modified Latarjet procedure, and the clinical outcome of this technique at medium-term follow-up is yet to be determined. Twenty-six patients with chronic post-traumatic anterior shoulder instability were included in this retrospective case-control study. Patients in group 1 (n = 12) were surgically treated with the classic congruent-arc Latarjet, where the CAL is sacrificed. In group 2 (n = 14), the CAL was reconstructed using a pectoralis minor fascia flap (PMFF). Primary outcomes were the return to sports activity and functional assessment based on the Western Ontario Shoulder Instability Index (WOSI) and the Constant Score (CS) at minimum 5 years follow-up. Patient's demographics, sport activities, duration of surgery, the rate of recurrent dislocations, and specific complications related to the surgical technique were recorded as secondary variables. There was a decrease of the WOSI in both groups, indicating a decrease of symptoms at follow-up compared to the preoperative level. There was no statistically significant difference between groups 1 and 2 for the total WOSI as well as for all subscales. There was an increase of the CS in both groups in all four items at follow-up compared to preoperatively, indicating an increase in shoulder function at follow-up. There was a statistically significant difference between groups 1 and 2 for the total CS, as well as for the items power, mobility, and activity, but not for pain. Most patients (n = 20) returned to their preoperative sports activity, 13 at the same level. However, seven patients who used to perform their sports competitively chose to perform their activity at a noncompetitive level after the Latarjet procedure. All were younger than 35 years of age. Six patients did not return to their preoperative sports activity. All except one were over 35 years of age. The duration of surgery ranged from 75 to 125 minutes with a mean ± SD of 94.23 ± 15.06 minutes for both groups with no significant difference between the groups (p = 0.117). None of the patients had intra- or postoperative complications related to the surgical procedure. Especially, no patient had recurrent dislocations of the affected shoulder following the Latarjet procedure. The use of a PMFF is a safe technique for reconstruction of the CAL, which does not result in a longer surgery time or higher rate of complications. The reconstruction of the CAL during the modified Latarjet procedure may lead to better functional results in medium-term follow-up.

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.

Risk Factors for Intra-Articular Bone and Cartilage Lesions in Patients Undergoing Surgical Treatment for Posterior Instability

Objectives:Patients with posterior shoulder instability often present with significant differences in history of injury and complaints compared to anterior instability that can lead to challenges in diagnosis and treatment. These patients may have bone and cartilage lesions in addition to caspulolabral injuries, though the risk factors for these intra-articular lesions are unclear. The purpose of this study was to describe intraoperative incidence of glenohumeral bone and cartilage lesions in a cohort of patients undergoing primary posterior stabilization using data from a prospectively collected, multicenter shoulder instability cohort. We hypothesized that patients with traumatic posterior instability with greater number of instability events would have higher rate of bone and cartilage injuries compared to those without fewer instability episodes.Methods:Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group instability patient cohort was utilized for this study. This is a multi-center study encompassing a prospective evaluation of patients ages 12 to 99 years of age undergoing primary surgical treatment for shoulder instability by 24 orthopedic surgeons at 11 sites in the United States. Demographic data and specifics regarding the patient’s instability history were recorded, including patient age, sex, body mass index (BMI), history of smoking, and Beighton score. The number of instability events was classified as 0, 1, 2 to 5, or more than 5. The duration of symptoms was classified as <1 month, 1-3 months, 4-6 months, 7-12 months, or greater than 1 year. The glenohumeral joint was evaluated by the treating surgeon at the time of surgical treatment for bone and cartilage injuries, and patients were classified as having a bone or cartilage lesion (BCL) if there was any grade 3 or 4 glenoid or humeral cartilage lesion, reverse Hill-Sachs lesion, bony Bankart lesion, or glenoid bone loss. The effects of number of instability events on the presence of BCLs was investigated using Fisher’s exact tests. Multivariate analysis using logistic regression modeling was performed to investigate the independent contributions of demographic variables and injury-specific variables to the likelihood of having a BCL. Significance was defined as p<0.05.Results:There were 271 patients identified for analysis. Bone and cartilage lesions were identified in 59 patients (21.8%) at the time of surgical treatment (Table 1). The most common lesion was a glenoid cartilage injury, which was identified in 28 patients (10.3%). Patients with BCLs were significantly older and had significantly higher BMI relative to patients without BCLs (Table 2). There was a significant difference between the number of instability events and the presence of BCLs (p = 0.035), with the highest rate observed in patients with 2-5 instability events (33.9%) (Figure 1). Through multivariate logistic regression modeling, increasing age (p=0.002), increasing BMI (p=0.012), and 2 to 5 reported instability events (p=0.001) were significant independent predictors of the presence of BCLs.Conclusion:Bone and cartilage lesions are seen significantly more frequently with increasing patient age, increasing BMI, and patients with 2-5 instability events. Early surgical stabilization for posterior instability may be considered to potentially limit the extent of associated intra-articular injury.Table 1.Frequency of Bone and Cartilage Lesions Identified in Patients Undergoing Primary Surgery for Posterior InstabilityIntra-Articular Lesion N % Glenoid cartilage injury*2810.3%Humeral cartilage injury*207.4%Reverse Hill-Sachs165.9%Glenoid bone loss114.1%Bony Bankart83.0%Any bone or cartilage lesion5921.8%*Indicates Outerbridge Grade 3 or 4 lesionsTable 2.Comparison of Patients With and Without Bone and Cartilage Lesions No Bone/Cartilage Lesion (N = 212) Bone/Cartilage Lesion (N = 59) Mean or N Standard Deviation or % Mean or N Standard Deviation or % P Value Age (Years)22.87.726.19.60.025Body Mass Index (kg/)26.34.628.65.20.0014Male Sex (N)17381.6%5084.8%0.70Smoker (N)73.3%46.8%0.26Hyperlax (Beighton >4)5224.5%915.3%0.16Pre-Operative Kerlan-Jobe Score49.321.842.418.30.094Pre-Operative WOSI Score43.618.438.917.70.11Pre-Operative SAS13.04.514.14.20.13WOSI: Western Ontario Shoulder Instability; SAS: Shoulder Activity ScoreFigure 1.

Arthroscopic Latarjet Procedure: A Technique Using Double Round ENDOBUTTONs and Specific Glenoid and Coracoid Guides

The Latarjet procedure is a method used for the treatment of shoulder instability in the presence of bone loss. A decade after the first description of the fully arthroscopic Latarjet procedure, modifications to the technique were reported to decrease the risk of complications and improve the position of the bone block. A recent trend toward the use of buttons to fix the coracoid has been reported. The technique described here is an arthroscopic Latarjet procedure that uses 2 pairs of round buttons as an alternative to screw fixation or the use of a single button, and the technique aims to combine the original procedure with safe and stable fixation.

Use of allograft to reconstruct anterior bony glenoid defect in chronic glenohumeral instability: a systematic review.

Bone-block procedures are well-established in anterior chronic shoulder instability treatment. Autograft with the coracoid process (Bristow-Latarjet procedures) and iliac crest (Eden-Hybbinette) are the most frequent source of bone but the use of allograft is also possible. The objective of this review is to assess clinical and radiographic outcomes after bony allograft reconstruction in anterior glenohumeral instability. Medline, Cochrane, Embase databases were searched for studies reporting on bone allograft reconstruction in anterior glenohumeral instability with glenoid defect. We conducted a systematic review of studies with all levels of evidence reporting on clinical or radiological outcomes or both. IV. Ten studies met the inclusion criteria for the review; 283 shoulders were included with a mean age of 26years (17-63) and mean follow-up of 34months (4-168). Glenoid reconstruction was performed using bone from different source: femoral head (1 study), distal tibia allograft (5 studies), and iliac crest (4 studies). Allografts were fresh in 4 studies, demineralized in 2 studies, and freeze-dried after sterilization in 1 study. All scores performed in the different studies increased between pre-operative and post-operative evaluations (mean + 36.8 points for the ASES). Global rate of recurrence was 3.9% (11 patients) (0-11%), comprising 6 cases of dislocation (2.1%) and 5 subluxations (1.8%). Allograft healing occurred in 93.5% of cases. This systematic review data suggest that allograft reconstructions in anterior glenohumeral instability could be a viable alternative to similar reconstructions with autografts and provide close clinical/radiological outcomes, at short and mid-term follow-up. Prospective randomized studies are needed to confirm these results.