Western Ontario Shoulder Instability Index Score Research Articles

Return to Play and Outcomes in Baseball Players After Superior Labral Anterior-Posterior Repairs

Background: Few studies have documented the outcomes of superior labral anterior-posterior (SLAP) repairs in baseball players. Furthermore, the results of these previous studies varied widely and were based on small numbers of patients. Hypothesis/Purpose: The purpose was to report return-to-play (RTP) rates and validated subjective outcome scores for baseball players after SLAP repair. It was hypothesized that RTP rates and outcomes would be significantly different between pitchers and nonpitchers, as well as among baseball levels. Study Design: Case series; Level of evidence, 4. Methods: A series of 216 baseball players was identified who had isolated SLAP repair or SLAP repair with debridement of partial-thickness (<25%) rotator cuff tear at our surgical centers. Patients were contacted by phone a minimum of 2 years after surgery and asked questions about their ability to RTP. Patients were also asked questions to complete the Western Ontario Shoulder Instability Index (WOSI), Veteran’s RAND 12-Item Health Survey (VR-12), and Kerlan-Jobe Orthopaedic Clinic (KJOC) questionnaires. Statistical equivalence in RTP rate, VR-12, and WOSI scores was determined between players with and without concomitant rotator cuff debridement using 2 one-sided tests and risk difference measures. Differences in RTP were tested among baseball levels (high school, college, professional) and positions (pitcher vs nonpitcher) using chi-square analyses (P < .05). Differences in outcomes scores were compared using t tests and analyses of variance (P < .05). Results: Of the 216 baseball players, 133 were reached by phone for follow-up interview (mean, 78 months; range, 27-146 months). Overall, 62% successfully returned to play. There were no differences in RTP rates or subjective outcomes among baseball levels or between procedures. RTP rates were 59% for pitchers and 76% for nonpitchers (P = .060). Subjectively, the percentage of patients who felt the same or better at follow-up compared to preinjury was significantly higher among nonpitchers (66%) than pitchers (43%). There was no difference in KJOC scores between the pitchers (75.3 ± 19.4) and nonpitchers (76.2 ± 17.4) who successfully returned to play, although these scores were well below the minimum desired score of 90 for healthy baseball players. Conclusion: SLAP repair should continue to be considered as an option for SLAP tear treatment only after nonsurgical management has failed. Some players may be able to return to baseball after SLAP repair, although regaining preinjury health and performance is challenging.

The Degree of Shoulder Involvement in Sports (DOSIS) scale is a valid and responsive instrumentation for shoulder assessment in patients after surgery for anterior instability.

The purpose of this study was to evaluate validity and responsiveness of the Degree of Shoulder Involvement in Sport (DOSIS) scale. A web-based survey was developed to test the construct validity of the DOSIS scale. Fifty-three patients with a median age of 33years (range 17-59) were included in the study. Convergent validity was evaluated by external correlation (Spearman's rank correlation coefficient, r) of the DOSIS with the Brophy-Marx and Tegner activity scales, the Western Ontario shoulder instability index (WOSI), the Simple Shoulder Test (SST), and the Short-Form 36 (SF-36). Responsiveness was analysed by relative efficiency calculation of the DOSIS versus the Brophy-Marx and Tegner activity scales. The DOSIS showed strong correlation with the Brophy-Marx and Tegner activity scales, a moderate correlation with the WOSI and SST scores, and a moderate correlation with the physical functioning, rolephysical and role emotional subscores of the SF-36. The distribution of the DOSIS scores had no serious ceiling or floor effects. The DOSIS demonstrated lesser responsiveness when compared to the Brophy-Marx and Tegner activity scales. The DOSIS showed an adequate validity and responsiveness. The clinical relevance of this study is that the DOSIS scale can be used for sport-specific shoulder assessment in patients after surgery for anterior instability. III.

Remplissage Versus Modified Latarjet For Off-Track Hill-Sachs Lesions With Subcritical Glenoid Bone Loss

Objectives:Off track Hill-Sachs lesions have been associated with high rate of recurrent shoulder instability. Both arthroscopic Bankart with Remplissage and modified Latarjet have been described to treat off-track Hill-Sachs lesions. However, few comparative studies exist between the two techniques in heterogeneous populations. The purpose of this study was to examine the outcome of the two procedures in patients with off-track Hill-Sachs lesions with subcritical (<25%) glenoid bone loss, both in the primary and revision setting.Methods:Arthroscopic Bankart with Remplissage was performed in thirty-one patients and modified Latarjet was performed in forty patients with recurrent anterior shoulder instability, off-track Hill-Sachs lesion, and less than 25% glenoid bone loss. Surgeries were performed at two centers. Patients were divided based on if they have had no previous surgical stabilization (Group A) or if they have had one or more previous surgical stabilization (Group B). The mean follow up time was four years. Patients were assessed for their risk of recurrence using the Instability Severity Index score and had preoperative 3-dimensional imaging to assess humeral and glenoid bone loss. Single Assessment Numeric Evaluation (SANE), Western Ontario Shoulder Instability Index (WOSI), radiographs, range of motion, recurrence rate, subsequent procedures and complications were analyzed.Results:In the thirty-two patients of group A, seventeen had remplissage and fifteen had Latarjet performed. Within group A, there were no difference found between the two techniques in regards to SANE, WOSI, range of motion (p>0.35). There were no complications, recurrence or revision with both techniques in group A. In the thirty-nine patients of group B, fourteen had remplissage and twenty-five had Latarjet performed. In group B, the reoperation surgery rate was significantly higher in the remplissage group (36% vs 8%, p=0.044). The reoperation was performed predominately for pain in patients with remplissage and for recurrent instability with Latarjet. Recurrence instability rate were similar between the remplissage and Latarjet group (14% vs 8%, p=0.45). The WOSI score was similar between the remplissage and Latarjet group (405 vs 461, p=0.66). The complication rate was also similar (36% vs 40%, p=1).Conclusion:For off-track Hill-Sachs lesions with subcritical glenoid bone loss, both the remplissage and modified Latarjet can achieve excellent clinical results in the primary setting (no previous instability surgery). However, in the revision setting (one or more previous instability surgery), patients with remplissage may have a higher reoperation rate.

Outcomes of Latarjet versus Distal Tibial Allograft for Anterior Shoulder Instability Repair: A Prospective Matched Cohort Analysis

Objectives:Recently, the use of fresh distal tibia allograft (DTA) for glenoid reconstruction in anterior shoulder instability has been described, with encouraging short-term outcomes, however, there is little available comparative data to the Latarjet procedure, long considered the gold standard for bone loss treatment. Thus, the purpose of this study was to determine the clinical outcomes for patients undergoing DTA compared to a matched cohort of patients undergoing Latarjet.Methods:A review of prospectively collected data of patients with a minimum 15% anterior glenoid bone loss who underwent shoulder stabilization with either DTA or Latarjet with a minimum follow-up of 2 years was conducted. Consecutive patients undergoing DTA were matched by age, body mass index, and number of previous ipsilateral shoulder surgeries to patients undergoing Latarjet in a 1-to- 1 format. Patients were evaluated preoperatively and at a minimum 2 years post operatively with American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index (WOSI) outcomes assessments. Complications, reoperations, and episodes of recurrent instability were also analyzed. Statistical analysis was performed with student T-tests, with P<0.05 considered significant.Results:A total of 60 patients (30 Latarjet, 30 DTA) with an average age of 26.5±7.8 years were analyzed at an average 46±17 months (range, 24-87) following surgery. Twenty-two patients (73%) in each group underwent prior ipsilateral shoulder surgery (range, 1 to 3 surgeries) prior to Latarjet or DTA. There were no statistical differences in age, BMI, or number of prior surgeries between the groups. There were no differences between the groups in regards to recurrent instability events, subluxation, or apprehension on final examination (P>0.8). Patients in both groups experienced significant improvements in all outcomes scores following surgery (P>0.05 for all). When comparing final outcomes of Latarjet versus DTA, no significant differences were found in postoperative ASES, WOSI or SANE scores between the groups (P>0.05 for all). In the Latarjet group, 1 patient underwent reoperation (3.3%) with arthroscopic debridement with subacromial decompression for persistent anterolateral shoulder pain. In the DTA group, 1 patient (3.3%) underwent reoperation with DTA revision for asymptomatic hardware failure. There were no cases of neurovascular injuries or other complications in either cohort.Conclusion:At an average follow-up of nearly 4 years, fresh DTA reconstruction for recurrent anterior shoulder instability results in a clinically stable joint with similar clinical outcomes and recurrence rates compared to Latarjet. Longer-term studies are needed to determine if these results are maintained over time.

Arthroscopic Treatment of Shoulder Instability with Glenoid Bone Loss Using Distal Tibia Allograft Augmentation

Objectives:The purpose of this study was to retrospectively analyze prospectively collected data to present the clinical and radiological short term outcomes of patients who underwent anatomic glenoid reconstruction using distal tibia allograft to treat shoulder instability with glenoid bone loss.Methods:Over four years, 44 patients (31 patients were male and 13 female with mean age of 29.73 years) underwent arthroscopic stabilization with capsulelabral Bankart repair and allograft bony augmentation of the glenoid for recurrent shoulder instability with significant bone loss by the same surgeon. 14 patients were revision cases of previous surgery. Preoperative and postoperative functional assessment was performed with the Western Ontario Shoulder Instability Index (WOSI) questionnaire, and radiological assessment was performed with radiographs and CT scans. The Average follow-up was 2 years.Results:97% (43/44) patients had no dislocations or subluxations at the most recent followup. The mean pre and postoperative WOSI scores were 40.54 and 72.65 respectively (p<0.001). No patients developed nerve injury. One patient presented with hardware failure at 3 years post-op. Two other patients had graft absorption and 6 patients had partial graft resorption but none had symptoms of instability. The mean postoperative active shoulder range of motion was forward flexion 170.1o, abduction 168.9o, internal rotation 69.5o and external rotation 57.5o. Grafts positioning was flush with the glenoid in 93% of cases, vertical positioning was excellent in 89% (35 o’clock).Conclusion:Arthroscopic stabilization of the shoulder with distal tibia allograft augmentation is a good safety profile technique with good results at average of two years follow up.

Translation, adaptation and measurement properties of an electronic version of the Danish Western Ontario Shoulder Instability Index (WOSI)

ObjectivesTo translate and adapt the Western Ontario Shoulder Instability (WOSI) questionnaire into Danish and, to evaluate measurement properties of an electronic Danish WOSI version.MethodsThe Swedish WOSI version was used for...

Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial

BackgroundLabral repair and biceps tenodesis are routine operations for superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their efficacy is lacking. We evaluated the effect of...

Comparaison des allogreffes distales du tibia et des butées de type de Latarjet dans l’instabilité antérieure : étude prospective

Introduction Recently, the use of fresh distal tibia allograft (DTA) for glenoid reconstruction in anterior shoulder instability has been described with encouraging short-term outcomes. However, the outcomes of patients undergoing DTA have not been compared to patients undergoing the Latarjet procedure, which has been considered the standard for shoulder stabilization for clinically significant anterior glenoid bone loss. The purpose of this study was to determine clinical outcomes for patients undergoing DTA compared to a matched cohort of patients undergoing Latarjet. Methods A review of prospectively collected data of patients with minimum 15% anterior glenoid bone loss, minimum follow-up of 2 years, and who underwent shoulder stabilization with either DTA or Latarjet was conducted. Consecutive patients undergoing DTA were matched by age, BMI, and number of previous ipsilateral shoulder surgeries to patients undergoing Latarjet. Patients were evaluated preoperatively and at minimum 2 years postoperatively with American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index (WOSI) outcomes assessments. Complications, reoperations and episodes of recurrent instability were also analyzed. Statistical analysis was performed with Student t-tests, with P > 0.05 considered significant. Results A total of 60 patients (30 Latarjet, 30 DTA) with an average age of 24.3 ± 6.9 years were analyzed at an average 46 ± 17 months (range, 24–87) following surgery. Twenty-two patients (73%) in each group underwent prior ipsilateral shoulder surgery (range, 1–3 surgeries). There were no statistical differences in age, BMI, or number of prior surgeries between the groups, signifying adequate matching ( P > 0.05 for all). Both groups had significant improvements in all preoperative to postoperative outcome scores ( P > 0.05). When comparing final outcomes of Latarjet versus DTA, Latarjet patients had significantly higher ASES scores (93 ± 8 vs. 87 ± 13, P = 0.03); no significant differences were found in postoperative WOSI or SANE scores. In the Latarjet group, 2 patients underwent reoperation (6.7%), including 1 patient who redislocated after a traumatic motocross accident and 1 patient who underwent arthroscopic debridement for anterolateral shoulder pain. In the DTA group, 1 patient (3.3%) underwent reoperation including DTA revision for asymptomatic hardware failure. There were no cases of neurovascular injuries or other complications in either cohort. Discussion and conclusion At an average follow-up of nearly 4 years, fresh DTA reconstruction for recurrent anterior shoulder instability results in a clinically stable joint with equivalent clinical outcomes and recurrence rates compared to Latarjet. Longer-term studies are needed to determine if these results are maintained over time.

Arthroscopic Treatment for Shoulder Instability with Glenoid Bone Loss Using Distal Tibia Allograft Augmentation - Short Term Results

Objectives:Background: The results of arthroscopic anterior labral (Bankart) repair have been shown to have high failure rate in patients with significant glenoid bone loss. Several reconstruction procedures using bone graft have been described to overcome the bone loss, including autogenous coracoid transfer to the anterior glenoid (Latarjet procedure) as well as iliac crest autograft and tibial allografts. In recent years, trends toward minimally invasive shoulder surgery along with improvements in technology and technique have led surgeons to expand the application of arthroscopic treatment.Purpose:This study aims to perform a retrospective analysis of prospectively collected data to evaluate the clinical and radiological follow up of patient who underwent anatomic glenoid reconstruction using distal tibia allograft for the treatment of shoulder instability with glenoid bone loss at 1-year post operation time point.Methods:Between December 2011 and January 2015, 55 patients underwent arthroscopic stabilization of the shoulder by means of capsule-labral reattachment to glenoid ream and bony augmentation of glenoid bone loss with distal tibial allograft for recurrent instability of the shoulder. Preoperative and postoperative evaluation included general assessment by the western Ontario shoulder instability index (WOSI) questionnaire, preoperative and postoperative radiographs and CT scans.Results:Fifty-five patients have been evaluated with mean age of 29.73 years at time of the index operation. There were 40 males (mean age of 29.66) and 15 female (mean age of 29.93). Minimum follow up time was 12 months. The following adverse effects were recorded: none suffered from recurrent dislocation, 2 patients suffered from bone resorption but without overt instability, 1 patient had malunion due to screw fracture, none of the patients had nonunion. The mean pre-operative WOSI score was 36.54 and the mean postoperative WOSI score was 61.0.Conclusion:Arthroscopic stabilization of the shoulder with distal tibia allograft augmentation demonstrates promising result at 1year follow up.

Comparison of Time to Recurrence of Instability After Open and Arthroscopic Bankart Repair Techniques.

Background:The results of open and arthroscopic instability repairs have been shown to be equivalent in recent literature.Purpose:To compare the time to recurrence (TTR) of instability and disease-specific outcome measures in patients undergoing open and arthroscopic Bankart repair.Study Design:Cohort study; Level of evidence, 3.Methods:Patients with recurrent traumatic anterior shoulder instability and a Bankart lesion on diagnostic arthroscopy underwent either open Bankart repair (OB) or arthroscopic Bankart and suture capsulorrhaphy (ABSC) using suture anchors. There was a minimum follow-up of 24 months. The primary outcome measures included Western Ontario Shoulder Instability Index (WOSI) score and time to recurrence of instability (dislocation or subluxation). Rowe score, Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons (ASES) score, and Short Form–12 (SF-12) score were also compared.Results:A total of 82 shoulders in 80 patients (ABSC, n = 58; OB, n = 24) were evaluated at a mean of 39 months postoperatively. There were 4 clinical failures in the OB group (4 dislocations) and 7 clinical failures in the ABSC group (2 dislocations and 5 subluxations; P = .72 vs OB). The mean time to recurrence of postoperative instability was significantly shorter in the ABSC group (12.6 ± 2.7 months) compared with the OB group (34.2 ± 12 months; P = .04). The WOSI score in the OB group (265 ± 48.1) was better but not statistically significantly compared with the ABSC group (449.8 ± 63.8; P = .06).Conclusion:The time to recurrence of instability after open Bankart repair is significantly longer compared with arthroscopic Bankart repair.Clinical Relevance:Delayed time to recurrence after open Bankart repair suggests that the open technique may be more suited to withstand the high stress and demands of a heavy-duty profession (contact athletes and heavy manual labor).

Outcomes of the Remplissage Procedure and Its Effects on Return to Sports

Background: Short-term outcomes for patients with large, engaging Hill-Sachs lesions who underwent remplissage have demonstrated good results. However, limited data are available for longer term outcomes. Purpose: To evaluate the long-term outcomes of remplissage and determine the long-term rate of return to specific sports postoperatively. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of patients treated with the remplissage procedure from 2007 to 2013. All underwent preoperative magnetic resonance imaging demonstrating large Hill-Sachs lesions by the Rowe criteria and glenoid bone loss <20%. All Hill-Sachs lesions were “off track” by an arthroscopic examination and preoperative imaging. At final follow-up, patients underwent a range of motion evaluation and were administered a detailed outcome survey, which included Western Ontario Shoulder Instability Index (WOSI) and American Shoulder and Elbow Surgeons (ASES) scores as well as questions regarding sports, employment, physical activities, and dislocation events. Results: A total of 50 patients (51 shoulders) were included in the study. The average patient age at surgery was 29.8 years (range, 15.0-72.4 years), and the average follow-up time was 60.7 months (range, 25.5-97.6 months); 20.0% of patients underwent previous surgery on their shoulder. The average postoperative WOSI score was 79.5%, and the average ASES score was 89.3. Six shoulders had dislocation events (11.8%) postoperatively: 3 were traumatic, and 3 were atraumatic. Increased preoperative dislocations led to a greater risk of a postoperative dislocation (P < .001). There was also a trend toward higher postoperative dislocation rates in patients who underwent revision (P = .062). The average loss of external rotation was 5.26° (P = .13). The rate of return to ≥1 sports was 95.5% of patients at an average of 7.0 months postoperatively; 81.0% returned to their previous intensity and level of sport. Of patients who played a throwing sport, 65.5% (n = 19) stated that they had problems throwing, and 58.6% (n = 17) felt that they could not normally wind up throwing a ball. Direct rates of return to overhead sports were volleyball, 100%; basketball, 69%; baseball, 50%; and football, 50%. Conclusion: The redislocation rate after remplissage was 11.8% at an average of 5 years, with 95.5% of patients returning to full sports at an average of 7 months. For throwing sports, 65.5% of patients complained of decreased range of motion during throwing. The results should be considered preoperatively in candidates for remplissage who are engaged in throwing sports.

Recurrent Anterior Shoulder Instability With Combined Bone Loss

Background: Recurrent anterior glenohumeral dislocation in the setting of an engaging Hill-Sachs lesion is high. The Latarjet procedure has been well described for restoring glenohumeral stability in patients with >25% glenoid bone loss. However, the treatment for patients with combined humeral head and mild (<25%) glenoid bone loss remains unclear. Purpose/Hypothesis: This study reports on the outcomes of the modified Latarjet for patients with combined humeral and glenoid defects and compares the results for patients with ≤25% glenoid bone loss versus patients with >25% glenoid bone loss. The hypothesis was that the 2 groups would have equivalent subjective outcomes and recurrence rates. Study Design: Cohort Study; Level of evidence, 3. Methods: Modified Latarjet was performed in 40 patients with recurrent anterior shoulder instability, engaging Hill-Sachs by examination confirmed with arthroscopy, and ≤25% anterior glenoid bone loss (group A). A second group of 12 patients were identified to have >25% glenoid bone loss with an engaging Hill-Sachs lesion (group B). The mean follow-up time was 3.5 years. All patients were assessed for their risk of recurrence using the Instability Severity Index score and Beighton score and had preoperative 3-dimensional imaging to assess humeral and glenoid bone loss. Single Assessment Numeric Evaluation (SANE), Western Ontario Shoulder Instability Index (WOSI), recurrence rate, radiographs, range of motion, and dynamometer strength were used to assess outcomes. A multivariate analysis was performed. Results: Glenoid bone loss averaged 15% in group A compared with 34% in group B. Both groups had comparable WOSI scores (356 vs 475; P = .311). In multivariate analysis, the number of previous surgeries and Beighton score were directly correlated with WOSI score in Latarjet patients. The SANE score was better in group A (86 vs 77; P = .02). Group B experienced more loss of external rotation (9.2° vs 15.8°; P = .0001) and weaker thumbs-down abduction and external rotation strength (P < .032). Subscapularis, abduction, and external rotation strength averaged at least 75% of the contralateral shoulder in both groups. Graft resorption was similar in both groups (32% vs 33%; P < .999). The overall recurrent instability rate for the study, defined as any subsequent subluxations or dislocation, was 15%; recurrent instability rates (15% vs 17%; P > .999) were similar for both groups. The complication rate was 25% for both groups. Conclusion: The modified Latarjet procedure provides satisfactory outcomes for patients with combined bone loss, which is known to have high recurrence rates with traditional arthroscopic stabilization. Previous surgical stabilization procedures and the Beighton score adversely affect outcome after modified Latarjet. Furthermore, the number of previous surgeries and Beighton score can be used to predict WOSI score in Latarjet patients. Further study is needed to determine if these results hold true in the long term.

Correlations between three patient-assessed shoulder instability scales.

To evaluate the correlations between three patient-assessed shoulder instability scales before and after Latarjet stabilisation for traumatic anteroinferior glenohumeral instability. Records of 30 men and 2 women (mean age, 26.7 years) who had not undergone surgery for antero-inferior shoulder instability and records of 31 men and one woman (mean age, 27 years) who had undergone Latarjet stabilisation for anteroinferior shoulder instability and had been followed up for a mean period of 21.3 months were reviewed. Correlations between the Western Ontario Shoulder Instability Index (WOSI), the Melbourne Instability Shoulder Score (MISS), and the L'Insalata Shoulder Questionnaire (L'Insalata) were assessed. The mean score of each scale was significantly greater in the postoperative than preoperative group (p<0.001). Within each group, the mean scores of the 3 scales differed significantly (ANOVA, p=0.001). The mean L'Insalata score was significantly higher than the mean WOSI and MISS scores (p<0.01, posthoc analysis), but the latter 2 scores did not differ significantly (p>0.01, post-hoc analysis). Correlations of all scale pairs were significant (p<0.001). The WOSIMISS correlations in the pre- and post-operative groups were moderate. The L'Insalata-WOSI correlations in the pre- and post-operative groups were moderate and high, respectively. The L'Insalata-MISS correlations in the pre- and post-operative groups were high and moderate, respectively. The MISS and WOSI scales are moderately correlated. Correlation of the L'Insalata scale with other scales depends on the operative status of the patient. The use of the L'Insalata scale alone is not recommended.

Clinical Outcomes Following Revision Anterior Shoulder Stabilization

Objectives:The purpose of this study was to determine the clinical outcomes following revision anterior shoulder stabilization performed either via all-arthroscopic soft tissue repair or via Latarjet coracoid transfer.Methods:A retrospective review of prospectively collected data on 91 shoulders undergoing revision anterior shoulder stabilization was performed. All patients underwent prior soft tissue stabilization; those with prior open bone grafting procedures were excluded. For patients with 25% glenoid bone loss, Latarjet was performed (n=28). Patients were queried regarding recurrent instability (subluxation or dislocation). Clinical outcomes were evaluated using validated patient reported outcome questionnaires including the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), visual analog scale (VAS) for pain, and Western Ontario Shoulder Instability Index (WOSI).Results:A total of 63 shoulders in 62 patients (46 males, 16 females) with an average age of 23.2 ± 6.9 years were included in the revision arthroscopy group. At an average follow-up of 46.9 ± 16.8 months (range, 15 to 78), the mean WOSI score was 80.1 (range, 15.0 to 100), and there were significant improvements (p<0.001) in ASES (63.7 to 85.1), SST (6.2 to 9.1), and VAS pain scores (2.89 to 0.81). Recurrent instability occurred in 12 of 63 shoulders (19%); the number of prior surgeries and baseline hyperlaxity were significant risk factors for failure (p<0.001 and p=0.04, respectively). No patients developed clinical or radiographic evidence of arthritis. A total of 28 shoulders in 28 patients (21 male, 7 female) with an average age of 27.5 years (range 14 to 45) were included in the Latarjet group. Thirteen (46%) had more than one previous stabilization attempt. ), the average WOSI score was 71.9, and there were significant improvements (p<0.001) in ASES (65.7 to 87.0), SST (7.2 to 10.3), and VAS (3.1 to 1.1). Recurrent instability occurred in 2 of 28 shoulders (7%), including 1 patient with symptomatic subluxation and 1 patient with a recurrent dislocation resulting in rapid arthrosis requiring revision to hemiarthroplasty at 20 months after Latarjet.Conclusion:Both arthroscopic revision stabilization and Latarjet coracoid transfer result in satisfactory outcomes in patients who have failed previous arthroscopic capsulolabral repair. Recurrent instability rates were higher in the all-arthroscopic group (19% versus 7%). Longer-term studies are required to determine whether similar results are maintained over time, and to provide guidance on focused clinical indications for this challenging patient population.

Treatment And Results Of Combined Mild Bone Loss Instability With The Modified Laterjet

Objectives:Recurrent anterior glenohumeral dislocation in the setting of an engaging Hill-Sachs lesion is high. The Latarjet procedure has been well-described for restoring glenohumeral stability in patients with over 25% glenoid bone loss. However, the treatment for patients with combined humeral head and mild (<25%) glenoid bone loss remains unclear. We report on the outcomes of the modified Latarjet for this population.Methods:Modified Latarjet was performed in twenty three patients with recurrent anterior shoulder instability, engaging Hill-Sachs by exam confirmed with arthroscopy, and less than 25% anterior glenoid bone loss. The mean follow-up was 3.5 years. All patients were assessed for their risk of recurrence using the Instability Severity Index Score (ISIS), had pre-operative 3D imaging to assess humeral and glenoid bone loss. Single Assessment Numeric Evaluation (SANE), Western Ontario Shoulder Instability Index (WOSI), recurrence rate, radiographs, range of motion and dynamometer strength were used to assess outcomes.Results:Average pre-operative instability severity index score was 6.2 (range 4-9). Pre-operative glenoid bone loss averaged 15.1% (range 5-25%). The humeral defect averaged 40.4% in width and 13.7% in depth on axial computed tomography scan, with an average Hill-Sachs angle of 28°. The mean WOSI index was 457 of 2100 (range 0-1398). The mean SANE score was 81.2 (range 60-100). Five out of ten competitive athletes returned to play for at least one season. There were no recurrent dislocation and three patients had a single episode of recurrent subluxation. Loss of external rotation at the side averaged 8°, and there was no significant loss of abduction. Subscapularis, abduction and external rotation strength averaged greater than 85% of the contralateral shoulder. Fourteen patients on average had 1.4 (range 1-4) previous open or arthroscopic stabilization procedures prior to the Latarjet, nine others had Latarjet done primarily. WOSI scores correlated directly with number of previous surgery (r=0.81, p=0.02). Average WOSI score was 239 (range 0-510) in primary Latarjet, 495 (range 42-1024) in patients with one previous stabilization procedure, and 674 (range 192-1398) in patients with two or more previous stabilization procedures (ANOVA p<0.001). There were three deep infections, two graft fractures, two painful hardware, one broken screw with graft malunion, and one radiographic graft nonunion. All infections, malunion and nonunion occurred in patients with failed previous stabilization procedures. No long-term nerve palsies were found. Resorption of the graft at the superior screw was seen in 28% of patients.Conclusion:The modified Latarjet is a reasonable choice for the treatment of an engaging Hill-Sachs lesion with concomitant mild anterior glenoid bone loss in this very demanding group of patients. However, the complication rate is significant.

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

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

Arthroscopic Versus Open Stabilization for Anterior Shoulder Subluxations.

Background:Most of the literature on shoulder instability focuses on patients experiencing anterior glenohumeral dislocation, with little known about the treatment of anterior subluxation events.Purpose:To determine the outcomes of surgical stabilization of patients with anterior glenohumeral subluxations and to compare open and arthroscopic approaches.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:We prospectively enrolled patients with anterior glenohumeral subluxations undergoing surgical stabilization. Patients were offered randomization between open and arthroscopic stabilization. Inclusion criteria included patients with anterior glenohumeral subluxations undergoing Bankart repair, while exclusions included the presence of glenoid or humeral bone loss, multidirectional instability, capsular tear/humeral avulsion of the glenohumeral ligament lesion, and rotator cuff tear requiring repair. Patients were randomized to an open Bankart repair through a subscapularis takedown or an arthroscopic Bankart repair, both using the same bioabsorbable suture anchors, and they were followed for a minimum of 2 years. Outcomes were evaluated with the Single Assessment Numeric Evaluation (SANE), Western Ontario Shoulder Instability Index (WOSI), American Shoulder and Elbow Surgeons Score (ASES), Simple Shoulder Test (SST), Rowe, and Tegner activity scores.Results:A total of 26 patients were enrolled, with 7 being lost to follow-up. Complete follow-up data were available on 19 subjects (74%): 10 in the open group and 9 in the arthroscopic group. There were no significant differences noted between the randomized groups, with a 2-year WOSI score of 320 in the open subjects and 330 in the arthroscopic subjects, and similar findings in the other scoring scales. There were no cases of dislocation following surgery. There were 3 patients with recurrent instability (subluxations only) in each group at a mean of 17 months, for an overall recurrent subluxation rate of 31%. These subjects with recurrence had lower outcome scores (WOSI, 532; SANE, 88.4). The outcomes of the 9 subjects with ≤3 subluxation events were superior to those of the 10 subjects with >3 events prior to stabilization. The patients with ≤3 events had a WOSI score of 143, compared with 470 (P = .042), and an ASES mean score of 98.8, compared with 87.1 (P = .048). Four of the 6 patients with recurrent subluxations had sustained >3 subluxations prior to stabilization.Conclusion:Overall, patients with Bankart lesions resulting from an anterior glenohumeral subluxation event had excellent outcomes with surgical stabilization. The overall recurrence in the 19 subjects with at least 2-year follow-up was 6 cases (31%), with no instances of dislocation in this young, active cohort. There was no significant benefit to open or arthroscopic stabilization, and we did find that stabilization of subluxation patients with ≤3 events resulted in superior outcomes compared with chronic recurrent subluxation patients with >3 events. We recommend early surgical stabilization of young athletes with Bankart lesions that result from anterior subluxation events.

The Arthroscopic Latarjet Procedure for Anterior Shoulder Instability

Background: The arthroscopic Latarjet procedure combines the benefits of arthroscopic surgery with the low rate of recurrent instability associated with the Latarjet procedure. Only short-term outcomes after arthroscopic Latarjet procedure have been reported. Purpose: To evaluate the rate of recurrent instability and patient outcomes a minimum of 5 years after stabilization performed with the arthroscopic Latarjet procedure. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent the arthroscopic Latarjet procedure before June 2008 completed a questionnaire to determine whether they had experienced a dislocation, subluxation, or further surgery. The patients also completed the Western Ontario Shoulder Instability Index (WOSI). Results: A total of 62 of 87 patients (64/89 shoulders) were contacted for follow-up. Mean follow-up time was 76.4 months (range, 61.2-100.7 months). No patients had reported a dislocation since their surgery. One patient reported having subluxations since the surgery. Thus, 1 patient (1.59%) had recurrent instability after the procedure. The mean ± standard deviation aggregate WOSI score was 90.6% ± 9.4%. Mean WOSI domain scores were as follows: Physical Symptoms, 90.1% ± 8.7%; Sports/Recreation/Work, 90.3% ± 12.9%; Lifestyle, 93.7% ± 9.8%; and Emotions, 88.7% ± 17.3%. Conclusion: The rate of recurrent instability after arthroscopic Latarjet procedure is low in this series of patients with a minimum 5-year follow-up. Patient outcomes as measured by the WOSI are good.

Aircast Award for Basic Science - Return to Play Following In-season Anterior Shoulder Instability: A Prospective Multicenter Study

Objectives:There is no consensus on the optimal treatment of young in-season athletes with anterior shoulder instability and limited data are available to guide return to play and treatment. The purpose of this study was to examine the likelihood of return to sport following an in-season shoulder instability event based on the type of instability (subluxation vs. dislocation). Additionally, injury factors and patient reported outcome scores administered at the time of injury were evaluated to assess the predictability of eventual successful return to sport and time to return sport during the competitive season following injury.Methods:Over two academic years, 45 contact intercollegiate athletes were prospectively enrolled in a multicenter observational study to assess return to play following in-season anterior glenohumeral instability. The primary outcomes of interest were the ability to return to sport and time lost from sport following an acute anterior shoulder instability event. Baseline data collection included sport played, previous instability events, direction of instability, and type of instability (subluxation or dislocation). Patient reported outcome scores specific to the shoulder were obtained at the time of injury and included the Western Ontario Shoulder Instability Index (WOSI), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), and American Shoulder and Elbow Score (ASES). All observed patients underwent a standardized accelerated rehabilitation program without shoulder immobilization, following the initial shoulder instability event. Subjects were followed during the course of their competitive season to determine return to play success and recurrent instability.Results:Thirty-three of 45 (73%) athletes returned to sport for either all or part of the season after a median 5 days lost from competition (IQR=13)(Fig 1). Of the 33 athletes returning to in-season sport following an instability event, 63% (22/33) completed the season. Athletes with a subluxation were 5.3 times more likely (OR=5.32, 95%CI: 1.00, 28.07, p=0.049) to return to sport following an initial in-season shoulder instability event when compared to those with dislocations. Logistic regression analysis suggests that the WOSI (OR=1.05; 95% CI 1.00, 1.09; p=0.037) and SST (OR=1.03, 95% CI 1.00, 1.05; p=0.044) administered after the initial instability event are predictive of ability to return to play . For every 1 point higher the WOSI scaled score at the time of injury, the athlete was 5% more likely to return to play during the same season. Time loss from sport following a shoulder instability event was inversely correlated with the WOSI (p=0.039), SST (p=0.007), and ASES (p=0.02) scores at the time of initial injury. The SST demonstrated the strongest correlation with time lost from sport, and for every 10 points higher the SST scale score was at the time of injury an athlete returned to sport 1.2 (95%CI: 0.4, 1.9) days sooner (p=0.004). Based on the logistic regression analysis, time lost from sport is predicted using the SST score after the initial instability event (Table 1).Conclusion:In the largest prospective study evaluating shoulder instability in mid-season contact athletes, we demonstrate that 73% of athletes return to play after one week. While the majority of athletes who return to sport complete the season, recurrent instability events are common regardless of whether the initial injury was a subluxation or dislocation.

Measurement properties of the Western Ontario Shoulder Instability index in Dutch patients with shoulder instability.

BackgroundThe Western Ontario Shoulder Instability index (WOSI) is a patient-reported outcome measure for patients with shoulder instability. The purpose of this study was to validate the WOSI in a Dutch population by evaluating its structural validity, internal consistency, measurement error, reliability, and construct validity. Floor and ceiling effects were also addressed.MethodsTwo cohorts were recruited, including a total of 138 patients with shoulder instability. Confirmatory factor analysis was used to assess the structural validity and Cronbach’s α to assess internal consistency. The measurement error was calculated as the smallest detectable change (SDC). Reliability (test–retest) was estimated in a subgroup of 99 patients who completed the re-test after a mean of 13 days (5–30 days). Reliability was calculated with the intraclass correlation coefficient (ICC). Construct validity was evaluated by comparing the WOSI with the Oxford Shoulder Instability Score (OSIS), the Simple Shoulder Test, the Oxford Shoulder Score, the Disability of the Arm, Shoulder, and Hand assessment (DASH), and the Short Form-36 Health Survey. Measurement properties were evaluated for both the total WOSI score and its four domains.ResultsFactor analysis did not confirm the validity of the four domains. Best results were found for a one-factor model. Internal consistency was good, with Cronbach’s α ranging from 0.93 to 0.96. Reliability was excellent (ICC 0.88–0.92 for all subscales). The measurement error (SDC) was 23.0% for the total WOSI and 23% to 28% for the subscales (on a scale of 0–100). Regarding the construct validity, 76% of the results were in accordance with the hypotheses, including a high correlation with the OSIS (0.82) and DASH (0.81) assessments. No floor or ceiling effects were found.ConclusionThe Dutch version of WOSI showed good reliability and validity in a cohort of patients with shoulder instability, although the factor structure remains unclear.