Western Ontario Shoulder Instability Score Research Articles

Faster strength recovery and better strength ratio with arthroscopic Latarjet compared to the open technique: An observational study

IntroductionThe arthroscopic bone block has shown reliability and reproducibility regarding functional scores and shoulder mobility compared to the open bone block technique. The recovery of muscle strength, especially the strength ratio external rotator/internal rotator (ER/IR), is crucial to recovering satisfactory function. This ratio should be as near to 1 as possible, meaning a good strength balance. Little is known about the difference in strength recovery between the open and arthroscopic techniques. HypothesisArthroscopic Latarjet reduces surgical stress and improves the strength recovery and strength ratio. ObjectivesTo compare arthroscopic and open Latarjet procedures for shoulder muscle strength and functional outcomes. Material and methodsIt was an observational longitudinal and prospective cohort follow-up. Two groups of patients were accessible for comparison: 35 in an arthroscopy group and 38 in an open group. The main outcome was the muscle strength of shoulder muscles measured with a dynamometer and expressed in Newton (N) at day 21 (D21), D45, D90, D180, and D365 in the operated and contralateral shoulders. The measurements were made for the pectoralis major, the three deltoid fascicles, and the subscapularis. The shoulder ER/IR strength ratio was calculated. Other variables were the range of motion (ROM), the Walch-Duplay (WD), the Western Ontario Shoulder Instability score (WOSI), and the Visual Analogic Scale for pain assessment. The strength, ROM, and functional scores were compared between open and arthroscopy with linear mixed models. ResultsThe median strengths at 52 weeks were significantly higher than at 3 weeks (P<10−4): anterior deltoid (AD) 8N (Q1:7, Q3: 9) versus 4N (Q1:2, Q3: 5), lateral deltoid (LD) 9N (Q1:9, Q3: 11) versus 6N (Q1:4, Q3: 7), posterior deltoid (PD) 14N (Q1:12, Q3: 15) versus 9N (Q1:8, Q3: 10), subscapularis 10N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 8), and pectoralis major (PM) 11N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 10). The overall strengths were lower in the open group compared to the arthroscopy group: AD −2.1N (CI95%[−3.1−−1.2], p=0.0005), LD −1.3N (CI95% [−2.4−−0.15], p=0.03), PD −0.35N (CI95% [−1–0.9], p=0.52), subscapularis −2.1N (CI95% [−3.3−−0.7], p=0.006), and PM −1.4N (CI95% [−2.2−−0.02], p=0.03). The ER/IR ratio was stable throughout the follow-up for both the operated and contralateral shoulders (p>0.5). The overall mean ratio was 1.3 (median 1.2, Q1: 1, Q3:1.45) for the operated shoulder and 1.1 (median 1, Q1: 0.9, Q3:1.3) for the contralateral shoulder (p=0.0004). The average ER/IR ratio was 0.27 points higher in the open group (CI95% [0.1–0.46], p=0.003). The ROM was similar between the two groups, and there was no correlation between the ER/IR ratio and the ROM (p>0.5). The VAS < 3 weeks and WD > 12 weeks were significantly poorer in the open group: +0.61 (CI95% [0.03–1.16] p=0.02), and −7.3 points (CI95% [−13−−0.01], p=0.05), on average, respectively. ConclusionThe patients in the arthroscopy group had a better ER/IR strength ratio (closer to 1) and better WOSI after 12 weeks. The strength and the ROM were not correlated with each other. Level of evidenceIII.

Anterior shoulder dislocation with avulsion fracture of the greater tuberosity results in reliable good outcomes after closed reduction

BackgroundAvulsion of the greater tuberosity (GT) due to traumatic anterior shoulder dislocation (ASD) is a commonly observed fracture pattern. After closed reduction of the dislocated humerus, the greater tuberosity typically reduces itself into its anatomic position enabling the patient to undergo conservative treatment. The aim of this study was to retrospectively review a consecutive series of patients with conservatively treated GT avulsion fractures after closed reduction of an ASD and analyze radiographic outcome, shoulder function and glenohumeral stability and the conversion rate to surgical treatment. Material and methodsAll patients who underwent closed reduction of a GT avulsion fracture after ASD with the primary intention of conservative treatment between 2017 and 2022 were included. Complications (i.e. conversion to surgical treatment), shoulder function assessed with the American Shoulder and Elbow Surgeons (ASES) score and subjective shoulder value (SSV), instability assessed with the Western Ontario Shoulder Instability (WOSI) score, radiological impingement (greater tuberosity index = GTI and impingement index = II) and GT fracture pattern were assessed as outcome measurements. ResultsA total of 29 patients (mean age 44 years, 27% female) with a mean follow-up of 32.6 (range, 8-96) months were enrolled. Seven patients (24%) underwent surgery due to secondary displacement (n=4, 14%) or impingement symptoms (n=3, 10%). All patients who underwent secondary surgery showed a multifragmentary fracture pattern of the GT. Shoulder stiffness (n=7) and neuropraxia of the axillary nerve (n=3) were observed temporarily and resolved during the follow-up period. The ASES and SSV of the conservatively treated patients at the last follow-up was 89.2±19.1 respectively 86±18.2%. No recurrent glenohumeral dislocation was documented. The mean WOSI score at last follow-up was 8(0-71). The mean GTI decreased from 1.2±0.1 after ASD to 1.1±0.1 at the last follow-up (p=0.002). The mean II decreased from 0.6±0.5 after ASD to 0.4±0.3 at the last follow-up (p=0.110). ConclusionThe greater tuberosity avulsion fragment reduces typically into a close to anatomic position after closed reduction and the greater tuberosity index even improves with further conservative treatment over time. Close radiological follow-up is necessary to rule out secondary displacement which occurs typically in a multifragmentary fracture pattern. Patients without the need for surgery showed good clinical outcomes without recurrence of glenohumeral instability.

Association of Instability History and Off-Track Hill-Sachs Lesions in Anterior Shoulder Instability.

The glenoid track concept is now widely accepted, and its evaluation is considered essential for making decisions about surgery. To define preoperative descriptive data and clinical and functional features in patients with anterior glenohumeral instability according to glenoid track status and to analyze the influence of off-track Hill-Sachs (HS) lesions on preoperative shoulder function. Case-control study; Level of evidence, 3. Preoperative magnetic resonance imaging or computed tomography scans were used to measure the glenoid track. Descriptive data and preoperative objective and subjective clinical and functional features were compared between patients with on-track HS lesions versus off-track HS lesions. Multivariate regression analysis was conducted to identify potential risk factors for off-track HS lesion development. A total of 235 patients (201 men, 34 women; mean age, 29.6 ± 8.6 years) were included- 134 shoulders (57%) with on-track HS lesions and 101 shoulders (43%) with off-track HS lesions. Age <20 years at first dislocation, number of dislocations, and ≥2 years between first dislocation and surgery were significantly different between the study groups (P = .005, P = .0001, and P = .01, respectively). Regarding these characteristics, the odds ratios for the risk of developing an off-track lesion were 2.67 (95% CI, 1.2-5.99)-1.2 times higher for each additional instability episode (95% CI, 1.025-1.14) and 2.42 times higher (95% CI, 1.176-4.608) for patients whose first dislocation was ≥2 years before surgery, respectively. Patients with off-track HS lesions had a significantly greater degree of instability (P = .04), worse Rowe scores (48.8 ± 15.3 vs 54.8 ± 28.3 for on-track HS lesions; P = .04), and lower Western Ontario Shoulder Instability scores (975 ± 454 vs 1179 ± 428 for on-track HS lesions; P = .01). Characteristics related to a history of instability (age <20 years at first instability episode, larger number of dislocations, ≥2 years between first dislocation and surgery) were found to be risk factors for the development of an off-track HS lesion in this study. Off-track lesions led to a higher degree of instability and worse objective and subjective preoperative shoulder function versus on-track HS lesions.

Poster 194: Arthroscopic Reconstruction of Comminuted Glenoid Fractures Using Distal Tibia Allograft Results in Excellent Post-Operative Outcomes

Objectives: Boney Bankart injuries with a fragment from the anterior rim of the glenoid are not the most frequent ones after an anterior shoulder dislocation but can cause severe impairment of the joint and residual instability directly related with the amount of bone avulsed. Different treatment options have been described including fixation or reconstruction of the glenoid bone using distal tibia allograft. The primary objective of this study is to analyze and compare clinical outcomes, Western Ontario Shoulder Instability (WOSI) scores, complication, and re-dislocation rates. Methods: This study included patients who underwent arthroscopic surgery for glenoid fracture between 2012-2020. Patients were included if they sustained a type Ia glenoid fracture according to Ideberg-Goss classification and if they were treated arthroscopically within three months of injury with one of two surgical techniques; Fixation (including fracture fragment reduction and fixation with screws, buttons, or sutures and anchors), and glenoid reconstruction. Patients were excluded if they had concomitant fractures to ipsilateral humerus or clavicle during injury and history of ipsilateral shoulder instability. Demographic information, WOSI scores, and complications related to the surgery, or new dislocation events were recorded. Results: Thirty-eight patients were included with both the fixation and reconstruction groups had similar demographics and baseline characteristics, except for the percentage of patients with comminution which was higher in the reconstruction group (p=0.04) (Table 1). Both the fixation and reconstruction groups has similar pre- and post-operative glenoid AP measurements (Table 1). Patient-reported outcomes were similar post-operatively between the two groups (p=0.546) (Figure 1). Conclusions: Arthroscopic glenoid fracture fixation has good outcomes but concerns exist regarding cartilage damage. Complex comminuted fracture patterns are suitable for reconstruction with patients achieving comparable outcomes to those who undergo fracture fixation. [Table: see text]

Poster 185: Arthroscopic Inferior to Superior Capsular Shift Results in Superior Clinical Outcomes Compared to Arthroscopic Bankart Repair For the Treatment of Anterior Capsulolabral Tears After Shoulder Dislocation

Objectives: In the setting of anterior shoulder instability, both boney and soft tissue structures are at risk of injury. Often, there is an injury to the anterior capsulolabral complex. This pathology is most often treated with a traditional arthroscopic Bankart repair. The open Bankart is regaining popularity as some surgeons report a lower re-dislocation rate as compared to its arthroscopic counterpart. Some believe that a better capsular shift is achieved with open surgery. We recently developed a technique for performing this capsular shift arthroscopically. The purpose of this study is to analyze and compare clinical outcomes of patients with traumatic anterior shoulder instability treated with two different arthroscopic techniques, arthroscopic capsular shift and arthroscopic Bankart repair (Figure 1). The primary objective of this study is to analyze and compare clinical outcomes, Western Ontario Shoulder Instability (WOSI) scores, complication, and re-dislocation rates. We hypothesize that patients treated with arthroscopic capsular shift will have similar clinical outcomes and a lower failure rate at one year compared with the other surgical cohort. Methods: This study included patients who underwent arthroscopic soft-tissue stabilization surgery for shoulder instability between 2012-2021. Patients were included if they had an isolated primary soft- tissue repair performed arthroscopically with one of the above-mentioned surgical techniques. Patients were excluded if they had concomitant glenoid fractures, less than one year of clinical follow-up, posterior instability, multidirectional instability, and presence of HAGL lesions Demographic information, WOSI scores, pre-operative glenoid and humeral head dimensions, and new dislocation events were recorded. Results: Sixty-three patients met the inclusion and exclusion criteria. There were 27 patients in the Bankart repair group and 36 in the capsular shift group. The two groups had similar demographics and baseline characteristics, except for the length of clinical follow-up (which is due to the capsular shift technique being developed more recently) (p&lt;0.001) (Table 1). Both groups had similar pre-operative glenoid AP and Hill-Sachs depth measurements (p=0.358 and 0.329, respectively) (Table 1). Patient- reported outcomes were similar at baseline (p=0.602) and post-operatively (p=0.621). Both groups showed improvements in WOSI post-operatively (p&lt;0.001), however more patients met MCID in the capsular shift group as compared to the Bankart repair group (93% vs 75%, respectively). In terms of clinical outcomes, patients who received a capsular shift had a lower rate of re-dislocation as compared to the Bankart group (6% vs 22%). Conclusions: The arthroscopic capsular shift technique results in better post-operative clinical outcomes as compared to arthroscopic Bankart repair with a lower recurrence rate, lower rate of post-operative apprehension, and an increased proportion of patients who meet MCID for WOSI. This technique could be a better alternative for Bankart repair in patients with soft-tissue pathologies following anterior shoulder dislocations, however longer-term studies are necessary to determine the longevity of these outcomes. [Table: see text]

The influence of posterior acromial morphology on outcomes and return to pushups in young patients undergoing arthroscopic posterior capsulolabral repair

Prior evidence has identified specific posterior acromial morphology as significantly associated with unidirectional posterior shoulder instability. The purpose of this study is to determine the influence of posterior acromial morphology on the outcomes of arthroscopic posterior capsulolabral repair (APCLR) for unidirectional posterior shoulder instability. Additionally, we sought to determine the influence of posterior acromial morphology on the rate and time to return to pushups following APCLR. We performed a retrospective review of prospectively collected data. The study included consecutive patients undergoing APCLR. Data collected included demographics, radiographic measurements including posterior acromial height (PAH) and posterior acromial tilt on preoperative scapular-Y radiographs, and patient-reported outcome measures at the preoperative and postoperative visits. In addition, starting at 6 months postoperative, patients were asked if they could perform pushups defined as at least 10 repetitions. At the final follow-up, we collected the number of pushups patients were able to perform. Thirty-two consecutive patients underwent APCLR with a mean follow-up of 26 months (range, 12-41). Significant improvement from preoperative to 2 years postoperative was demonstrated in Subjective Shoulder Value (50-85), VAS (6-2.5), American Shoulder and Elbow Surgeons (48 to 83), and Western Ontario Shoulder Instability (WOSI) (1437-777), P=.001. The recurrent instability rate was 3/32 (9%). Patients with PAH>23 (N=17) had a recurrent instability rate of 18% (3/17) versus PAH ≤ 23 (N=15) 0% (0/15), worse WOSI scores (P=.41), and a lower number of pushups (P=.48). The percentage of patients reporting the ability to perform pushups was (6 months/1 year/2 years) (50%/78%/95%). The mean number of pushups reported at the final follow-up was 33 (range, 1-60). Following APCLR, approximately 50% of patients resume pushups at 6 months postoperatively, and 80% return at 1 year. Patients reported performing a mean of 33 pushups following APCLR at the final follow-up. Patients with a PAH greater than 23 on preoperative scapular-Y radiographs had a higher rate of recurrent posterior instability, worse WOSI scores, and lower return to pushups; however, the results did not meet statistical significance. Therefore, future larger studies are needed to determine if posterior acromial morphology is independently associated with worse outcomes and increased recurrent instability rates following APCLR.

Outcomes of Open Bankart Repair Plus Inferior Capsular Shift Compared with Latarjet Procedure in Contact Athletes with Recurrent Anterior Shoulder Instability.

Open Bankart repair plus inferior capsular shift (OBICS) and Latarjet procedure (LA) are considered appropriate treatment alternatives for high-performance athletes. The purpose of this study was to evaluate the functional outcomes and recurrence rate of each surgery. Our hypothesis: there were no differences between the two treatments. A prospective cohort study was conducted with n=90 contact athletes divided into two groups of 45 patients. One group was treated with OBICS, and the other one with LA. The mean follow-up period was 25 (24-32) months for the OBICS group and 26 (24-31) months for the LA group. Primary functional outcomes of each group were assessed at baseline, six months, one year, and two years after surgery. The functional outcomes were also compared between the groups. The evaluation tools used were the Western Ontario Shoulder Instability score (WOSI) and the American Shoulder and Elbow Surgeons scale (ASES). In addition, recurrent instability and range of motion (ROM) were also evaluated. In each group, significant changes were found in the WOSI score and ASES scale from pre-op to postop. However, there were no significant differences between the functional outcomes of the groups at the final follow-up (P-values 0.73 and 0.19). Three dislocations and one subluxation (8.8%) were reported in the OBICS group, and three subluxations were reported in the LA group (6.6%), revealing no significant differences between the groups (P=0.37). Moreover, there were no significant differences between preoperative and postoperative ROM in each group or in terms of external rotation (ER) and ER in 90º abduction between the groups. No differences were found between OBICS and LA surgery. Both procedures can be indicated according to the surgeon's preference to reduce recurrence rates in contact athletes with recurrent anterior shoulder instability.

Phone Administration of the Western Ontario Shoulder Instability Index Is More Reliable Than Administration via Email.

The Western Ontario Shoulder Instability (WOSI) questionnaire is a 21-item questionnaire to evaluate quality of life in patients with shoulder instability. Completing the questionnaire is time-consuming because each item is evaluated on a visual analog scale. Telephone or email versions of the score are appealing alternatives to administering it during the standard in-person patient visit; however, their validity and reliability remain unknown. (1) Does the numerical scale (NS) version of the WOSI correlate with the original WOSI and Quick-DASH? (2) Do telephone and email administration of the NS-WOSI have good reliability and consistency? (3) Compared with the original WOSI form, does the NS form lead to faster completion for patients and quicker data extraction for researchers? Between 2014 and 2019, 50 patients with a documented history of shoulder dislocation with persistent symptomatic shoulder instability, whether anterior, posterior, or multidirectional; patients scheduled for surgery; and patients with traumatic or nontraumatic injuries were prospectively recruited from the outpatient clinic of two university hospitals acting as Level 1 trauma centers and sports traumatology tertiary referral centers. The median (IQR) age was 28 years (24 to 36), and 80% (40 of 50) were men. Most (52% [26 of 50]) patients had two to five lifetime shoulder dislocations. Validity of the NS-WOSI was assessed using the Pearson correlation coefficient during an in-person visit; the original WOSI questionnaire (or its previously validated French-language version), NS-WOSI, and Quick-DASH questionnaires were administered in a random order. After a minimum 7-day interval, 78% (39 of 50) of patients completed the phone interview, and 74% (37 of 50) of patients completed the email version of the NS-WOSI score to evaluate NS-WOSI's reliability using the intraclass correlation coefficient (ICC), which was interpreted as poor (< 0.5), moderate (0.50-0.75), strong (0.75-0.90), and very strong (> 0.90). The standard error of measurement (SEM) was used to evaluate variability around the true score, with a low value indicating a high reliability. The 95% minimal detectable change (MDC 95% ) was calculated to evaluate the minimal change in score that was not related to measurement errors. Lastly, the Cronbach alpha was used to assess internal consistency (intercorrelation strength), where a value > 0.70 was considered good. The time needed for the patient to complete the various versions and for researchers to extract data was recorded. The NS-WOSI score was very strongly correlated with the original WOSI score (r = 0.96 [95% confidence interval (CI) 0.93 to 0.98]; p < 0.001). Although telephone-acquired and email-acquired data for the NS-WOSI questionnaires were correlated with the NS-WOSI (telephone r = 0.91 [95% CI 0.83 to 0.95]; p < 0.001; email r = 0.84 [95% CI 0.71 to 0.91]; p < 0.001), the ICC was higher for telephone interviews (0.92 [95% CI 0.86 to 0.96] versus email 0.80 [95% CI 0.64 to 0.89]), indicating that although both had good reliability, the phone interview was more suitable. The phone interview was also preferable to email regarding SEM (3% [52 of 2100 points] versus 6% [132 of 2100 points]) and the MDC 95% (7% [144 of 2100 points] versus 17% [366 of 2100 points]). The 95% CI of the MDC acquired by email was superior to the reported minimum clinically important difference for the original WOSI (7% [152 of 2100 points]), meaning that an error of measurement could wrongly be interpreted as a clinically significant change in score. Internal consistency was deemed good, with a Cronbach alpha of 0.96 (95% CI 0.92 to 98) and 0.89 (95% CI 0.79 to 0.94) for NS-WOSI telephone and email, respectively. The time to complete the NS-WOSI was reduced compared with the original WOSI (221 ± 153 seconds versus 266 ± 146 seconds, mean difference -45 seconds [95% CI -72 to -12]; p = 0.009). Lastly, data extraction was faster (62 ± 15 seconds versus 209 ± 52 seconds, mean difference -147 seconds [95% CI -164 to -130]; p < 0.001) with the NS-WOSI than with the original WOSI. The NS-WOSI in person, by telephone, or by email is a valid, reliable, and timesaving alternative to the original WOSI questionnaire. However, the reliability of data acquisition by telephone interviews was superior to that of email. Given that there were no important differences in performance for the NS-WOSI, regardless of whether it was administered in person or by phone, we suggest that physicians use both interchangeably based on patient convenience. However, we do not recommend using the email version, especially for research purposes, since it was not as reliable when compared with in-person administration. The responsiveness of the modified NS-WOSI, as well as factors influencing response rates to phone interview, are questions that remain to be explored.

A comparative analysis of titanium anatomic plate and titanium reconstructive plate for treatment of extra-articular fractures of the scapula (Miller types IIb, IIc, and IV).

Because of the irregular shape of the scapula and the different types of fractures, a standard internal fixation device is lacking in clinical practice, even though there are many options available. This study aimed to compare the therapeutic efficacy of titanium anatomic and reconstructive plates for extra-articular fractures of the scapula (Miller types IIb, IIc, and IV). A retrospective study of 41 patients who underwent treatment for extra-articular fractures of the scapula between March 2017 and March 2020 was conducted. Patients were divided into 2 groups based on the fixation device: titanium anatomic plate group (20 patients) and titanium reconstructive plate group (21 patients). After follow-up for 12-18 months, the general characteristics, perioperative characteristics, postoperative follow-up findings, and imaging data of the 2 groups were compared. The surgical procedures were uneventful in both groups. The anatomic plate group significantly outperformed the reconstructive plate group with respect to surgical duration and intraoperative blood loss (P<.001). At 3-month postoperative follow-up, the Constant-Murley score (P=.026), shoulder flexion range of motion, and shoulder abduction range of motion in the anatomic plate group were all significantly better than those in the reconstructive plate group (P<.001). The postoperative Western Ontario Shoulder Instability scores of the 2 groups were similar. Imaging showed functional recovery and stable and reliable fixation in both groups. Time to bone union was similar in both groups (9.10±1.25 weeks in anatomic plate group and 9.24±1.41 weeks in reconstructive plate group, P=.742). No complications occurred in any patient, such as fixation failure, instability, or bone nonunion. Surgeons should favorably consider titanium anatomic plates for the treatment of extra-articular scapular fractures owing to their clear efficacy associated with a shorter surgical time, less intraoperative blood loss, better fixation, and rapid short-term functional recovery.

No Difference in Outcomes After Arthroscopic Bankart Repair With Remplissage or Arthroscopic Latarjet Procedure for Anterior Shoulder Instability

PurposeTo evaluate the outcomes of arthroscopic Bankart repair with remplissage (ABRR) compared with the arthroscopic Latarjet (AL) procedure for anterior shoulder instability in patients with a labral tear and a concomitant engaging Hill-Sachs lesion.MethodsA retrospective review of patients who underwent either ABRR or the AL procedure for a diagnosis of anterior shoulder instability with a concomitant engaging Hill-Sachs lesion between 2011 and 2019 was performed. Recurrent instability, the visual analog scale score, the Subjective Shoulder Value, the Western Ontario Shoulder Instability score, patient satisfaction, willingness to undergo surgery again, and return to work or sport were evaluated.ResultsOur study included 41 patients treated with ABRR and 26 treated with the AL procedure. At final follow-up, there was no difference between patients who underwent ABRR and those who underwent the AL procedure in the reported Western Ontario Shoulder Instability score (21.8% vs 28.2%, P = .33) or any of its components, the visual analog scale score (0.9 vs 1.4, P = .32), the Subjective Shoulder Value (78.4 vs 74.5, P = .6062), the rate of satisfaction (81.6% vs 85.6%, P = .54), or whether patients would undergo surgery again (81.6% vs 96.1%, P = .16). Overall, 5 patients in the ABRR group and 2 patients in the AL group had recurrent instability events (12.2% vs 7.8%, P = .70), with no significant difference in the rate of recurrent dislocation (12.2% vs 3.8%, P = .39).ConclusionsIn patients with anterior shoulder instability and a concomitant Hill-Sachs lesion, both ABRR and the AL procedure were shown to be reliable treatments, with a low rate of recurrent instability and excellent patient-reported outcomes in appropriately selected patients. However, our study could not determine whether there was critical glenoid bone loss in patients undergoing ABRR, and surgeons should still exercise caution in performing ABRR in patients with high-grade glenoid bone loss or in those with failed prior stabilizations.Level of EvidenceLevel III, retrospective cohort study.

Associations between patient-reported scores, strength and physical performance tests following shoulder stabilisation surgery

Introduction and Aims: Shoulder stabilisation surgery results in substantial time loss from participation in sport. Following surgery, most athletes desire to return to pre-injury sporting activity at their pre-injury level. However, high rates of re-injury have been reported and strength and functional performance tests may provide valuable insight into an athlete’s upper body function and readiness to return to sport following stabilisation surgery. The aim of this research was to investigate and compare (to the unaffected limb) post-operative measures of strength and performance, in patients after stabilisation surgery for shoulder instability. Methods: We evaluated a pilot group of 17 athletic males at 4 to 6 months following shoulder stabilisation surgery. Peak isometric external and internal rotation force using a handheld dynamometer was assessed, together with the Athletic Shoulder (ASH) test involving three long-lever isometric tests in an I, Y and T position on a force plate. Limb symmetry indices (LSIs) were calculated for the operated limb, as a percentage of the non-operated limb for rotator strength, as well as the peak force and rate of force development (RFD) over 100ms for each of the individual ASH tests. Western Ontario Shoulder Instability (WOSI) and Shoulder Instability Return to Sport after Injury (SIRSI) questionnaires were also assessed. Correlation coefficients were undertaken to assess the relationship between rotator strength, performance tests and patient-reported outcomes. Results: Only 35%, 59%, and 77% patients demonstrated an LSI >90% for peak force in the I, Y and T test positions, respectively, while only 47%, 35%, and 53% patients demonstrated an LSI >90% for RFD in these same positions. No associations were observed between patient-reported scores and isometric internal and external rotator strength (p>0.05). Moderate, negative associations were observed for WOSI scores and LSIs of peak force in the I test (r = -0.601; p = 0.018) and Y-test (r = -0.611; p = 0.016), positions of the ASH test, as well as the LSI in RFD in the I position (r = -0.517; p = 0.049). No associations were observed between patient-reported scores and isometric internal and external rotator strength (p>0.05). Discussion: In this early pilot trial of athletes, long-lever isometric tests, for both peak force and RFD, appeared to better relate to self-reported function and quality of life than isometric strength measures using an HHD. Future research investigating performance-related factors, and their association with re-injury and return to sport, are required. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract.

Long Term Outcomes of Anterior Shoulder Instability in Throwers and Overhead Athletes at a Mean Follow-up of 15 years (240)

Objectives:There is a paucity of literature regarding outcomes of anterior shoulder instability (ASI) in throwers and overhead athletes (OHA). The purpose of this study was to report the pathology, treatment strategies, and outcomes of ASI in throwers and overhead athletes utilizing an established US geographic population-based cohort.Methods:An established geographic database of more than 500,000 patients was used to identify athletes <40 years of age with ASI between 1994 and 2016. Medical records were reviewed to obtain demographics, type of sport, surgical details, and clinical outcomes. Patients were contacted after final clinical follow-up for patient reported outcomes (PRO). The Western Ontario Shoulder Instability (WOSI) score, return to sport at previous level of performance (RPP), rate of return to play (RTP) and time to RTP were recorded. Statistical analysis was performed comparing throwers to non-throwers and OHA to non-overhead athletes (NOHA).Results:The study population consisted of 171 patients, 114 NOHA and 57 OHA. Of the OHA, 40 were throwers. The mean follow-up was 14.7 ± 5.6 years for PRO’s and 11.7 ± 7.3 years for last clinical evaluation. No difference in overall instability events was seen in either group. Throwers were more likely to present with subluxations while non-throwers were more likely to present with frank dislocations. NOHA and non-throwers were more likely than OHA and throwers to have a history of trauma related to ASI, respectively (P = <.001, P = .002). Throwers were more likely to undergo an open surgical procedure (45%) than non-throwers (15%) (P = .038). The rate of recurrent instability between groups was similar. Throwers returned to sport at a lower rate than non-throwers, however this did not reach significance (64% vs 83%, P = .100). Throwers and OHA reported similar WOSI scores, RPP and time to RTP grouped by surgical or conservative management compared to non-throwers and NOHA, respectively.Conclusions:In a US cohort of patients, throwers and OHA had a similar number of instability events compared to non-throwers and NOHA, respectively. Non-throwers and NOHA were more likely to present with frank dislocation which is supported by the significantly higher rates of trauma in both groups. Notably, the WOSI score, RPP, rate of RTP and time to RTP showed no difference between throwers and OHA when compared to their non-throwing and NOHA counterparts.

Return to Play in Adolescent Baseball Players after SLAP Repair (131)

Objectives:Superior labrum from anterior to posterior (SLAP) tears are increasingly common shoulder injuries in adolescent athletes who participate in repetitive overhead throwing. The purpose of this study is to evaluate adolescent baseball athletes who undergo SLAP repair in order to determine their long-term progression of play, surgical outcomes, and overall satisfaction with surgery.Methods:Patients between the ages of 10-19 who underwent a SLAP repair over a 10-year period from 2008-2018 with minimum two year follow-up were identified by a database query in the medical records of a single institution. From this cohort, non-baseball athletes and injuries to non-throwing shoulders were excluded. After identifying the cohort, patients were contacted via phone to complete functional outcome scores including Conway Score, Western Ontario Shoulder Instability (WOSI) Index, Kerlan-Jobe Orthopedic Clinic (KJOC) Shoulder and Elbow Score, Short Form 12 Mental (MCS)/Physical (PCS) survey and a custom return to play questionnaire.Results:During this time period, 59 baseball players met the inclusion criteria for this study and 76.3% (45/59) of patients were available to be contacted to complete final follow-up surveys at a minimum of 2 years. All patients were male with a mean age of 17.4 +/- 1.5 (14-19) years. The mean follow-up of this cohort was 5.3 +/- 2.6 (2.1-12.1) years. The overall return to play rate was 75.6% (34/45). The average time from surgery to initiation of throwing was 5.9 +/- 2.0 (2-12) months and the average time to return to full competition was 11.3 +/- 3.5 (6-22) months after the surgery. After the SLAP repair, those who returned to play continuing playing baseball competitively for 3.0 +/- 1.9 (0.5-8.0) years after surgery. At the time of final follow-up, 71.1% (32/45) of players had stopped playing baseball. Of those who had stopped playing competitive baseball, 12 (37.5%) reported it was because they were not recruited to the next level, 10 (31.3%) reported they lost the desire to play and 10 (31.3%) reported their shoulder prevented them from playing. The overall mean KOJC, WOSI, SF-12 MCS and SF-12 PCS scores were 60.0 +/- 27.4 (range, 0-100), 21.0+/-20.6% (0-73.8%), 55.2+/-3.9 (37.4-59.8) and 55.2+/-5.6 (range, 37.9-65.7) respectively. The overall satisfaction score was 83.2% with 86.7% (39/45) saying they given the opportunity they would undergo surgery again.Conclusions:The results of this study demonstrated a low return to play rate and low patient reported outcomes on baseball specific surveys among adolescent baseball players who underwent a SLAP repair. Mean functional outcome scores between pitchers and position players were not found to be significantly different. Based on these findings, orthopedic surgeons can better counsel their adolescent baseball players on expectations for future return to play and functional outcomes after SLAP repair.

Arthroscopic Glenoid Bone Augmentation Using Iliac Crest Autograft Is Safe and Effective for Anterior Shoulder Instability With Bone Loss

PurposeTo establish a safety profile for an arthroscopic anatomic glenoid reconstruction using autologous iliac crest bone graft to treat shoulder instability with significant bone loss and to evaluate short-term clinical and radiological outcomes.MethodsA retrospective analysis of prospectively collected data was conducted for the patients who were treated for shoulder instability with bone loss using arthroscopic autologous iliac crest bone graft between November 2014 and June 2018. The safety profile was established by detective intraoperative or postoperative complications such as neurovascular injuries, infections, major bleeding, and subluxations. Short-term clinical and radiologic outcomes also were evaluated.ResultsThirteen patients were included in the study. A safety profile was observed, with no occurrence of intraoperative complications, neurovascular injuries, infection, or major bleeding. There were no dislocations or positive apprehension tests on clinical examination postoperatively. Postoperative Western Ontario Shoulder Instability (WOSI) scores were significantly greater than preoperative WOSI scores, with a mean improvement of 35.0 ± 20.2 (P < .001). Twelve patients (92.3%) received postoperative computed tomography scans, with 11 of 12 patients (91.7%) displaying complete graft union.ConclusionsArthroscopic treatment of shoulder instability with bone loss via autologous iliac crest bone graft is shown to be a safe operative procedure that results in favourable short-term clinical and radiologic outcomes, with a significant improvement in WOSI scores and high rates of graft union. Although graft resorption was seen in most patients who had postoperative computed tomography imaging, there were no instances of clinical graft failure.Level of EvidenceLevel IV, therapeutic case series.

Résultats cliniques et reprise de l’activité sportive après un traitement chirurgical de l’instabilité antérieure récidivante de l’épaule par Latarjet modifiée

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 methodsIn all, 32 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.

Clinical Relevance of Persistent Off-Track Hill-Sachs Lesion After Arthroscopic Latarjet Procedure

Background: The Latarjet procedure is often used to address off-track Hill-Sachs lesions (OFF-HS) in shoulders with anterior instability. There are concerns as to whether the Latarjet procedure is able to convert all OFF-HS into on-track Hill-Sachs lesions (ON-HS) and whether this limitation could explain the cases of recurrent postoperative instability. Hypothesis: Latarjet surgery converts many preoperative OFF-HS lesions, but not all of them, and there is a difference in the failure rate between shoulders with converted lesions and those with persistent OFF-HS lesions. Study Design: Case series; Level of evidence, 4. Methods: Patients with anterior shoulder instability and an OFF-HS lesion treated with an arthroscopic classic Latarjet procedure between January 2010 and September 2017 were retrospectively evaluated. Patients with moderate or severe shoulder arthrosis, rotator cuff tears, or age older than 50 years were excluded. Glenoid track (GT), HS, HS interval (HSI), and the difference between HSI and GT (ΔHSI-GT) were measured preoperatively. A postoperative computed tomography scan and a clinical evaluation, including the Rowe and Western Ontario Shoulder Instability scores, were performed at a minimum 1- and 2-year follow-up, respectively. Postoperatively, 2 groups of patients were obtained: (1) patients with postoperative persistent OFF-HS; (2) patients with postoperative ON-HS. Clinical and imaging data were compared between the 2 groups. Results: A total of 51 patients (n = 51 shoulders), with a mean age of 29.8 ± 8.4 years (range, 15-50 years), met the inclusion criteria. Six shoulders (11.8%) still showed OFF-HS lesions despite Latarjet surgery. There were no postoperative dislocations, but 3 patients reported subluxations. The subluxation rate was significantly higher in the postoperative persistent OFF-HS group (2 [33%] vs 1 [2.2%]; P = .033). There was a wider preoperative HSI (29.8 ± 2.4 mm vs 22.9 ± 3.5 mm; P < .001) and a larger preoperative ΔHSI-GT (12.2 ± 3.8 mm vs 4.82 ± 3.2 mm; P < .001) in the persistent OFF-HS group. A receiver operating characteristic curve was performed based on preoperative ΔHSI-GT values. A preoperative ΔHSI-GT value ≥7.45 mm predicted a persistent OFF-HS after Latarjet surgery (sensitivity, 100%; specificity, 87%; positive predictive value, 50%; and negative predictive value, 100%). Conclusion: Latarjet surgery converted many preoperative OFF-HS lesions into ON-HS lesions, but not all of them. Six patients (11.8%) retained an OFF-HS and had a statistically significantly higher failure rate after Latarjet surgery compared with those with postoperative ON-HS lesions. Because there were few postoperative OFF-HS lesions and few recurrences, findings are statistically fragile and should be confirmed with larger series.

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.

Traumatic Glenohumeral Dislocation in Pediatric Patients Is Associated With a High Risk of Recurrent Instability.

The natural history of traumatic glenohumeral dislocation is well-established in young adults, but it is less clear in pediatric patients. We aimed to determine the rate of recurrent instability and medium-term functional outcome following shoulder dislocation in patients aged 14 years or younger. All patients aged 14 years or younger who sustained a glenohumeral dislocation from 2008 to 2019 presenting to our regional health-board were identified. Patients who had subluxations associated with generalized laxity were excluded. Data was collected regarding further dislocations, stabilization surgery, sporting activity and patient-reported outcomes using the Western Ontario Shoulder Instability (WOSI) Index and Quick Disabilities of the Arm, Shoulder, and Hand score. Forty-one patients with a radiologically confirmed traumatic glenohumeral dislocation were suitable for study inclusion [mean age at injury 12.3 y (range: 7.2 to 14.0 y), male sex 29 (70.7%), median 7.9 y follow-up]. The incidence rate of pediatric glenohumeral dislocation was 2.5 cases per 100,000 population (aged 0 to 14 y) per year. Recurrent dislocation occurred in 43.9% (n=18/41) at a median time of 14.7 months postinjury (range: 1 to 54 mo). Skeletal maturity was associated with significantly higher proportion of recurrent instability (immature 6/24 vs. mature 12/17, P=0.01). One in 5 patients required surgical intervention for recurrent instability [mean 8 (range: 1 to 14) dislocations before surgery]. Twenty-eight patients had completed outcome questionnaires. The median modified WOSI score was 87.1% [270 (interquartile range: 65 to 795)] and the median Quick Disabilities of the Arm, Shoulder, and Hand score was 3.4 (interquartile range: 0 to 9.7). Recurrent shoulder instability was significantly associated with poorer WOSI score (unstable 71.4% vs. stable 94.3%, 95% confidence interval of the difference 6.2-36.9, P=0.04). Traumatic glenohumeral dislocation in patients aged 14 years or younger occurs rarely but is not a benign event. One in 2 patients experienced recurrent dislocation and 1 in 5 ultimately underwent surgical stabilization. Level IV.

Open Classic Latarjet Procedure Performed Using Freehand Technique-Surgical Technique and Outcome.

Latarjet procedure is commonly performed for recurrent anterior shoulder instability with glenoid side bone loss. Classic Latarjet procedure can be performed using specially designed drill guides, jigs, or by freehand technique. Here we have described a technical note on classic Latarjet procedure performed with freehand technique utilizing simple rulers and caliper. The functional and radiological outcomes of our patients have also been analysed. 149 open classic Latarjet procedures were performed using our technique between March 2015 and July 2018. The mean age of the patients was 32.95years (Range 22-59years). The functional outcome of the patients was measured using Western Ontario Shoulder Instability (WOSI) and Oxford Shoulder Instability Score (OSIS) at 2years of follow-up. Screw and graft positioning were studied in 24 consecutive patients with a postoperative computed tomography (CT) scan. There was no incidence of recurrent subluxation or dislocation post-surgery. Mean OSIS score increased from 15.63 ± 3.20 preoperatively to 42.44 ± 3.88 postoperatively (p value < 0.05). WOSI score decreased significantly from 62.54% ± 8.24 to 10.26 ± 6.33 postoperatively at 2-year follow-up (p value < 0.05). Postoperative CT scan also showed satisfactory screw placement in all patients. Open Latarjet procedure performed using freehand technique provides good functional and radiological outcomes in patients with recurrent anterior shoulder instability with glenoid side bone loss. The online version contains supplementary material available at 10.1007/s43465-021-00385-7.

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.