Off-track Hill-Sachs lesions predispose to recurrence after nonoperative management of first-time anterior shoulder dislocations.

PURPOSE: The purpose of this study was to evaluate whether the presence of an off-track Hill-Sachs lesion has an impact on the recurrence rate after nonoperative management of first-time anterior shoulder dislocations. METHODS: A retrospective cohort study was planned with a follow-up via questionnaire after a minimum of 24 months. Fifty four patients were included in the study (mean age: 29.5 years; 16 female, 38 male). All of these patients opted for primary nonoperative management after first-time traumatic anterior shoulder dislocation, in some cases even against the clinician's advice. The glenoid track and the Hill-Sachs interval were evaluated in the MRI scans. The clinical outcome was evaluated via a shoulder-specific questionnaire, ASES-Score and Constant Score. Further, patients were asked to report on recurrent dislocation (yes/no), time to recurrent dislocation, pain, feeling of instability and satisfaction with nonoperative management. RESULTS: In 7 (13%) patients, an off-track Hill-Sachs lesion was present, while in 36 (67%) the lesion was on-track and 11 (20%) did not have a structural Hill-Sachs lesion at all. In total, 31 (57%) patients suffered recurrent dislocations. In the off-track group, all shoulders dislocated again (100%), while 21 (58%) in the on-track group and 3 (27%) in the no structural Hill--Sachs lesion group had a recurrent dislocation, p = 0.008. The mean age in the group with a recurrence was 23.7 ± 10.1 years, while those patients without recurrent dislocation were 37.4 ± 13.1 years old, p < 0.01. The risk for recurrence in patients under 30 years of age was higher than in those older than 30 years (OR = 12.66, p < 0.001). There were no significant differences between patients with on- and off-track lesions regarding patients' sex, height, weight and time to reduction and glenoid diameter. Off-track patients were younger than on-track patients (24.9 ± 7.3 years vs. 29.6 ± 13.6 years). However, this difference was not statistically significant. CONCLUSION: The presence of an off-track Hill-Sachs lesion leads to significantly higher recurrence rates compared to on-track or no structural Hill--Sachs lesions in patients with nonoperative management and should be considered when choosing the right treatment option. Therefore, surgical intervention should be considered in patients with off-track Hill-Sachs lesions. LEVEL OF EVIDENCE: IV.

Postoperative Recurrence of Instability After Arthroscopic Bankart Repair for Shoulders With Primary Instability Compared With Recurrent Instability: Influence of Bipolar Bone Defect Size.

BACKGROUND: In shoulders with traumatic anterior instability, a bipolar bone defect has recently been recognized as an important indicator of the prognosis. PURPOSE: To investigate the influence of bipolar bone defects on postoperative recurrence after arthroscopic Bankart repair performed at primary instability. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The study group consisted of 45 patients (45 shoulders) who underwent arthroscopic Bankart repair at primary instability before recurrence and were followed for at least 2 years. The control group consisted of 95 patients (95 shoulders) with recurrent instability who underwent Bankart repair and were followed for at least 2 years. Glenoid defects and Hill-Sachs lesions were classified into 5 size categories on 3-dimensional computed tomography and were allocated scores ranging from 0 for no defect to 4 for the largest defect. The shoulders were classified according to the total score for both lesions (0-8 points). The postoperative recurrence rate was investigated for each score of bipolar bone defects and was compared between patients with primary instability and patients with recurrent instability. The same analysis was performed for the age at operation (<20 years, 20-29 years, or ≥30 years) and for the presence of an off-track Hill-Sachs lesion. RESULTS: Bipolar bone defects were smaller in shoulders with primary instability (mean ± SD defect score, 1.4 ± 1.5 points) than in those with recurrent instability (3.6 ± 1.9 points) and were larger in older patients than in younger patients at the time of primary instability. The postoperative recurrence rate was low (6.7%) in shoulders with primary instability regardless of the size of the bipolar bone defect and the patient's age, whereas the postoperative recurrence rate was high (23.2%) in shoulders with recurrent instability, especially among patients younger than 20 years with bipolar bone defects of 2 points or greater. An off-track Hill-Sachs lesion was found in only 1 patient in the oldest age group (2.2%) at primary instability, but it was found in 19 patients (20%) at recurrent instability, including 14 patients younger than 30 years. Among patients with an off-track lesion, the postoperative recurrence rate was significantly higher in patients younger than 20 years with recurrent instability (recurrence rates: <20 years, 71.4%; 20-29 years, 14.3%; ≥30 years, 0%). CONCLUSION: The recurrence rate was consistently low in patients with primary instability and was significantly influenced by bipolar bone defect size and patient age in patients with recurrent instability.

Descriptive Epidemiology of the MOON Shoulder Instability Cohort.

BACKGROUND: Shoulder instability is a common diagnosis among patients undergoing shoulder surgery. PURPOSE: To perform a descriptive analysis of patients undergoing surgery for shoulder instability through a large multicenter consortium. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients undergoing surgery for shoulder instability who were enrolled in the MOON Shoulder Instability Study were included. Baseline demographics included age, sex, body mass index, and race. Baseline patient-reported outcomes (PROs) included the American Shoulder and Elbow Surgeons (ASES) score, Shoulder Activity Score, Western Ontario Shoulder Instability Index (WOSI), 36-Item Health Survey (RAND-36), and Single Assessment Numeric Evaluation (SANE). The preoperative physician examination included active range of motion (ROM) and strength testing. Preoperative imaging assessments with plain radiography, magnetic resonance imaging (MRI), and computed tomography were also included and analyzed. RESULTS: Twenty-six surgeons had enrolled 863 patients (709 male, 154 female) across 10 clinical sites. The mean age for the cohort was 24 years (range, 12-63 years). Male patients represented 82% of the cohort. The primary direction of instability was anterior for both male (74%) and female (73%) patients. Football (24%) and basketball (13%) were the most common sports in which the primary shoulder injury occurred. No clinically significant differences were found in preoperative ROM between the affected and unaffected sides for any measurement taken. Preoperative MRI scans were obtained in 798 patients (92%). An anterior labral tear was the most common injury found on preoperative MRI, seen in 66% of patients, followed by a Hill-Sachs lesion in 41%. Poor PRO scores were recorded preoperatively (mean: ASES, 72.4; WOSI, 43.3; SANE, 46.6). CONCLUSION: The MOON Shoulder Instability Study has enrolled the largest cohort of patients undergoing shoulder stabilization to date. Anterior instability is most common among shoulder instability patients, and most patients undergoing shoulder stabilization are in their early 20s or younger. The results of this study provide important epidemiological information for patients undergoing shoulder stabilization surgery.

Clinical Outcome of Arthroscopic Bankart Repair Combined With Simultaneous Capsular Repair.

BACKGROUND: A capsular tear and humeral avulsion of the glenohumeral ligament lesion are not uncommon findings in association with a Bankart lesion. However, there have been few reports regarding the prevalence of such capsular lesions and the postoperative recurrence after capsular repair. Purpose/Hypothesis: This study investigated the prevalence of capsular lesions and clarified their influence on the postoperative recurrence of instability. In addition, factors were identified that were associated with the occurrence of capsular lesions and the postoperative recurrence of instability. We hypothesized that clinical outcomes would be improved by combining arthroscopic Bankart repair with simultaneous capsular repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Capsular lesions were retrospectively examined through operative records, still pictures, and videos in 172 shoulders with traumatic anterior instability. First, the prevalence of capsular lesions and their severity were investigated. Then, postoperative recurrence was determined in shoulders observed for a minimum of 2 years. Finally, factors were assessed that were associated with the occurrence of capsular lesions and the postoperative recurrence of instability. RESULTS: A capsular lesion was recognized in 37 shoulders (21.5%), being severe and mild in 20 and 17, respectively. All were repaired simultaneously with the arthroscopic Bankart procedure. After follow-up for at least 2 years, recurrence of instability was detected in 10 of 34 shoulders (29.4%), including 6 (31.6%) with severe capsular lesions and 4 (26.7%) with mild lesions. The recurrence rate was significantly higher in shoulders with a capsular lesion than in shoulders without a capsular lesion (18 of 120, 15%; P = .013), but there was no significant difference between severe and mild lesions. Regardless of the sport played, capsular lesions were significantly more frequent in patients ≥30 years old, patients with complete dislocation, and patients with a coexisting Hill-Sachs lesion. Postoperative recurrence of instability was significantly more frequent in patients <30 years and competitive athletes. CONCLUSION: In shoulders undergoing arthroscopic Bankart repair, capsular lesions were often present and were associated with higher postoperative recurrence of instability. While these lesions were more frequent in older patients, postoperative recurrence of instability was more likely in young competitive athletes.