Defining Critical Humeral Bone Loss: Inferior Craniocaudal Hill-Sachs Extension as Predictor of Recurrent Instability After Primary Arthroscopic Bankart Repair.

BACKGROUND: The glenoid track concept for shoulder instability primarily describes the medial-lateral relationship between a Hill-Sachs lesion and the glenoid. However, the Hill-Sachs position in the craniocaudal dimension has not been thoroughly studied. HYPOTHESIS: Hill-Sachs lesions with greater inferior extension are associated with increased risk of recurrent instability after primary arthroscopic Bankart repair. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The authors performed a retrospective analysis of patients with on-track Hill-Sachs lesions who underwent primary arthroscopic Bankart repair (without remplissage) between 2007 and 2019 and had a minimum 2-year follow-up. Recurrent instability was defined as recurrent dislocation or subluxation after the index procedure. The craniocaudal position of the Hill-Sachs lesion was measured against the midhumeral axis on sagittal magnetic resonance imaging (MRI) using either a Hill-Sachs bisecting line through the humeral head center (sagittal midpoint angle [SMA], a measure of Hill-Sachs craniocaudal position) or a line tangent to the inferior Hill-Sachs edge (lower-edge angle [LEA], a measure of Hill-Sachs caudal extension). Univariate and multivariate regression were used to determine the predictive value of both SMA and LEA for recurrent instability. RESULTS: In total, 176 patients were included with a mean age of 20.6 years, mean follow-up of 5.9 years, and contact sport participation of 69.3%. Of these patients, 42 (23.9%) experienced recurrent instability (30 dislocations, 12 subluxations) at a mean time of 1.7 years after surgery. Recurrent instability was found to be significantly associated with LEA >90° (ie, Hill-Sachs lesions extending below the humeral head equator), with an OR of 3.29 (P = .022). SMA predicted recurrent instability to a lesser degree (OR, 2.22; P = .052). Post hoc evaluation demonstrated that LEA >90° predicted recurrent dislocations (subset of recurrent instability) with an OR of 4.80 (P = .003). LEA and SMA were found to be collinear with Hill-Sachs interval and distance to dislocation, suggesting that greater LEA and SMA proportionally reflect lesion severity in both the craniocaudal and medial-lateral dimensions. CONCLUSION: Inferior extension of an otherwise on-track Hill-Sachs lesion is a highly predictive risk factor for recurrent instability after primary arthroscopic Bankart repair. Evaluation of Hill-Sachs extension below the humeral equator (inferior equatorial extension) on sagittal MRI is a clinically facile screening tool for higher-risk lesions with subcritical glenoid bone loss. This threshold for critical humeral bone loss may inform surgical stratification for procedures such as remplissage or other approaches for at-risk on-track lesions.

Humeral Head Reconstruction of Reverse Hill-Sachs Lesions.

Compared with anterior instability, posterior shoulder dislocations are a rare entity and are often missed at presentation. A concomitant anteromedial impression fracture of the humeral head, or a reverse Hill-Sachs lesion, is commonly present with these dislocations and is more pronounced with a longer timeline to reduction. Treatment of these defects ranges from nonsurgical treatment to soft-tissue procedures, bony reconstruction, and arthroplasty. Management may be dictated by various factors, such as patient demands, defect size and location, concomitant injuries, and underlying etiology. Small reverse Hill-Sachs defects without engagement can generally be treated nonsurgically or with benign neglect, whereas larger defects (>20%) often require surgery. The most reported surgical techniques are the (arthroscopic) McLaughlin and modified McLaughlin procedure, disimpaction and bone grafting, or reconstruction of the defect with autograft or with fresh (or fresh-frozen) osteochondral allograft. Finally, arthroplasty is generally required for large defects, where more than 45% to 50% of the articular cartilage is involved. Overall, reported outcomes generally reflect patient satisfaction for most patients, with a low incidence of secondary instability or posttraumatic arthritis, although better results are achieved when recognizing and treating these injuries in the more acute setting.

Simultaneous acromioclavicular dislocation, proximal humeral fracture, and reverse Hill-Sachs lesion: a case report.

BACKGROUND: In cases with injuries to the shoulder region, the combination of acromioclavicular joint dislocation, reverse Hill-Sachs lesion, and proximal humeral fracture is a very rare condition. CASE PRESENTATION: This study described a 38-year-old male Persian patient with simultaneous acromioclavicular joint dislocation, proximal humeral fracture, and reverse Hill-Sachs lesion due to motor vehicle crash injury who underwent arthroscopic acromioclavicular joint fixation using tight rope technique. In the 7-month follow-up period following the surgical fixation, range of motion was approximately normal. Reduction and hardware were intact, no dislocation or apprehension to dislocation was observed. Patient only had minor shoulder pain at the end of range of motion and a dull pain on the site of incision over the clavicle in deep touch. Our findings showed acceptable arthroscopic outcomes in the management of such complex case. CONCLUSION: Our experience on this case showed acceptable outcomes of the arthroscopic treatment of the acromioclavicular joint dislocation in the management of such a complex case with associated injuries to the shoulder region.

Editorial Commentary: Shoulder Remplissage Is a Beneficial Addition to Bankart or Glenoid Bone Loss Treatment: Stay on Track and Use Wisely.

In patients with on-track shoulder Hill-Sachs lesions, the addition of remplissage using a double-pulley technique to Bankart repair improves outcomes including residual apprehension and without loss of external rotation. A caveat is that measurement of both the Hill-Sachs lesion and glenoid bone loss may be inconsistent. A second caveat is that determination of the glenoid track can be affected by scapular positioning. Not all "on-track" lesions are alike. In terms of outcome assessment, apprehension has up to 95% specificity for anterior shoulder instability and is a key finding in determining the results of shoulder stabilization. Recurrent instability may not be as sensitive of an outcome measure, because patients will avoid positions of apprehension. Finally, remplissage should be used cautiously in peripheral track lesions. For smaller Hill-Sachs lesions, remplissage can provide extraordinary success, and for larger lesions that are close to engaging, glenoid bone loss must also be treated, especially in a younger, active patient.

A novel modified McLaughlin surgery for treating locked chronic posterior shoulder dislocation.

BACKGROUND: Posterior shoulder dislocation is an uncommon orthopaedics injury and is frequently missed or misdiagnosed, accounting for 2%-4% of all shoulder dislocations, and is associated with the reverse Hill-Sachs lesion. Once posterior shoulder dislocation develops into a chronic disease, it will bring a lot of trouble to the treatment, especially in repairing the humeral defects. Surgical strategies are also developing and innovating to deal with this injury, including transfer of subscapularis tendon or lesser tubercle, humeral rotational osteotomy, autogenous bone graft or allograft. Shoulder replacement seems to be the ultimate and only option when the injury becomes irreparable, although some studies have shown unsatisfactory follow-up results. Considering no gold-standard treatment for locked posterior shoulder dislocation, we described a novel modified McLaughlin procedure for locked chronic posterior shoulder dislocation and evaluated the functional outcomes. METHODS: This study included five locked chronic posterior shoulder dislocation patients with an associated reverse Hill-Sachs lesion, in which the compression surface covered 30-40% of the humeral head. The mean period from injury to receiving surgery was 11.6 weeks (6-24 weeks). All five patients underwent the modified McLaughlin procedure, mainly divided into three steps, including open reduction, transfer of the partial lesser tuberosity and artificial bone to repair the reverse Hill-Sachs defects. The kernel technique was to fix the transferred tuberosity with two lag screws and strengthen it with two Ethibond sutures. The Constant-Murley score (CMS), the range of shoulder motion and the complications were recorded to assess and compare the functional situation of the shoulder postoperatively and postoperatively. RESULTS: After an average of 19.8 months (12-30) of follow-up, the mean CMS improved to 85.8 ± 4.9 (79-91) compared with 46.0 ± 4.5 (40-52) preoperatively, which showed a significant difference (p = 0.001). In the final follow-up, all five patients showed no symptoms of shoulder instability, and there was no pain or limited activity in daily life, thus all patients were satisfied with the results. CONCLUSION: Repairing the reverse Hill-Sachs lesion by transferring the partial lesser tuberosity combined with artificial bone fixed by lag screws and sutures can ensure shoulder stability and provide pain relief and good function in patients with locked chronic posterior shoulder dislocation associated with the humeral head defect.

Long-term recurrence rate in anterior shoulder instability after Bankart repair based on the on- and off-track concept.

BACKGROUND: Since its first proposal, the concept of on- and off-track lesions in anterior shoulder instability has gained clinical relevance as a tool to predict the failure rate of arthroscopic Bankart repair. Current literature only reports either short-term follow-up or long-term results of small sample sizes. The aim of this study was to provide a long-term evaluation of recurrent instability following arthroscopic Bankart repair in a large cohort using the on-track vs. off-track concept as a predictor for failure. METHODS: We retrospectively analyzed 271 patients who underwent primary arthroscopic Bankart repair for anterior shoulder instability between 1998 and 2007. All patients with a minimum follow-up of 78 months and a preoperative computed tomographic (CT) or magnetic resonance imaging (MRI) scan were included into the study. Preoperative CT and/or MRI scans were used to determine the glenoid track and width of Hill-Sachs lesion. Recurrence of instability was defined as presence of instability symptoms (dislocation, subluxation, and/or apprehension) or revision surgery (stabilization procedure) and was assessed as the primary outcome parameter. RESULTS: The glenoid track of 163 shoulders was assessed (female n = 51, male n = 112) with a mean follow-up of 124 months (99.4-145.6, standard deviation = 2.5) and a mean age of 24 years (20-34.). An off-track Hill-Sachs lesion was found in 77 cases (47%), and in 86 cases (53 %) it was on-track. The rate of recurrent instability in the off-track group was 74% (n = 57) compared with 27% (n = 23) in the on-track group (P < .001). The overall rate of revision surgery due to instability was 29% (n = 48) after a mean time of 50.9 months (±42.8) following Bankart repair. The rate of revision surgery in the off-track group was 48% (n = 37) after a mean of 53.5 months (±42.0) vs. 13% (n = 11) after 42.3 months (±46.3) in the on-track group (P < .001). CONCLUSION: This study shows that the on- and off-track concept helps to distinguish patients for whom an isolated arthroscopic Bankart repair yields long-term benefits. Because of the high rate of recurrent instability in the off-track group, an off-track lesion should be treated surgically in such a way that the off-track lesion is converted into an on-track lesion.

Editorial Commentary: Arthroscopic Bankart Repair With Remplissage, Irrespective of Glenoid Bone Loss, May Be Advantageous Over Latarjet: Don't Widen the Lane, Just Fill in the Pothole!

Anterior glenohumeral instability has an incidence of 21.9 individuals per 100,000 in the general population. When recurrent instability occurs, bone loss to the anteroinferior glenoid can occur. The concept of "on-track" and "off-track" Hill-Sachs lesions is significant in cases of bipolar bone loss, because if humeral-sided bony injury also requires treatment, a remplissage combined with arthroscopic Bankart repair (ABR) may be an alternative to a Latarjet procedure. The Latarjet often is touted as a "definitive," because it adds bone to increase the glenoid surface area that the humeral head must travel to dislocate, and adds the dynamic "sling effect" of the conjoint tendon to further tension the lower part of the subscapularis in abduction and reduce anterior-directed forces. However, compared with ABR plus remplissage, Latarjet shows a greater risk of complications: as high as a 7.37 times relative risk. As an evidence-based surgeon who believes in the power of soft-tissue repair plus ABR, I prefer to avoid the increased complication risks of a primary Latarjet when possible. Also, my patients describe the postoperative shoulder as feeling more like the contralateral, unaffected shoulder after ABR than Latarjet.

[Bilateral posterior shoulder dislocation with associated reverse Hill-Sachs lesions after electrical injury].

After workers suffer electric shock, the ankylosis and contraction of muscle groups around the shoulder joint are more likely to lead to posterior dislocation and fracture, of which 80% are complicated with reverse Hill-Sachs injury of humeral head. This paper reports a case of bilateral posterior dislocation of shoulder joint combined with Hill-Sachs injury caused by electric shock in the Department of Orthopedics, Affiliated Huzhou Hospital, Zhejiang University School of Medicine in August 2020. The diagnosis of left posterior shoulder dislocation was clear, and the diagnosis of right posterior shoulder dislocation was missed. The patient successfully reconstructed the stability of the shoulder joint by actively performing shoulder arthroscopic surgery to repair the joint capsule. After 6 months of follow-up, there was no further dislocation and the function was good.

Two-year follow-up after operative treatment of an osseous Bankart lesion with a flap-detached cartilage lesion of the glenoid: A case report.

Glenoid articular cartilage lesion is a rare complication following traumatic anterior dislocation of the shoulder. We report the case of a 14-year-old male rugby player with traumatic anterior shoulder instability, an extensively flapped lesion on the glenoid articular cartilage, and an osseous Bankart lesion. Arthroscopic findings revealed that the glenoid cartilage was flap-detached, extending from the anteroinferior to the center. Repair of the osseous Bankart lesion using suture anchors and resection of the unstable peripheral part of the cartilage was performed arthroscopically. The main region of the injured articular surface was left untouched. During postoperative follow-up, absorption of the glenoid articular surface near the suture anchor holes was identified. Arthroscopic examination three months post-surgery showed that the flap detached lesion of the residual cartilage was stable and appeared adapted on the glenoid surface. The resected area was covered by fibrous tissue. A follow-up computed tomography scan revealed that the osseous lesion was united. The patient returned to his previous sports capacity eight months following the operation. At the 2-year-follow-up, magnetic resonance imaging revealed that the glenoid surface was remodeled to a flattened round shape with no signs of osteoarthritis, exhibiting proper conformity of the joint surfaces to the humeral head. Arthroscopic Bankart repair using suture anchors may cause bone resorption at the glenoid surface, leading to remodeling of the glenoid surface from the damaged glenoid cartilage lesion in young patients.

Microinstability characterised by small and easily overlooked anterior labral or Hill-Sachs lesions can be managed with arthroscopic anterior labral repair.

PURPOSE: Some young individuals present with shoulder pain without a definite history or complaint of instability. However, careful history taking, physical examination, and high-quality magnetic resonance imaging may reveal evidence of instability of which the patient is unaware. Therefore, a clearer definition of these ambiguous patients is needed. This study aimed to report the characteristics and surgical outcomes of patients with microinstability compared to those of patients with classic recurrent anterior shoulder instability. METHODS: From 2005 to 2018, 35 patients with microinstability (group M) underwent arthroscopic anterior labral repair (AALR) and were compared to 35 sex- and age-matched patients with classic recurrent anterior shoulder instability (group C) who also underwent AALR. Baseline characteristics, preoperative apprehension test findings, preoperative imaging for the presence of anterior labral and Hill-Sachs lesions, preoperative and postoperative (over 2 years) range of motion (ROM) and functional scores, final complications, and patient satisfaction were analysed. RESULTS: The most common chief complaints in groups M and C were pain (29/35) and both pain and instability (27/35), respectively. Only pain during the apprehension test was predominant in group M (M vs. C, 27 vs. 1, p < 0.001). High incidence of chronic repetitive injuries (26/35) and acute trauma (28/35) were observed in groups M and C, respectively. Over half of the patients in group M showed anterior labral lesions on magnetic resonance arthrography (MRA, 18/35), and 21 patients had Hill-Sachs lesions on MRA/three-dimensional computed tomography. Finally, 29 patients showed either anterior labral or Hill-Sachs lesions on preoperative imaging. The lesion severity was higher in group C than that in group M. All patients underwent AALR with/without the remplissage procedure, with no significant differences in final clinical outcomes, complications, and patient satisfaction between the groups. CONCLUSIONS: Microinstability is diagnostically challenging and can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability. Pain on anterior apprehension test and subtle labral and/or Hill-Sachs lesion on imaging study could be diagnostic clues. This condition can be managed with arthroscopic anterior labral repair with or without the remplissage procedure. The possibility of microinstability in young patients with shoulder pain should always be considered, and small anterior labral or Hill-Sachs lesions should be closely monitored. LEVEL OF EVIDENCE: III.

On-the-Edge Anchor Placement May Be Protective Against Glenoid Rim Erosion After Arthroscopic Bankart Repair Compared to On-the-Face Anchor Placement.

PURPOSE: This retrospective study aimed to compare the effects of 2 different anchoring placements on glenoid rim erosion after arthroscopic Bankart repair (ABR). METHODS: Shoulders that underwent ABR from January 2013 to July 2020 were divided into 2 groups according to anchor placement (on-the-face, group F; on-the-edge, group E). We retrospectively calculated the percent change of glenoid width (Δ) on the first postoperative computed tomography scan (CT; performed within 6 months) and second postoperative CT (performed at 6 to 12 months) relative to the width on the preoperative CT and compared percent changes between the 2 groups. Also, we investigated the influence of preoperative glenoid structures (normal, erosion, bony Bankart) and the postoperative recurrence rate. RESULTS: We examined 225 shoulders in 214 patients (group F, n = 151; group E, n = 74). At first CT, anchoring placement was significantly associated with postoperative decrease of glenoid width (group F, -7.6% ± 7.9%; group E, -0.1% ± 9.7%; P < .0001). The difference between groups F and E was significant in shoulders with a preoperative glenoid defect (bony Bankart, -6.6% ± 8.8% vs 2.5% ± 11.2%, respectively; P < .0001; erosion, -6.6% ± 6.2% vs -2.6% ± 5.3%, respectively; P = .03). In 112 shoulders, CT was performed twice; Δ was -6.9% ± 7.3% in group F (n = 64) and -1.7% ± 10.1% in group E (n = 48; P = .005) at the first CT and -3.2% ± 10.0% and 1.0% ± 10.6% (P = .10), respectively, at the second CT, indicating recovery of glenoid width in both groups. The postoperative recurrence rate in patients with at least 2 years' follow-up was 14.7% in group F and 14.6% in group E. CONCLUSIONS: In the early stage after ABR, on-the-edge glenoid anchor placement was associated with less glenoid rim erosion than on-the-face anchor placement. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Glenoid track measurement using magnetic resonance imaging arthrography is predictive of recurrent instability following arthroscopic shoulder stabilisation.

PURPOSE: The primary aim of this study was to investigate medium-term survivorship following arthroscopic Bankart repair (ABR) for anterior glenohumeral instability. The secondary aim was to determine whether the pre-operative magnetic resonance (MR) arthrography glenoid track measurement predicted recurrent instability following ABR. METHODS: Over a 9-year period (2008-2017), 215 patients underwent ABR. Median age was 26 years (IQR 22-32.5; range 14-77). There were 173 males (81%). 175 patients (81%) had available pre-operative MR arthrography, which was used to determine the presence of "off-track" bone loss. Retrospective analysis was undertaken to determine recurrence of instability at a median follow-up of 76 months (range 21-125 months). Survivorship analysis was undertaken using Kaplan-Meier methodology: the endpoints examined were repeat dislocation, revision stabilisation, and symptomatic instability. RESULTS: 56 patients (26%) presented with further instability, including 29 patients with recurrent dislocation and 15 patients required revision stabilisation. Cumulative incidence of instability was 10% at 1 year, 27% at 5 years and 28% at 7 years. No significant difference in instability was seen between men and women 7 years after stabilisation (19% vs 17%; p = 0.87). Age at time of surgery did not predict recurrence. "Off-track" lesions were identified in 29 patients (16.1%). The incidence of redislocation was significantly higher in these patients (24% vs 3%; p = 0.01; relative risk 7.2; 95% CI 2.45-20.5; p = 0.001). Recurrent instability without frank redislocation was also significantly higher in this group (60% vs 18%; RR 3.33, 95% CI 2.02-5.20; p < 0.0001). CONCLUSIONS: This study has reported a significant rate of recurrent instability in longer-term follow-up after ABR. It has also identified pre-operative MR arthrography as an important predictor of recurrent instability, which may be used to risk stratify patients with anterior instability in a typical UK population. LEVEL OF EVIDENCE: III (cohort study).

Arthroscopic Bankart repair with an individualized capsular shift restores physiological capsular volume in patients with anterior shoulder instability.

PURPOSE: Capsular volume reduction in the context of anterior arthroscopic shoulder stabilization represents an important but uncontrolled parameter. The aim of this study was to analyse capsular volume reduction by arthroscopic Bankart repair with an individualized capsular shift in patients with and without ligamentous hyperlaxity compared to a control group. METHODS: In the context of a prospective controlled study, intraoperative capsular volume measurements were performed in 32 patients with anterior shoulder instability before and after arthroscopic Bankart repair with an individualized capsular shift. The results were compared to those of a control group of 50 patients without instability. Physiological shoulder joint volumes were calculated and correlated with biometric parameters (sex, age, height, weight and BMI). RESULTS: Patients with anterior shoulder instability showed a mean preinterventional capsular volume of 35.6 ± 10.6 mL, which was found to be significantly reduced to 19.3 ± 5.4 mL following arthroscopic Bankart repair with an individualized capsular shift (relative capsular volume reduction: 45.9 ± 21.9%; P < 0.01). Pre-interventional volumes were significantly greater in hyperlax than in non-hyperlax patients, while post-interventional volumes did not differ significantly. The average shoulder joint volume of the control group was 21.1 ± 7.0 mL, which was significantly correlated with sex, height and weight (P < 0.01). Postinterventional capsular volumes did not significantly differ from those of the controls (n.s.). CONCLUSION: Arthroscopic Bankart repair with an individualized capsular shift enabled the restoration of physiological capsular volume conditions in hyperlax and non-hyperlax patients with anterior shoulder instability. Current findings allow for individual adjustment and intraoperative control of capsular volume reduction to avoid over- or under correction of the shoulder joint volume. Future clinical studies should evaluate, whether individualized approaches to arthroscopic shoulder stabilization are associated with superior clinical outcome.

The Hill-Sachs interval to glenoid track width ratio is comparable to the instability severity index score for predicting risk of recurrent instability after arthroscopic Bankart repair.

PURPOSE: The purpose of this study was to clinically validate the Hill-Sachs interval to glenoid track width ratio (H/G ratio) compared with the instability severity index (ISI) score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair. METHODS: A retrospective evaluation was performed using data from patients with anteroinferior shoulder instability who underwent arthroscopic Bankart repair with a follow-up period of at least 24 months. A receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values for the H/G ratio and the ISI score to predict an increased risk of recurrent instability. The area under the ROC curve (AUC) of the two methods and the sensitivity and specificity of their optimal cut-off values were compared. RESULTS: A total of 222 patients were included, among whom 31 (14.0%) experienced recurrent instability during the follow-up period. The optimal cut-off values for predicting an increased risk of recurrent instability were an H/G ratio of ≥ 0.7 and ISI score of ≥ 4. There were no significant differences between the AUC of the two methods (H/G ratio AUC = 0.821, standard error = 0.035 and ISI score AUC = 0.792, standard error = 0.04; n.s.) nor between the sensitivity and specificity of the optimal cut-off values (n.s. and n.s., respectively). CONCLUSIONS: The H/G ratio is comparable to the ISI score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair. Surgeons are recommended to consider other strategies to treat anterior shoulder instability if H/G ratio is ≥ 0.7. LEVEL OF EVIDENCE: III.

Humeral Head Osteochondral Allograft Reconstruction with Arthroscopic Anterior Shoulder Stabilization at a Long-Term Follow-Up: A Case Report.

CASE: The authors report a case of recurrent anterior shoulder instability in a 19-year-old man. Intraoperative arthroscopic examination identified Bankart and engaging Hill-Sachs lesions. The patient was treated with humeral head osteochondral allograft reconstruction and concomitant arthroscopic anterior stabilization. At the 14-year follow-up, there was no recurrent instability. CONCLUSION: Humeral head osteochondral allograft reconstruction combined with an arthroscopic anterior stabilization procedure can be successful for recurrent shoulder instability and engaging Hill-Sachs lesion.

Mid-term to long-term results of primary arthroscopic Bankart repair for traumatic anterior shoulder instability: a retrospective study.

BACKGROUND: The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. The aim of the study is to determine the mid-/long-term functional outcome, failure rates and predictors of failure after primary arthroscopic Bankart repair for traumatic anterior shoulder instability. METHODS: A total of 100 patients were primarily operated using arthroscopic Bankart repair after traumatic anterior shoulder instability. Medical records were retrospectively reviewed, and patients were assessed using postal questionnaire after a mean follow-up of 8.3 years [3-14]. Clinical assessment was performed using Constant score, Rowe score, and American Shoulder and Elbow Surgeons score. RESULTS: The overall recurrence rate was 22%. The Kaplan-Meier failure-free survival estimates. were 80% at 5 years and 70% at 10 years. Nearly half (54.5%) of recurrences occurred at 2 years postoperative. Compared with normal shoulder, there were statistical differences in all 3 scores. Failure rate was significantly affected by age at the time of surgery with 86% of recurrence cases observed in patients aged 30 years or younger. Nevertheless, Younger age at the time of surgery (P = 0.007) as well age at the time of initial instability (P = 0.03) was found to correlate negatively with early recurrence within 2 years of surgery. Among those with recurrent instability, recurrence rate was found to be higher if there had been more than 5 instability episodes preoperatively (P = 0.01). Return to the preinjury sport and occupational level was possible in 41 and 78%, respectively. CONCLUSION: Failure-free survival rates dropped dramatically over time. Alternative reconstruction techniques should be considered in those aged ≤30 years due to the high recurrence rate.

Type V superior labral anterior-posterior (SLAP) lesion in recurrent anterior glenohumeral instability.

BACKGROUND: The literature has reported debatable diagnostic accuracy of clinical provocative tests for a type II superior labral anteroposterior (SLAP) lesion, especially in the context of a type V SLAP (concurrent Bankart and type II SLAP) lesion. This study was conducted to determine whether the investigated provocative tests offer reliable predictive values in the diagnosis of type II SLAP lesions in patients with recurrent anterior glenohumeral (GH) instability. METHODS: This prospective case-control study carried out between September 2014 and September 2018 included 51 patients with post-traumatic recurrent anterior GH instability. Patients were prospectively evaluated for type II SLAP lesions by 9 provocative tests: Jobe relocation test, abduction-external rotation test, anterior slide test, biceps load test I, biceps load test II, pain provocation test, labral tension test, crank test, and the O'Driscoll dynamic labral shear test. The results of these tests were compared with findings of diagnostic arthroscopic GH examinations (control). RESULTS: Statistical analysis revealed the mean age of the studied group to be 26.1 ± 7.56 years, with male predominance (50 patients; 98.04%). Arthroscopic examination revealed a Bankart lesion in isolation and in association with a type II SLAP lesion (ie, a type V SLAP lesion) in 15 (29.4%) and 36 (70.6%) patients, respectively. The anterior slide test yielded the highest positive and lowest negative likelihood ratios (2.91 and 0.52, respectively). CONCLUSION: Except for the anterior slide test, which can be validated for the clinical diagnosis of type II SLAP lesions in patients with traumatic recurrent anterior GH instability, the investigated tests offer poor predictive values and should be cautiously used in clinical practice.

Progression of Erosive Changes of Glenoid Rim After Arthroscopic Bankart Repair.

PURPOSE: To evaluate changes of the glenoid after arthroscopic Bankart repair (ABR) in patients with different preoperative glenoid structures. METHODS: Patients who underwent ABR for traumatic anterior shoulder instability were retrospectively investigated. They were divided into 3 groups on the basis of preoperative glenoid structure by computed tomography (CT): normal glenoid (group N), glenoid erosion (group E), or glenoid defect associated with a bony Bankart lesion (group B). Shoulders in group B were also stratified according to the postoperative status of the bone fragment (union, nonunion, or resorbed). Postoperative changes of glenoid width (Δ) (increase: Δ ≥5%, stable: Δ >-5% to <5%, decrease: Δ ≤-5%) and the extent of glenoid bone loss were investigated by 3-dimensional CT. RESULTS: A total of 186 shoulders were divided into 3 groups: group N (n = 61), group E (n = 46), and group B (n = 79). At initial postoperative CT, the glenoid width was decreased in 41 shoulders, stable in 20 shoulders, and increased in no shoulders from group N. The respective numbers were 27, 18, and 1 in group E, and 50, 22, and 7 in group B. The glenoid width was reduced in all groups (mean percent change: -8.8%, -5.9%, and -6.1%, respectively). In group B, glenoid width decreased in most of the shoulders without bone union. The glenoid bone loss on the preoperative and postoperative final CT was, respectively, 0% and 8.6% in group N (P < .0001), 9.9% and 12.4% in group E (P = .03), and 10.4% and 7.2% in group B (P = .01). Final glenoid bone loss >13.5% was recognized in 18.2% of group N, 35.7% of group E, and 21.8% of group B. CONCLUSIONS: Glenoid width often decreased after ABR because of anterior glenoid rim erosion, and this change was frequent in patients with preoperative normal glenoid, glenoid erosion, or without postoperative union of a bony Bankart lesion. LEVEL OF EVIDENCE: Level 3, Case-control study.

[Arthroscopic treatment of irreducible hip posterior dislocation caused by acetabular labrum bony Bankart lesions].

OBJECTIVE: To investigate the effectiveness of arthroscopic treatment for irreducible hip posterior dislocation caused by acetabular labrum bony Bankart lesions. METHODS: Between February 2008 and August 2016, 11 patients with irreducible hip posterior dislocation caused by acetabular labrum bony Bankart lesions, were treated with arthroscopic reduction and fixation of bony Bankart lesions. There were 7 males and 4 females, with an average age of 23.7 years (mean, 15-36 years). The injury was caused by traffic accident in 8 cases and falling from height in 3 cases. The interval between hip dislocation and the first manual reduction was 2-8 hours (mean, 5.3 hours) and between the first manual reduction and arthroscopic surgery was 6-31 days (mean, 12.8 days). The preoperative visual analogue scale (VAS) was 5.2±0.9, the modified Harris score was 32±8, and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) was 30±5. RESULTS: The operative time was 90-150 minutes (mean, 120.9 minutes), with no hip arthroscopic surgery related complications. All incisions healed by first intention. All patients were followed up 26-68 months (mean, 42.7 months). Postoperative X-ray films showed that all hip joints were reduction; CT showed that the reduction of posterior acetabular wall fracture was satisfactory. And all fractures healed at last follow-up with no avascular necrosis of the femoral head or osteoarthritis. At last follow-up, the VAS score was 0.5±0.5, the modified Harris score was 94±5, and the WOMAC score was 95±4. There were significant differences in those indexes between pre- and post-operation ( P<0.05). CONCLUSION: The irreducible hip posterior dislocation caused by acetabular labrum bony Bankart lesions is rare. Arthroscopic therapy has the advantages of less trauma, quick recovery, and less complications.

Arthroscopic Bankart repair following traumatic recurrent shoulder dislocation: A prospective review of 30 cases.

BACKGROUND: Literature on outcomes of arthroscopic Bankart repair at the intervening time intervals in traumatic recurrent dislocation of shoulder joint is limited. STUDY DESIGN: Case series. SUBJECTS AND METHODS: A prospective review of 30 shoulders, aged 20-40 years with clinically and magnetic resonance imaging established findings that were treated with primary arthroscopic Bankart repair and followed up for a minimum of 2 years. Outcomes were evaluated using Rowe score and University of California at Los Angeles (UCLA) scoring system. RESULTS: The mean age was 26.40 years. All patients had definite trauma history. Average number of dislocation was 13.77 + 18.435 (range: 3-100). Time duration from first dislocation to surgery was an average of 4.80 + 3.576 years. The average size of the lesion was approximately 31% of the glenoid circumference. The number of suture anchors used for fixation did not correlate significantly with any of the scores. The mean Rowe and UCLA scores were 94.16 ± 9.7 and 33.83 ± 3.32, respectively, at final follow-up. The average duration of hospital stay was 7 days. Of the 30 patients, 2 (6.66%) had dislocation events post-operatively. Returns to pre-injury level were available for 27 (90%) of 30 patients. Multivariate analysis of independent Variables: age; side and number of dislocations, time to surgery, duration of surgery, size of lesion, number of anchors, and concurrent Hill-Sachs lesion, shown to have no significant relationship to outcomes. CONCLUSION: Arthroscopic Bankart repair is an effective and safe technique for treating anterior glenohumeral instability in patients with recurrent traumatic shoulder dislocation.