Salvage Latarjet may provide worse outcomes in terms of recurrent instability and returning to sports compared to primary Latarjet: a systematic review of comparative studies.

BACKGROUND: The Latarjet procedure (LP) is performed as a primary stabilization procedure (primary LP) and a salvage procedure when an earlier shoulder stabilization procedure has failed (salvage LP). However, whether primary LP or salvage LP provides better outcomes for anterior shoulder instability remains unknown. METHODS: Two independent reviewers performed the literature search based on the PRISMA guidelines. A comprehensive search of PubMed, Embase, web of science and Cochrane Library was performed from their inception date to December 4, 2023. Inclusion criteria mainly included the comparison of postoperative outcomes between primary and salvage LP, English language, and full text availability. Two reviewers independently examined the literature, collected data, and evaluated the methodological robustness of the included studies. The Methodological Index for Nonrandomized Studies was used to evaluate the quality of nonrandomized studies. Recurrent instability, complications, reoperations, return to sports, patient-reported outcomes, and range of motion were assessed. Statistical evaluations were conducted using Manager V.5.4.1 (The Cochrane Collaboration, Software Update, Oxford, UK). RESULTS: Twelve studies were included in the systematic review, with 940 shoulders undergoing primary LP and 631 shoulders undergoing salvage LP. Statistically significant differences in favor of primary LP were found in 2 of the 11 and 2 of 4 included studies in terms of recurrent instability and returning to the same sports (RTS) at preinjury level, respectively. In terms of the visual analog scale, subjective shoulder value and the Western Ontario Shoulder Instability Index, 2 of the 4, 1 of the 3 and 1 of the 3 included studies reported statistically significant differences in favor of primary LP. Differences were not noticed regarding complications, reoperations, the time to RTS, the Rowe score, the Athletic Shoulder Outcome Scoring System, and forward flexion. CONCLUSION: Current evidence suggests that compared with primary LP, salvage LP may provide inferior postoperative outcomes in terms of recurrent instability and the rate of RTS at preinjury level. Primary and salvage LP may yield comparable efficacy in terms of complications, reoperations, the rate of RTS, the time to RTS, pain, shoulder function, and range of motion. PROSPERO ID: CRD42023492027.

Can the presence of SLAP-5 lesions be predicted by using the critical shoulder angle in traumatic anterior shoulder instability?

OBJECTIVE: Although SLAP-5 lesions are associated with recurrent dislocations, their causes and pathomechanisms have not been fully elucidated. This study aimed to investigate the association between SLAP-5 lesions and scapular morphology in traumatic anterior shoulder instability (ASI). We hypothesized that there may be a relationship between SLAP-5 lesions and scapular morphology in traumatic ASI patients. MATERIALS AND METHODS: The study included 74 patients with isolated Bankart lesions and 69 with SLAP-5 lesions who underwent arthroscopic labral repair for ASI. Critical shoulder angle (CSA) was measured on the roentgenograms, while glenoid inclination (GI) and glenoid version (GV) were measured on magnetic resonance imaging (MRI) by two observers in two separate sessions blinded to each other. Both groups were compared in terms of CSA, GI, and GV. RESULTS: The mean ages of Bankart and SLAP-5 patients were 28.4±9.1 and 27.9±7.7 (P=0.89), respectively; their mean CSA values were 33.1°±2.6° and 28.2°±2.4°, respectively (P<0.001). The ROC analysis's cut-off value was 30.5°, with 75.0% sensitivity and 76.7% specificity (AUC = 0.830). SLAP-5 lesions were more common on the dominant side than isolated Bankart lesions (P=0.021), but no difference was found between the groups in terms of GI and GV (P=0.334, P=0.081, respectively). CONCLUSIONS: In ASI, low CSA values appeared to be related to SLAP-5 lesions, and the cut-off value of CSA for SLAP lesion formation was 30.5° with 75.0% sensitivity and 76.7% specificity. Scapula morphology may be related to the SLAP-5 lesions, and CSA can be used as an additional parameter in provocative diagnostic tests and medical imaging techniques for the detection of SLAP lesions accompanying Bankart lesions. LEVEL OF EVIDENCE: III retrospective case-control study.

High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review.

PURPOSE: The purpose of this study was to examine reported MCID and PASS values for PROMs following shoulder instability surgery and assess variability in published values depending on the surgery performed. Secondarily, our aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS usage in studies on shoulder instability surgery. METHODS: A systematic review of MCID and PASS values following Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, Pubmed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English, and studies reporting utilization MCID or PASS for patient reported outcome measures (PROMS) following Latarjet, Bankart, Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using median and range. Categorical variables, including PROMs reported and MCID/PASS methods, were described using percentages. As MCID is a patient-level metric and not a group-level metric, the authors validated that all included studies reported proportions (%) of subjects that met or exceeded the MCID. RESULTS: A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely utilized outcome threshold which was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (ASES) (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (SANE) (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (WOSI) (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit (SCB) or maximal outcome improvement (MOI). CONCLUSION: Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. While MCID has been the most frequently reported metric, there is considerable inter-study variability observed in their values. CLINICAL RELEVANCE: Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental, since they allow us to know what is a clinically significant improvement for the patient.

Shoulder Instability-Return to Sports After Injury (SIRSI) Scale Shows That Lack of Psychological Readiness Predicts Outcomes and Recurrence Following Surgical Stabilization.

PURPOSE: This study aimed to evaluate the predictive ability of psychological readiness to return to sports on clinical outcomes and recurrences in athletes who return to sports following shoulder instability surgery. METHODS: A retrospective analysis was performed of patients who underwent shoulder instability surgery between September 2020 and October 2021 (arthroscopic Bankart repair or Latarjet procedure) with a minimum follow-up of 2 years. Patients were grouped according to the achievement of psychological readiness to return to play using the SIRSI scale (≥ 55 points) measured at 6 months following surgery. Recurrences were measured and functional outcomes were evaluated by the Visual Analogue Scale (VAS), Rowe, and Athletic Shoulder Outcome Scoring System (ASOSS). The minimal clinically important difference (MCID) for the VAS and Rowe scores was calculated using the distribution-based method of ½ standard deviation of the delta (difference between postoperative and preoperative scores). The patient acceptable symptomatic state (PASS) for the VAS scale was set at 2.5 based on previous literature. To evaluate the predictive ability of SIRSI a regression model analysis and a receiver operating characteristic (ROC) curve were used. RESULTS: A total of 108 who achieved psychological readiness (PSR) and 41 who did not (NPSR) met the study criteria. PSR achieved significantly higher percentages of MCID and PASS thresholds for VAS than NPSR (MCID: 68.5% vs 48.7%, p=0.026; PASS: 92.5% vs 58.5%, p<0.001). However, there were no differences in the percentage of patients achieving MCID for the Rowe score between groups (98.1% vs 100%, p=0.999). The only strongest independent predictor of postoperative outcomes was being psychologically ready to return to sports. The SIRSI scale had an excellent predictive ability for recurrences (area under curve 0.745, 95% CI 0.5-0.8). Of those who sustained a recurrence, 20% were not psychologically ready compared to 4.3% who were (p= 0.002). A power analysis was not conducted for this study. CONCLUSION: The SIRSI scale is associated with postoperative clinical outcomes and recurrences in patients who returned to sports following shoulder instability surgery. Patients who were not psychologically ready following shoulder instability surgery had worse clinical outcomes with fewer patients achieving clinically significant outcomes (PASS and MCID) for pain, and a higher risk of recurrence. LEVEL OF EVIDENCE: Level IV, Retrospective cohort study.

Arthroscopic Autologous Iliac Crest Grafting with an Adjustable Loop Suspensory Device Yields Favorable Outcomes for Anterior Shoulder Instability with Glenoid Defects.

PURPOSE: This study aims to evaluate the clinical and radiological outcomes of the arthroscopic autologous iliac crest grafting (AICG) procedure with an adjustable-loop suspensory fixation device in the treatment of anterior shoulder instability (ASI) with glenoid bone defects. METHODS: A retrospective review was conducted on the patients who underwent arthroscopic AICG with an adjustable-loop suspensory fixation device from January 2017 to December 2020. Patients with traumatic ASI, significant glenoid bone defects, and a minimum follow-up of 24 months were included. Patient-reported outcomes (PROs), including the Oxford Shoulder Instability Score (OSIS), the Rowe score, the Walch-Duplay score, the Constant score, and the Visual Analogue Score (VAS), were compared preoperatively and postoperatively. Radiological assessments using computed tomography (CT) were performed before and after the procedure. Additional data on active range of motion, recurrence events, and complications were recorded. RESULTS: A total of 42 patients were included in the study, with a mean follow-up time of 35.2 months ranging from 25.1 to 55.9 months. Mean preoperative OSIS, Rowe score, Walch-Duplay score, and Constant score significantly improved from 24.4±7.2, 25.0±9.0, 25.2±9.8, 87.5±7.1 to 42.4±4.9, 92.4±8.1, 87.9±8.3, 93.6±4.5 at the last follow-up, respectively. All patients exceeded the minimal clinically important difference (MCID) for OSIS, Rowe, and Walch-Duplay scores. The graft union rate was 100%, and the glenoid area increased significantly from 82.5% preoperatively to 100.1% at the final follow-up. No patient experienced a recurrence of instability. Two recorded complications included one case of dysesthesia around the donor site and one case of postoperative shoulder stiffness. CONCLUSIONS: The outcomes of the arthroscopic AICG procedure, which utilizes an adjustable-loop suspensory fixation device, demonstrated stable bone graft fixation, high rates of graft integration, favorable clinical results, and a low incidence of complications. Moreover, the remodeling of the graft during the follow-up period significantly restored the width and concavity of the inferior glenoid, contributing to the overall recovery. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Arthroscopic Bankart with remplissage results in lower rates of recurrent instability with similar range of motion compared to isolated arthroscopic Bankart for anterior glenohumeral instability: A systematic review and meta-analysis.

PURPOSE: The addition of the remplissage procedure to an arthroscopic Bankart procedure has been shown to improve clinical outcomes, yet at the expense of potentially decreasing shoulder range of motion. The purpose of this study was to assess recurrent instability, range of motion, functional outcomes and rates of return to sport outcomes in patients undergoing an isolated arthroscopic Bankart repair compared to those undergoing arthroscopic Bankart repair in addition to the remplissage procedure. METHODS: According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, a search was conducted using three databases (MEDLINE/OVID, EMBASE and PubMed). Retrieved studies were screened based on predefined inclusion and exclusion criteria for comparative studies. Data were extracted and meta-analysis performed using a random-effects model. RESULTS: A total of 16 studies (13 level III studies, 2 level II studies and 1 level I) were included with a total of 507 and 704 patients in the Bankart plus remplissage and isolated Bankart repair groups, respectively. No studies reported glenoid bone loss of >20% with the least percentage of glenoid bone loss reported among studies being <1%. There was a significantly increased rate of recurrent dislocations (odds ratio [OR] = 4.22, 95% confidence interval [CI]: 2.380-7.48, p < 0.00001) and revision procedures (OR = 3.36, 95% CI: 1.52-7.41, p = 0.003) in the isolated Bankart repair group compared to the Bankart plus remplissage group. Additionally, there were no significant differences between groups in terms of external rotation at side (n.s.), in abduction (n.s.) or at forward flexion (n.s.) at final follow-up. Furthermore, return to preinjury level of sport favoured the Bankart plus remplissage group (OR = 0.54, 95% CI: 0.35-0.85, p = 0.007). CONCLUSION: Patients undergoing arthroscopic Bankart plus remplissage for anterior shoulder instability have lower rates of recurrent instability, higher rates of return to sport, and no significant difference in range of motion at final follow-up when compared to an isolated arthroscopic Bankart repair. Further large, prospective studies are needed to further determine which patients and degree of bone loss would benefit most from augmentation with the remplissage procedure. LEVEL OF EVIDENCE: Level III.

Modified double-pulley fixation provides better reduction of bone fragments and union compared to single-point fixation in bony Bankart lesions.

PURPOSE: The purpose of this study was to compare clinical scores and imaging outcomes of bony Bankart lesions that underwent single-point and modified double-pulley fixation after at least 2 years of follow-up. METHODS: Patients who underwent surgery to treat bony Bankart injuries were included and divided into groups A and B. A total of 69 patients were included (32 in group A and 37 in group B). Patients in group A underwent arthroscopic modified double-pulley fixation and patients in group B underwent arthroscopic single-point fixation. Three-dimensional computed tomography (3D-CT) was used to assess glenoid reduction one day after surgery. Postoperative bony union was assessed using 3D-CT and multiplanar reconstruction images 6 months after surgery. Constant-Murley, Rowe rating system, visual analogue scale and University of California at Los Angeles and American Shoulder and Elbow Surgeons scores were recorded before and after surgery. RESULTS: In terms of imaging measurements, there was no significant group difference in the preoperative size of the glenoid defect, the size of the bony fragment or the expected postoperative size of the glenoid defect. The sizes of the actual postoperative glenoid defects differed significantly between the groups (p = 0.027), as did the absolute difference between the expected and actual glenoid defect sizes (p < 0.001). At 6 months postoperatively, 50.0% of group A patients and 24.3% of group B patients exhibited complete bony union (p = 0.027); the rates of partial union were 37.5% and 56.8%, respectively. At the final follow-up, all clinical scores were significantly better than the preoperative scores (all p < 0.05), with no significant group differences (not significant). CONCLUSIONS: The use of the modified double-pulley technique with two anchors to treat bony Bankart injuries provides a better reduction of bone fragments than single-point fixation with two anchors and was associated with a higher rate of early bone union. LEVEL OF EVIDENCE: Level III.

The arthroscopic Latarjet procedure with a posterior guided system and suture-button fixation enables more precise bone block positioning in the axial plane versus anterior screws fixation.

PURPOSE: Adequate position of the bone block during arthroscopic Latarjet procedure is critical for an optimal functional outcome. However, this procedure is complex with a long learning curve. Our aim was to compare the bone block position between a dedicated glenoid posterior instrumentation and suture button fixation versus an anterior screw fixation, on a postoperative computed tomography (CT) scan. METHOD: Seventy-nine consecutive patients operated on for an anterior shoulder instability were included in this retrospective study. The same surgeon performed arthroscopically the Latarjet procedure either with an anterior drilling and screw fixation (Group A), or with a specific posterior glenoid guide pin, a posterior drilling, and a suture cortical button fixation (Group B). Evaluations were made by two independent observers. The position was evaluated by CT scan in the axial and sagittal planes. Learning curves with operative time, complications and clinical outcomes were assessed at a minimum of 2 years of follow-up. RESULTS: Thirty-five patients were included in Group A and 44 in Group B. In Group A, 27 bone blocks were flush (87.1%) and 38 in Group B (92.7%) (p < 0.01). In Group A, 72% of the bone block height was below the equator and 76%, in Group B (ns). The mean operating time was 123 ± 32.5 min in Group A and 95 ± 34.1 min in Group B (p < 0.0001). At the final follow-up, the mean aggregate Rowe score was respectively 94.6 ± 10.4 and 93.1 ± 9.8 points in Groups A and B. The mean aggregate Walch-Duplay score was respectively 94.2 ± 11.6 and 93.4 ± 10.6 points in Groups A and B. There were 11 complications (31.4%) in Group A and five complications (11.3%) in Group B (ns). CONCLUSION: The arthroscopic Latarjet procedure with a posterior drilling guided system and suture-button fixation allows more precise positioning in the axial plane than with anterior drilling and screw fixation. This posterior-guided procedure could reduce intraoperative and short-term complications. LEVEL OF EVIDENCE: Level IV.

High long-term failure rates after arthroscopic Bankart repair in younger patients with recurrent shoulder dislocations: A plea for early treatment.

PURPOSE: To determine arthroscopic Bankart repair outcomes and recurrence risk factors at a minimum 5-year follow-up. METHODS: Retrospective assessment of prospectively collected data, single-cohort study of patients who underwent arthroscopic Bankart repair with a minimum 5-year follow-up. Demographical and preoperative instability features were collected. Primary outcome was recurrent instability set as dislocation or subluxation. Secondary outcomes were revision surgery, postoperative instability degree according to Manta criteria, objective and subjective clinical and functional status, assessed by the Rowe, Western Ontario Shoulder Index (WOSI) and Subjective Shoulder Value (SSV) scores. Return to sport and postoperative sports activity at the final follow-up were also recorded. RESULTS: One-hundred and seventy-two patients, 82% men, average age at surgery 29.5 ± 9.2 years, were included. At a mean follow-up of 8.3 ± 2.6 years, recurrent instability occurred in 53 of 172 patients (30.8%). Revision surgery was required in 23/53 (43.4%) of shoulder with recurrent instability. Recurrence occurred within the first 2 years postoperative in 49% of the shoulders, whereas 51% of recurrences occurred after this period. Recurrence took place after a traumatic event in 25% and 56%, respectively. Recurrence rates were higher in patients who underwent surgery after two or more dislocations (p = 0.029). Patients younger at the time of first dislocation, younger at surgery and those with a higher preoperative degree of instability also showed significantly higher rates of recurrence (p = 0.04, p = 0.02, p = 0.03). Postoperative ROWE, WOSI and SSV scores were significantly worse in patients with recurrent instability (p < 0.001). Return-to-sports rate was also lower in patients with postoperative recurrence (p < 0.001). CONCLUSION: The arthroscopic Bankart repair was associated with a high long-term recurrence rate, and its effectiveness decreased over time. The lowest recurrence rates in arthroscopic Bankart repair were achieved in older patients with only one prior instability episode and a lower instability degree. LEVEL OF EVIDENCE: Level IV.

Outcomes following Arthroscopic Treatment of Off-Track Hill-Sachs Lesions Using Fresh Osteochondral Allograft Plugs: A Case Series.

BACKGROUND: Osteochondral allograft (OCA) transplantation is a well-described technique for the treatment of large, engaging Hill-Sachs lesions (HSLs). Traditionally, OCAs are size-matched to the defect, which can be expensive and time-consuming, and the majority of described techniques require an open approach. Recently, an all-arthroscopic approach to Hill-Sachs OCA transplantation using premade plugs was described, eliminating the need for size-matching and graft harvest. HYPOTHESIS/PURPOSE: The purpose of this study was to evaluate postoperative outcomes of patients who have undergone arthroscopic treatment of HSLs using premade OCA plugs. We hypothesized that these patients would have improved pain and function without recurrent instability. METHODS: A retrospective chart review was performed using operative reports for a single surgeon with search terms "Hill-Sachs" and "allograft." Patients were excluded if an open approach was used or if graft harvest was performed. Postoperative imaging was reviewed to assess for graft incorporation and reconstitution of the HSL. Recurrent instability and reoperation were recorded. Patients completed surveys including the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI). RESULTS: Five patients were identified through chart review and met inclusion criteria. All patients underwent concurrent labral repair and two patients underwent a concurrent open Latarjet procedure. Postoperative radiographs showed reconstitution of the HSLs in all patients. There were no complications in the postoperative period with no recurrent instability or reoperations in any patient. The average ASES score was 87% (higher score indicating better outcome) with standard deviation 9.7, and the average WOSI score was 27% (lower score indicating better outcome) with standard deviation 8.3. CONCLUSION: Favorable outcomes can be expected after arthroscopic treatment of Hill-Sachs lesions using premade OCA plugs. Further research is needed to assess larger patient cohorts and compare outcomes to size-matched approaches.

Complications following arthroscopic Bankart repair: a systematic review.

BACKGROUND: Complications are rare after arthroscopic Bankart repair, and as a result, there is a lack of guidance over rates of complications that can be used to consent patients. The purpose of this study is to systematically review the literature to assess the complications after arthroscopic Bankart repair, other than recurrent instability. METHODS: A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical studies reporting on the complications after arthroscopic Bankart repair were included. RESULTS: A total of 194 studies were included in the analysis, with 13,979 patients and 14,019 shoulders undergoing arthroscopic Bankart repair. The overall complication rate was 0.67%, with frozen shoulder being the most common complication occurring in 0.32%. Persistent pain occurred in 0.17%. The rates of nerve, hardware, and wound complications were 0.07%, 0.05%, and 0.03%, respectively. CONCLUSION: The arthroscopic Bankart repair has a very low rate of complications. Frozen shoulder and persistent pain are the most frequently encountered complications.

SECEC Didier Patte Prize 2023: the ABC classification of posterior shoulder instability.

BACKGROUND: The ABC classification has recently been proposed as a comprehensive classification system for posterior shoulder instability (PSI). The purpose of this study was to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification. METHODS: All consecutive patients presenting with unidirectional PSI from June 2019 to June 2021 were included in a prospective study. No patients were excluded, leaving a consecutive series of 100 cases of PSI in 91 patients. All recorded clinical and imaging data were used to create anonymized clinical case vignettes, which were evaluated twice according to the ABC classification at the end of the recruitment period in random sequential order by 4 independent raters (2 experienced shoulder surgeons and 2 orthopedic residents) to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification for PSI and to describe differences in characteristics among subtypes. Group A was defined as a first-time singular PSI event <3 months in the past regardless of etiology and is further subdivided into type 1 and type 2 depending on the occurrence of a subluxation (A1) or dislocation (A2). Group B comprises recurrent dynamic PSI regardless of time since onset and is further subdivided by the cause of instability into functional (B1) and structural (B2) dynamic PSI. Group C includes chronic static PSI with posterior humeral decentering that can be either constitutional (C1) or acquired (C2). RESULTS: None of the cases was deemed unsuitable to be classified based on the proposed system by the observers. After consensus agreement between the 2 expert raters, 16 cases were attributed to group A (8 type A1 and 8 type A2); 64, to group B (33 type B1 and 31 type B2); and 20, to group C (11 type C1 and 9 type C2). The expert raters agreed on the classification subtypes in 99% and 96% of the cases during the first rating and second rating, respectively (intraclass correlation coefficients [ICCs], 0.998 and 0.99, respectively). The intraobserver reliability was excellent for both raters. The beginners reached the same conclusion as the consensus agreement in 94% of the cases (ICC, 0.99) and 89% of the cases (ICC, 0.97) during the first round and 94% each (ICC, 0.97) during the second round. The intraobserver reliability was excellent for both beginners. Overall, discrepancies between raters were found between groups B1 and B2 (n = 14), groups B2 and C2 (n = 4), groups B1 and C1 (n = 1), and groups A1 and B2 (n = 1). In general, each subtype showed distinctive clinical and imaging characteristics that facilitated the diagnosis. CONCLUSION: The presented ABC classification for PSI is a comprehensive classification with a high reliability and reproducibility. However, a gradual transition and potential progression between the subtypes of PSI must be considered. The reliable distinction between different subtypes of PSI based on etiology and pathomechanism provides a standardized basis for future investigations on treatment recommendations.

Arthroscopic Bankart Repair vs. Latarjet Procedure for Recurrent Shoulder Instability: A Meta-Analysis of Clinical Outcomes and Complication Rates in General and Athletic Populations.

BACKGROUND: The Bankart repair and Latarjet procedure are both effective surgical methods for treating repeated recurrent anterior dislocation of the shoulder. However, there is still little consensus regarding the standard treatment for recurrent anterior instability of the shoulder. Typically, the choice of treatment has been influenced more by training and tradition rather than the existing evidence. This systematic review and meta-analysis aimed to compare patient-reported outcomes, recurrence, and complications between the two procedures, among both athletic and non-athletic cohorts. METHODS: Relevant clinical trials were identified through a systematic search of databases in April 2023 including PubMed, Scopus, Web of Science, and Cochrane. RCTs and cohort studies were included if they compared patient-reported outcomes or complication rates of open Latarjet procedure versus arthroscopic Bankart repair. Continuous data, such as patient-reported outcomes were pooled as the weighted mean difference (WMD). For dichotomous data such as recurrence and revision rates, the pooled risk ratio (RR) with 95% confidence intervals (CIs) was calculated using random effects meta-analysis. RESULTS: 21 clinical studies (3 RCTs) were included in the meta-analysis involving a total of 13176 operated shoulders. Arthroscopic Bankart showed a 3.08 times higher risk of recurrence and revision due to post operation instability (RR=3.08, 95% CI: 2.03 to 4.68) compared to those who had the Latarjet approach. The ROWE score, was higher in the Latarjet group by an average of 4.55 points (95% CI: 2.41 to 6.68). This difference was more pronounced in athletes, with an increase of 5.47 points (95% CI: 0.16 to 10.78), compared to the non-athletic population: 4.03 (95% CI: 2.04 to 6.02). Return to sport time was shorter by 0.40 months (95% CI: -0.75 to -0.05) in the Latarjet group. The total complication rate was approximately 47% lower in the Bankart group (RR=0.53, 95% CI: 0.31-0.90). Additionally, the risk of hematoma was 75% lower in patients undergoing the arthroscopic Bankart compared to the Latarjet procedure. External rotation, assessed both in abduction and adduction of the arm, as well as forward elevation, show no significant differences between the two groups. CONCLUSION: Our results demonstrate that the Latarjet procedure has a lower recurrence rate, excels in patient-reported outcomes, and requires less time for return to sports. Thus, it may be a superior alternative to arthroscopic Bankart repair. However, it is still associated with a higher incidence of complications.

The scapula spine may not be a suitable source of bone graft for glenoid reconstruction in critical bone loss.

AIMS: The hypothesis is that the scapula spine can provide a graft of suitable dimensions for use in cases of shoulder instability with critical bone loss. We aimed to investigate its utility with grafts of differing sizes. METHODS: The scapula spine was measured on CT scans of 50 patients who had undergone anterior stabilization. The theoretical ability to harvest a graft of either 2x1x1cm or 2x0.8x0.8cm was analyzed. RESULTS: Using the 2 x 1 x 1cm threshold, 36% of the scapulae had at least one zone from which a suitable graft could be obtained. 61% had only one zone from which a suitable graft could be obtained. Using the 2 x 0.8 x 0.8cm threshold, 72% had at least one zone from which a graft could be obtained. 47% met the threshold in one zone only. CONCLUSION: The scapula spine can be used as a source of autograft. Grafts up to 2 x 1 x 1cm can be harvested in some individuals, however the anatomy is very variable. TAKE HOME MESSAGE: The scapula spine can be used but we recommend that individualized preoperative planning is undertaken to ensure that a suitable graft can be harvested from the spine and to identify the exact location.

Good Clinical Outcomes and Low Recurrence Rate in Patients undergoing Arthroscopic Revision Latarjet for Failed Arthroscopic Bankart Repair.

BACKGROUND: The role of arthroscopic Latarjet stabilization after failed arthroscopic Bankart repair has yet to be definitively established and merits further investigation. OBJECTIVE: To assess clinical and radiological outcomes after arthroscopic Latarjet stabilization as a revision procedure for failed Bankart repair, as well as the return to athletic activity and complication rates. METHODS: Between 2009 and 2020, patients with a previous failed arthroscopic Bankart repair who were treated with an arthroscopic Latarjet were retrospectively evaluated. Clinical outcomes at a minimum of 24 months postoperatively included Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome score (CS), and Single Assessment Numeric Evaluation (SANE). Dislocations, subluxations, complications, pre and postoperative level of activity and degree of osteoarthritis were also assessed. RESULTS: A total of 77 patients, mean age at revision surgery 31.2 ± 9.1 and with either one (n = 59), two (n = 13), or three (n = 4) arthroscopic previous stabilizations underwent revision surgery using arthroscopic Latarjet procedure were studied. Postoperatively, the mean ROWE and CS scores increased from 41.8 ± 16 to 90.7 ± 14.3 (p<0.001) and from 50.5 ± 13.8 to 90.5 ± 10.3 (p<0.001), respectively. WOSI decreased from 1247 ± 367.6 to 548.9 ± 363 at the final follow-up (p<0.001). After a mean follow-up of 39.6 ± 23.1 months, 64 shoulders (83.1%) were subjectively graded as good to excellent using SANE score. Grade 1, 2, and 3 osteoarthritis, according to Ogawa et al were found in 18 (23.4%), 6 (7.8%), and 3 (3.9%) shoulders, respectively. Six dislocations after revision surgery were reported (7.8%). In four failed cases an Eden-Hybinette procedure was conducted and in remaining two patients an arthroscopic extraarticular anterior capsular reinforcement was performed. Significantly decreased level of athletic activity was observed postoperatively (p= 0.01). CONCLUSIONS: Arthroscopic Latarjet for revision of failed arthroscopic Bankart repair provides satisfactory patient-reported subjective outcomes with low rate of recurrences and complications. However, decreased level of athletic activity is expected.

Does previous arthroscopic Bankart repair influence coracoid graft osteolysis in Latarjet procedure? A case-control study with computed tomography scan data.

BACKGROUND: The Latarjet procedure is commonly performed in the treatment of recurrent shoulder instability and is also indicated as a salvage procedure for recurrence after failed arthroscopic Bankart repair. Although this procedure has shown success, there has been an increased awareness of complications in recent studies, especially graft osteolysis. Most relevant research has focused on the pathophysiology, incidence, or location of graft osteolysis or the risk factors for graft osteolysis; however, the data are limited to primary Latarjet procedures. This study aimed to investigate the effect of previous arthroscopic Bankart repair surgery on coracoid bone graft osteolysis in the Latarjet procedure. METHODS: This retrospective case-control study analyzed data from patients who underwent primary Latarjet procedures or revision Latarjet procedures following failed arthroscopic Bankart repair. Clinical outcome measures included range of motion, the Subjective Shoulder Value, and the Rowe score. Volumetric analysis of each transferred coracoid graft was performed using early postoperative and late postoperative computed tomography scan data, and the amount of graft osteolysis was then calculated as the percentage of volume reduction of each graft. RESULTS: A total of 32 patients who met the inclusion criteria were included in this study, with 24 patients in the primary Latarjet group (group I) and 8 patients in the revision Latarjet group (group II). The mean age of the patients was 32.5 ± 7.7 years, and the mean follow-up duration was 52.1 ± 8.9 months. Both study groups showed significant improvement in the Subjective Shoulder Value compared with baseline (P < .05). Comparison of postoperative clinical outcome measures showed no significant difference in any outcome parameter between the 2 study groups (P > .05). No recurrence was observed during the follow-up period. A positive apprehension sign was present in 6 patients (25%) in group I and 4 patients (50%) in group II (P > .05). Analysis of radiologic data revealed that all patients underwent some degree of graft osteolysis, with varying osteolysis ratios between 12% and 98%. The mean osteolysis ratio of the coracoid graft was 67.3% ± 22.6% in group I and 69.4% ± 25.6% in group II, with no significant difference between the 2 groups (P > .05). CONCLUSION: The findings of this study suggest that a considerable amount of coracoid graft osteolysis is observed after both primary Latarjet procedures and revision Latarjet procedures following failed arthroscopic Bankart repair. Previous arthroscopic Bankart repair did not seem to have a significant influence on the amount of graft osteolysis, and both primary and revision Latarjet procedures showed satisfactory clinical outcomes.

Outcomes of total shoulder arthroplasty in patients with prior anterior shoulder instability: minimum 5-year follow-up.

BACKGROUND: Patients with a history of anterior shoulder instability (ASI) commonly progress to glenohumeral arthritis or even dislocation arthropathy and often require total shoulder arthroplasty (TSA). The purposes of this study were to (1) report patient-reported outcomes (PROs) after TSA in patients with a history of ASI, (2) compare TSA outcomes of patients whose ASI was managed operatively vs. nonoperatively, and (3) report PROs of TSA in patients who previously underwent arthroscopic vs. open ASI management. METHODS: Patients were included if they had a history of ASI and had undergone TSA ≥5 years earlier, performed by a single surgeon, between October 2005 and January 2017. The exclusion criteria included prior rotator cuff repair, hemiarthroplasty, or glenohumeral joint infection before the index TSA procedure. Patients were separated into 2 groups: those whose ASI was previously operatively managed and those whose ASI was treated nonoperatively. This was a retrospective review of prospective collected data. Data collected was demographic, surgical and subjective. The PROs used were the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score. Failure was defined as revision TSA surgery, conversion to reverse TSA, or prosthetic joint infection. Kaplan-Meier survivorship analysis was performed. RESULTS: This study included 36 patients (27 men and 9 women) with a mean age of 56.4 years (range, 18.8-72.2 years). Patients in the operative ASI group were younger than those in the nonoperative ASI group (50.6 years vs. 64.0 years, P < .001). Operative ASI patients underwent 10 open and 11 arthroscopic anterior stabilization surgical procedures prior to TSA (mean, 2 procedures; range, 1-4 procedures). TSA failure occurred in 6 of 21 patients with operative ASI (28.6%), whereas no failures occurred in the nonoperative ASI group (P = .03). Follow-up was obtained in 28 of 30 eligible patients (93%) at an average of 7.45 years (range, 5.0-13.6 years). In the collective cohort, the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score significantly improved, with no differences in the postoperative PROs between the 2 groups. We found no significant differences when comparing PROs between prior open and prior arthroscopic ASI procedures or when comparing the number of prior ASI procedures. Kaplan-Meier analysis demonstrated a 79% 5-year survivorship rate in patients with prior ASI surgery and a 100% survivorship rate in nonoperatively managed ASI patients (P = .030). CONCLUSION: At mid-term follow-up, patients with a history of ASI undergoing TSA can expect continued improvement in function compared with preoperative values. However, TSA survivorship is decreased in patients with a history of ASI surgery compared with those without prior surgery.

Readability of online patient education materials for shoulder instability surgery in English and Spanish.

BACKGROUND: Online patient education materials (OPEMs) exist to inform patient medical decisions, yet the average adult in the United States reads at an eighth-grade level and 50% of Medicaid patients read at or below a fifth-grade level. To appropriately meet US health literacy needs, the American Medical Association and National Institutes of Health recommend that patient education materials not exceed a sixth-grade level. The purpose of this study was to assess and compare the readability of English and Spanish online patient education materials pertaining to shoulder instability surgery. METHODS: Google searches of the terms "shoulder instability surgery" and "cirugía de inestabilidad de hombro'' were conducted to include 25 eligible online patient education materials OPEMs per language. English OPEM readability was calculated using Flesch-Kincaid Grade Level, Flesch Reading Ease, Flesch Reading Ease Grade Level, Gunning-Fog Index, Coleman-Liau Index, and Simple Measure of Gobbledygook. Spanish OPEM readability was assessed using Fernandez-Huerta Index (FHI) (the Spanish equivalent of Flesch Reading Ease), FHI Grade Level, Gutiérrez de Polini's Fórmula de comprensibilidad, and INFLESZ. RESULTS: Readability index analysis revealed that the mean Flesch Reading Ease of English online patient education materials was significantly lower than the mean FHI of Spanish online patient education materials. English materials were also found to be written at a significantly higher grade level than Spanish materials. CONCLUSIONS: Shoulder instability surgery online patient education materials in both English and Spanish are written at higher reading levels than recommended by the American Medical Association and National Institutes of Health, though Spanish online patient education materials were more readable on average.

Arthroscopic Bankart Repair with Remplissage Yields Similar Outcomes to Open Latarjet for Primary and Revision Stabilization in The Setting of Subcritical Glenoid Bone Loss.

BACKGROUND: Management of patients with recurrent anterior glenohumeral instability in the setting of subcritical glenoid bone loss (GBL), defined in this study as 20% GBL or less, remains controversial. This study aimed to compare arthroscopic Bankart with remplissage (ABR+R) to open Latarjet for subcritical GBL in primary or revision procedures. We hypothesized that ABR+R would yield higher rates of recurrent instability and reoperation compared to Latarjet in both primary and revision settings. METHODS: A retrospective study was conducted on patients undergoing either arthroscopic ABR+R or an open Latarjet procedure. Patients with connective tissue disorders, critical GBL (>20%), < 2 year follow-up, or insufficient data were excluded. Recurrent instability and revision were the primary outcomes of interest. Additional outcomes of interest included subjective shoulder value (SSV), strength and range of motion (ROM) RESULTS: 108 patients (70 ABR+R, 38 Latarjet) were included with an average follow-up of 4.3 ±2.1 years. In the primary and revision settings, similar rates of recurrent instability (Primary: p=0.60; Revision: p=0.28) and reoperation (Primary: p=0.06; Revision: p=1.00) were observed between Latarjet and ABR+R. Primary ABR+R exhibited better SSV, active ROM, and internal rotation strength compared to primary open Latarjet. However, no differences were observed in the revision setting. CONCLUSION: Similar rates of recurrent instability and reoperation in addition to comparable outcomes with no differences in ROM were found for ABR+R and Latarjet in patients with subcritical GBL in both the primary and revision settings. ABR+R can be a safe and effective procedure in appropriately selected patients with less than 20% GBL for both primary and revision stabilization.

Clinical outcomes in prospective versus retrospective studies on arthroscopic Bankart repair: a systematic review.

BACKGROUND: The majority of the current literature on arthroscopic Bankart repair is retrospective, and discrepancies exist regarding clinical outcomes including recurrent instability and return to play among studies of different levels of evidence. PURPOSE: The purpose of this study is to perform a systematic review of the literature to compare the outcomes of prospective and retrospective studies on arthroscopic Bankart repair. METHODS: A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" was used, with all results being analyzed via strict inclusion and exclusion criteria. Three independent investigators extracted data and scored each included study based on the 10 criteria of the Modified Coleman Methodology Score out of 100. A χ2 test was performed to assess if recurrent instability, revision, return to play, and complications are independent of prospective and retrospective studies. RESULTS: A total of 193 studies were included in the analysis, with 53 prospective studies and 140 retrospective in design. These studies encompassed a total of 13,979 patients and 14,019 surgical procedures for Bankart repair for shoulder instability. The rate of redislocation in the prospective studies was 8.0% vs. 5.9% in retrospective studies (P < .001). The rate of recurrent subluxation in the prospective studies was 3.4% vs. 2.4% in retrospective studies (P = .004). The rate of revision was higher in retrospective studies at 4.9% vs. 3.9% in prospective studies (P = .013). There was no significant difference in terms of overall rate to return to play between prospective and retrospective studies (90% and 91%, respectively; P = .548). The overall rate of non-instability complications in the prospective cohort was 0.27% vs. 0.78% in the retrospective studies (P = .002). CONCLUSIONS: The overall rates of recurrent dislocations-subluxations are higher in prospective studies than retrospective studies. However, rates of revision were reportedly higher in retrospective studies. Complications after arthroscopic Bankart repair are rare in both prospective and retrospective studies, and there was no difference in rates of return to play.