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.

No Clear Difference in Clinical Outcomes Between Knotted and Knotless Arthroscopic Bankart Repair: A Systematic Review.

PURPOSE: The objective of the current study was to analyze if the arthroscopic Bankart repair using a knotless suture anchor has a better functional outcome than the conventional knot-tying Bankart repair. METHODS: Comprehensive literature search was done in Pubmed, Scopus, Embase, and Cochrane databases in May 2023. Studies comparing the clinical outcome of Bankart repair using knotless and knot-tying techniques were included in the study. In vitro, animal, and level 4 and 5 studies were excluded. The risk of bias of randomized controlled trials (RCT) was calculated according to the RoB 2 tool, and for non-randomized studies, MINORS criteria were used. Statistical analysis was done using RevMan software. RESULTS: A total of nine studies, including two RCT and seven non-randomized comparative studies involving 720 patients, were included in the systematic review. The ROWE score ranged 81.7 to 94.3 in the knot-tying and 86 to 96.3 in the knotless group. VAS scores at final follow-up ranged between 0.1 to 1.7 in the knot-tying and 0.7 to 2.5 in the knotless group. The rate of redislocation, subluxation, and revision surgery in the knot-tying group ranged from 0 to 14.7%, 16.7 to 29.7%, and 1.6 to 17.6%, respectively, while that in the knotless group ranged from 2.4 to 23.8%, 7.4 to 22.2%, and 2.4 to 19%, respectively. The mean external rotation was 54 to 65 degrees in the knot-tying and 61 to 99 in the knotless group. The mean forward-flexion was 164 to 172 in the knot-tying and 165 to 174 in the knotless group. Our subjective synthesis doesn't reveal any difference in the outcome between the two groups. CONCLUSION: The available literature does not demonstrate a clear difference in functional outcomes, residual pain, and rate of complications like redislocation, subluxation and revision surgery between Bankart repair performed with knotted and knotless anchors.

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.

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.

Clinical and Radiographic Outcomes Of Primary Versus Revision Arthroscopic Anatomic Glenoid Reconstruction with Distal Tibial Allograft For Anterior Shoulder Instability With Bone Loss.

PURPOSE: The purpose of this study was to assess the clinical and radiographic outcomes of arthroscopic anatomic glenoid reconstruction (AAGR) used for primary versus revision surgery for addressing anterior shoulder instability with bone loss. METHODS: We performed a retrospective review on consecutive patients who underwent AAGR from 2012 to 2020. Patients who received AAGR for anterior shoulder instability with bone loss and had a minimum follow-up of two-years were included. Exclusion criteria included patients with incomplete primary patient reported outcome scores (PROs), multi-directional instability, glenoid fracture, non-rigid fixation and concomitant HAGL, or rotator cuff repair. Our primary outcome was measured using the Western Ontario Shoulder Instability Index (WOSI) scores. Secondary outcomes included postoperative Disabilities of Arm, Shoulder, Hand (DASH) scores, complications, recurrence of instability and CT evaluation of graft position, resorption, and healing. RESULTS: There were 73 patients (52 primary and 21 revision) finally included. Both groups had comparable demographics and preoperative WOSI and DASH scores. The primary group had significantly better postoperative WOSI and DASH scores at final follow-up when compared to the revision group (WOSI: 21.0 vs 33.8, p=0.019; DASH: 7.3 vs 17.2, p=0.001). The primary group also showed significantly better WOSI scores than the revision group at 6-month, 1-year and 2-year time points (p=0.029, 0.022 and 0.003; respectively). The overall complication rate was 9.6% (5/52) in the primary group and 23.8% (5/21) in the revision group. Both groups showed good graft healing and placement in the A to P and ML orientation and had a similar rate of graft resorption/remodeling. There was no difference between the groups in the remainder of the CT measurements. CONCLUSION: Functional outcome scores and stiffness were significantly worse in patients undergoing an AAGR procedure after a failed instability surgery when compared with patients undergoing primary AAGR. There were no differences in postoperative recurrence of instability or radiographic outcomes. As a result, AAGR should be considered as a primary treatment option within current treatment algorithms for shoulder instability.

Objective calculation of glenoid bone loss in anterior shoulder instability based on the contour of the posteroinferior quadrant using the best-fit circle method: an accurate and reproducible evaluation.

BACKGROUND: Glenoid bone loss is proposed to be an important risk factor for recurrent anterior shoulder instability. The purpose of the present study was to develop an accurate and reproducible method for quantifying a bone loss in patients with anterior shoulder instability. METHODS: A total of 66 sets of computed tomography images of the glenoid were acquired and en face view was established. Based on the contour of the inferior half and posteroinferior quadrant of the glenoid, the best-fit circle was drawn using the least-squares method with a comparison of the radii. A bone loss was created via a simulated osteotomy, and a method for estimating the bone loss based on the contour of the posteroinferior quadrant was developed. RESULTS: The radii of the best-fit circle were 29.30±1.84 mm and 33.76±2.04 mm based on the inferior half and posteroinferior quadrant of the glenoid, respectively (P<0.01). Bone loss quantification using the contour of the inferior half or posteroinferior quadrant with simulated osteotomy showed a significant difference (P<0.01). For a 25% of glenoid bone loss, the estimated value using the traditional method on the contour of the posteroinferior quadrant was 34%. the A new method for accurate bone loss quantification was developed based on the contour of the posteroinferior quadrant of the glenoid. CONCLUSION: Estimation of the glenoid bone loss based on the rim of the posteroinferior quadrant may overestimate the glenoid bone loss due to the difference in the radius of the curvature of the inferior half and posteroinferior quadrant. A mathematical method was developed to correct this error and may aid in more accurately measuring the glenoid bone loss using the contour of the posteroinferior quadrant in patients with anterior shoulder instability.

Improvement of coracoid process union rates: a comparative study of conventional open and arthroscopic-assisted Bristow procedures for treating anterior shoulder instability in rugby players.

BACKGROUND: The Bristow coracoid transfer procedure is a reliable technique for treating anterior shoulder instability in patients with large glenoid bone loss or those involved in collision sports. However, its success is marred by its inferior bone union rate of the coracoid process as compared to the Latarjet procedure. This study aimed to evaluate whether arthroscopic confirmation of the secured coracoid fixation during the Bristow procedure improves the bone union rate and clinical outcomes as compared to the open procedure. METHODS: We retrospectively reviewed 104 rugby players (n = 111 shoulders) who underwent an open (n = 66 shoulders) or arthroscopy (AS)-assisted (n = 45 shoulders) Bristow procedure at our center from 2007 to April 2019. In the AS-assisted group, the screw fixation and coracoid stability and contact were confirmed under arthroscopic visualization. Graft union was evaluated through computed tomography at 3 months, 6 months, and 1 year postoperatively. Patient-reported outcome measures were assessed based on the American Shoulder and Elbow Surgeons score, Rowe score, and satisfaction rate. Recurrence, the rate of return to play (RTP), and the frequency of pain after RTP were also assessed. RESULTS: The mean follow-up period was 73.5 (range: 45-160) months for the open group and 32.3 (range: 24-56) months for the AS-assisted group. In the former, the rates of bone union were 50%, 72.7%, and 88.9% at 3 months, 6 months, and 1 year, respectively. In contrast, the AS-assisted group had significantly greater bone union rates-88.9%, 93.3%, and 95.6% at 3 months, 6 months, and 1 year, respectively. Both groups showed significant improvement in the American Shoulder and Elbow Surgeons and Rowe scores compared to preoperative values as well as high satisfaction rates (open: 92%; AS-assisted: 95.7%). There were no statistically significant differences in the recurrence and RTP rates as well as the frequency of pain after RTP between the 2 groups. CONCLUSION: The AS-assisted procedure allows early and high bone healing without compromising the clinical outcomes.

Return to sport after arthroscopic xenograft bone block associated with Bankart repair and subscapularis augmentation in competitive contact athletes with recurrent anterior shoulder instability.

BACKGROUND: Open Bankart repair and Latarjet stabilization are two of surgical procedures used in the treatment of shoulder instability in contact athletes. The aim of this study is to evaluate the outcomes of bone block arthroscopic procedure, performed with xenograft, in combination with Bankart repair and selective subscapularis augmentation (ASA) for contact athletes with recurrent anterior shoulder instability. METHODS: We retrospectively assessed contact athletes who underwent arthroscopic bone block with xenograft and Bankart repair with selective augmentation of subscapularis for recurrent anterior shoulder instability between January 2017 and December 2021. Shoulders with posterior instability or multidirectional instability were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score, WOSI score, ASES score) were assessed. A CT scan at 2-year follow-up was performed to assess the status of Bone block integration, its displacement and restoration of glenoid surface. RESULTS: 16 patients were included in the study with a mean age of 24. None of the patients treated with arthroscopic bone block and ASA presented new dislocation episodes. An increase in preoperative scores was observed at the last follow-up, in particular the ASES, Rowe, and WOSI scores increased from 69±7, 31±9 , 1235±46 respectively to 96.1±3.2, 94±6, 119±51. All athletes returned to sporting activity at or near the same level as pre-surgery. The glenoid bone surface increase from 83% to 116% at last follow-up. CONCLUSION: Bone block treatment with Xenograft combined with Bankart repair and ASA procedures has been shown to be effective in treating instability in contact athletes with significant glenoid deficit. All athletes returned to athletic activity at a level similar to the pre-intervention period.

Arthroscopic stabilization surgery for first-time anterior shoulder dislocations: a systematic review and meta-analysis.

BACKGROUND: The optimal management of first-time anterior shoulder dislocations (FTASDs) remains controversial. Therefore, the purpose of this study was to assess the efficacy of arthroscopic stabilization surgery for FTASDs through a systematic review and meta-analysis of existing literature. METHODS: MEDLINE, Embase, and Web of Science were searched from inception to December 18, 2022, for single-arm or comparative studies assessing FTASDs managed with arthroscopic stabilization surgery following first-time dislocation. Eligible comparative studies included studies assessing outcomes following immobilization for an FTASD, or arthroscopic stabilization following recurrent dislocations. Eligible levels of evidence were I to IV. Primary outcomes included rates of shoulder redislocations, cumulative shoulder instability, and subsequent shoulder stabilization surgery. RESULTS: Thirty-four studies with 2222 shoulder dislocations were included. Of these, 5 studies (n = 408 shoulders) were randomized trials comparing immobilization to arthroscopic Bankart repair (ABR) after a first dislocation. Another 16 studies were nonrandomized comparative studies assessing arthroscopic Bankart repair following first-time dislocation (ABR-F) to either immobilization (studies = 8, n = 399 shoulders) or arthroscopic Bankart repair following recurrent dislocations (ABR-R) (studies = 8, n = 943 shoulder). Mean follow-up was 59.4 ± 39.2 months across all studies. Cumulative loss to follow-up was 4.7% (range, 0%-32.7%). A composite rate of pooled redislocation, cumulative instability, and reoperations across ABR-F studies was 6.8%, 11.2%, and 6.1%, respectively. Meta-analysis found statistically significant reductions in rates of redislocation (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.04-0.3, P < .001), cumulative instability (OR 0.05, 95% CI 0.03-0.08, P < .001), and subsequent surgery (OR 0.08, 95% CI 0.04-0.15, P < .001) when comparing ABR-F to immobilization. Rates of cumulative instability (OR 0.32, 95% CI 0.22-0.47, P < .001) and subsequent surgery rates (OR 0.27, 95% CI 0.09-0.76, P = .01) were significantly reduced with ABR-F relative to ABR-R, with point estimate of effect favoring ABR-F for shoulder redislocation rates (OR 0.59, 95% CI 0.19-1.83, P = .36). Return to sport rates to preoperative levels or higher were 3.87 times higher following ABR-F compared to immobilization (95% CI 1.57-9.52, P < .001), with limited ABR-R studies reporting this outcome. The median fragility index of the 5 included randomized controlled trials (RCTs) was 2, meaning reversing only 2 outcome events rendered the trials' findings no longer statistically significant. CONCLUSION: Arthroscopic stabilization surgery for FTASDs leads to lower rates of redislocations, cumulative instability, and subsequent stabilization surgery relative to immobilization or arthroscopic stabilization surgery following recurrence. Although a limited number of RCTs have been published on the subject matter to date, the strength of their conclusions is limited by a small sample size and statistically fragile results.

Open Bankart repair plus inferior capsular shift versus isolated arthroscopic Bankart repair in collision athletes with recurrent anterior shoulder instability: a prospective study.

BACKGROUND: Open Bankart repair plus inferior capsular shift and isolated arthroscopic Bankart repair have never been prospectively compared under the concept of glenoid track in collision athletes with recurrent anterior shoulder instability. The aim of this study was to compare the functional outcomes, range of motion, and recurrence rate between these 2 surgical techniques. We hypothesized that open Bankart repair plus inferior capsular shift would provide similar functional outcomes to isolated arthroscopic Bankart repair but with a lower recurrence rate. METHODS: A prospective cohort study was conducted with 86 collision athletes divided into 2 groups of 43 patients each. All patients had a subcritical glenoid bone loss ≤13.5% and an on-track Hill Sachs lesion. The average follow-up was 66 (60-93) months for the open group and 68 (60-97) months for the arthroscopic group. The primary functional outcomes of each group were evaluated at baseline, 6 months, 1 year and for a minimum of 5 years after surgery. The functional outcomes were also compared between the 2 groups. The assessment tools included the Western Ontario Shoulder Instability Index (WOSI) score and American Shoulder and Elbow Surgeons scale (ASES) score. In addition, recurrent instability and range of motion were also evaluated. RESULTS: In each group, there were significant differences in Western Ontario Shoulder Instability Index score and American Shoulder and Elbow Surgeons scale score between the pre and postoperative periods. There were no differences between the groups at the end of follow-up (P = .47 and .22). Three dislocations (6.9%) in the open group and 10 dislocations (23.2%) in the arthroscopic group were reported showing significant differences (P = .012). In addition, there were no differences in range of motion between pre and postoperative periods for each group as well as between them. CONCLUSION: We found no differences in functional outcomes and range of motion between the 2 groups. The recurrence rate was significantly higher in the arthroscopic group. We recommend performing open Bankart repair plus inferior capsular shift as a treatment alternative in collision athletes with recurrent anterior shoulder instability.

Latarjet in women for anterior shoulder instability: a case series analysis.

PURPOSE: The Latarjet procedure is traditionally used to treat chronic anterior shoulder instability associated with glenoid bone loss. However, few series have analyzed outcomes in a female-only population. The objective of this study was to evaluate the clinical and radiological outcomes of a Latarjet bone block in this specific population. METHODS: This single-center retrospective study included 15 women (mean age 35 ± 11.3; 19-60) reviewed with a minimum follow-up of 2 years. The procedure was performed using the open bone block screw technique (n = 7) or by arthroscopy with cortical button (n = 8). Clinical evaluation was based on active range of motion measurements, Rowe and Walch-Duplay scores, and subjective shoulder value (SSV). Radiographic analysis explored bone block healing at the last follow-up. RESULTS: At a mean follow-up of 48 months (32-86), no recurrence was reported. The mean Rowe score was 91 points (70-100), Walch-Duplay 90 points (60-100), and SSV 87% (70-100). The active mobilities reached 169° (± 9°) in elevation, 57° (± 15°) in external rotation at side, and 89° (± 6°) in abduction. The return-to-sport rate was 91%. Five patients experienced persistent anterior pain, with screws requiring hardware removal in 2 (p = 0.02). Radiological assessment detected one case of nonunion (7%). CONCLUSION: Women treated with the Latarjet procedure experienced satisfactory midterm clinical outcomes. The arthroscopic technique using cortical button fixation seems to avoid residual anterior pain requiring hardware removal.

The arthroscopic treatment of anterior shoulder instability with glenoid bone loss shows similar clinical results after Latarjet procedure and iliac crest autograft transfer.

PURPOSE: Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts. METHODS: A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded. RESULTS: 177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.). CONCLUSION: The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates. LEVEL OF EVIDENCE: Level II.

Substantial influence of psychological factors on return to sports after anterior shoulder instability surgery: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to (1) determine the proportion of patients who underwent anterior shoulder instability surgery and did not return to sports for psychological reasons and (2) estimate differences in psychological readiness scores between patients who did and did not return to sports. METHODS: The EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE and Cochrane Library databases were searched for relevant studies. The data synthesis included the proportion of patients who did not return to sports for psychological reasons and the mean differences in the psychological readiness of athletes who returned and those who did not return to sports. Non-binomial data were analysed using the inverse-variance approach and expressed as the mean difference with 95% confidence intervals. RESULTS: The search yielded 700 records, of which 13 (1093 patients) were included. Fourteen psychological factors were identified as potential causes for not returning to sports. The rates of return to sports at any level or to the preinjury level were 79.3% and 61.9%, respectively. A total of 55.9% of the patients cited psychological factors as the primary reason for not returning to sports. The pooled estimate showed that patients who returned to sports had a significantly higher Shoulder Instability-Return to Sport After Injury score (P < 0.00001) than those who did not, with a mean difference of 30.24 (95% CI 24.95-35.53; I2 = 0%; n.s.). CONCLUSIONS: Psychological factors have a substantial impact on the rate of return to sports after anterior shoulder instability surgery. Patients who returned to sports had significantly higher psychological readiness than those who did not return to sports. Based on these results, healthcare professionals should include psychological and functional measurements when assessing athletes' readiness to return to sports. LEVEL OF EVIDENCE: Level IV.

Outcomes of primary Latarjet vs. revision Latarjet after prior surgery for anterior shoulder instability: a systematic review and meta-analysis.

BACKGROUND: Latarjet has become an increasingly popular treatment option for recurrent anterior shoulder instability. With the reported complication rates for primary Latarjet surgery, there are concerns about the complications of Latarjet as a revision surgery. It remains unclear if poor results after previous surgical management can be improved with revision Latarjet as well as with primary Latarjet. The aim of this systematic review and meta-analysis is to compare the outcomes of primary Latarjet and revision Latarjet for the treatment of anterior shoulder instability. METHODS: A systematic search was performed on 3 databases for studies that compared primary Latarjet with revision Latarjet used after failed arthroscopic stabilization or failed free bone block procedures. From the included studies, demographic data, clinical outcome scores, range of motion measurements, and postoperative complications were obtained. RESULTS: A total of 11 studies were included for data analysis. Compared with the primary Latarjet cohort, revision Latarjet cohorts had a higher infection rate (1.2% vs. 2.6%; RR 0.46, P = .039). The primary Latarjet group showed a greater rate of return to sport (89.7% vs. 80.5%; RR 1.12, P = .41) and less subjective feeling of instability (12.6% vs. 20.9%; RR 0.60, P = .085) compared with the revision Latarjet group; however, this was not statistically significant. There were no significant differences in complication rates, reoperation, recurrence, and range of motion between primary Latarjet and revision Latarjet groups. Clinical outcome scores such as visual analog scale and Rowe scores were not significantly different between the cohorts. CONCLUSION: Based on the current evidence, primary Latarjet presents reduced infection rates but similar clinical outcome measures, overall complication, and range of motion measurements than revision Latarjet performed after failed prior operative treatment.

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.

Remodeling process and clinical outcomes following all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and 1-tunnel double Endobutton fixation system.

BACKGROUND: Arthroscopically modified Eden-Hybinette procedures for glenohumeral stabilization have been used for a long time. With the advancement of arthroscopic techniques and the development of sophisticated instruments, a double Endobutton fixation system has been used clinically to secure bone graft to the glenoid rim placed through a specifically designed guide. The purpose of this report was to evaluate clinical outcomes and serial glenoid remodeling process following all-arthroscopic anatomical glenoid reconstruction using autologous iliac crest bone grafting technique through 1-tunnel fixation. METHODS: Forty-six patients with recurrent anterior dislocations and significant glenoid defects greater than 20% underwent arthroscopic surgery with a modified Eden-Hybinette technique. Instead of firm fixation, autologous iliac bone graft was fixed to the glenoid by double Endobutton fixation system through 1-tunnel placed in the glenoid surface. Follow-up examinations were performed at 3, 6, 12, and 24 months. The patients were followed up for a minimum of two years using the Rowe score, the Constant score, the Subjective Shoulder Value, and the Walch-Duplay score; patient satisfaction with the procedure outcome was also rated. Graft positions, healing, and absorption were evaluated postoperatively with computed tomography imaging. RESULTS: At a mean follow-up of 28 months, all patients were satisfied and had a stable shoulder. The Constant score improved from 82.9 to 88.9 points (P ＜ .001), the Rowe score, improved from 25.3 to 89.1 points (P < .001), the Subjective Shoulder Value improved from 31% to 87% (P < .001), and the Walch-Duplay score improved from 52.5 to 85.7 points (P ＜ .001). One donor-site fracture occurred during the follow-up period. All grafts were well-positioned and achieved optimal bone healing with zero excessive absorption. The preoperative glenoid surface (72.6% ± 4.5%) increased significantly immediately after surgery to 116.5% ± 9.6% (P ＜ .001). After a physiological remodeling process, the glenoid surface remained significantly increased at the last follow-up (99.2% ± 7.1%) (P ＜ .001). The glenoid surface area appeared to decrease serially when compared between the first 6 months and 12 months postoperatively, while there was no significant interval change between 12 and 24 months postoperatively. CONCLUSION: Patient outcomes were satisfactory following the all-arthroscopic modified Eden-Hybinette procedure using an autologous iliac crest grafting technique through one-tunnel fixation system with double Endobutton. Graft absorption mostly occurred on the edge and outside the ''best-fit'' circle of the glenoid. Glenoid remodeling occurred within the first year after all-arthroscopic glenoid reconstruction with an auto iliac bone graft.

Prognostic factors associated with failure to return to sport following primary arthroscopic Bankart repair: a retrospective multicenter study.

BACKGROUND: Even though many studies have been published regarding return-to-sport (RTS) rates following arthroscopic Bankart repair (ABR), evidence regarding prognostic factors for which patients do not RTS is limited. The aim of this study was to identify prognostic factors that are associated with failure to RTS and failure to return to preinjury level of sport (RTPS) following primary ABR. The hypothesis was that prognostic factors for failure to RTS and failure to RTPS would be similar to those predisposing recurrence. METHODS: A multicenter, retrospective case-control study including 6 Dutch hospitals was performed. Consecutive patients who underwent primary ABR between 2014 and 2019 were invited to participate and received a questionnaire. Sports participation was assessed before symptom onset, at 6 months postoperatively, and at final follow-up. Failure to RTS was defined as no return to any sport, and failure to RTPS was defined as no return to the same level (or a higher level) of sport. Prognostic factors for failure to RTS or failure to RTPS were identified using logistic regression. Covariates for the regression analysis were selected based on univariate analyses. RESULTS: This study included 318 patients with a mean follow-up period of 4.2 years (standard deviation, 1.8 years). Of these 318 patients, 26 (8.2%) did not RTS and 100 (31%) did not RTPS. Logistic regression analysis demonstrated that glenoid bone loss (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04-1.15; P = .001) and overhead use of the shoulder during work (OR, 3.77; 95% CI, 1.45-9.85; P = .007) were prognostic factors for failure to RTS. In addition, it showed that preoperative professional sports level (OR, 2.94; 95% CI, 1.07-8.05; P = .04) and preoperative body mass index (OR, 1.11; 95% CI, 1.01-1.21; P = .04) were prognostic factors for failure to RTPS. Repair of a bony Bankart lesion (OR, 0.35; 95% CI, 0.15-0.81; P = .02) and the presence of an anterior labral periosteal sleeve avulsion (ALPSA) (OR, 0.44; 95% CI, 0.20-0.97; P = .04) were identified as factors that facilitated RTPS. CONCLUSION: This study identified glenoid bone loss and overhead use of the shoulder during work to be associated with failure to RTS. Moreover, preoperative sports level and preoperative body mass index were found to be associated with failure to RTPS. In contrast, a bony Bankart lesion and an anterior labral periosteal sleeve avulsion (ALPSA) lesion facilitated RTPS. Future prospective studies are needed to confirm these factors and determine which part of the effect can be attributed to (failure of) surgical treatment or changes in behavior.

Overhead athletes have comparable intraoperative injury patterns and clinical outcomes to non-overhead athletes following surgical stabilization for first-time anterior shoulder instability at average 6-year follow-up.

BACKGROUND AND HYPOTHESIS: Anterior shoulder instability is a common problem affecting young, athletic populations that results in potential career-altering functional limitations. However, little is known regarding the differences in clinical outcomes after operative management of overhead vs. non-overhead athletes presenting with first-time anterior shoulder instability. We hypothesized that overhead athletes would have milder clinical presentations, similar surgical characteristics, and diminished postoperative outcomes when compared with non-overhead athletes after surgical stabilization following first-time anterior shoulder instability episodes. METHODS: Patients with first-time anterior shoulder instability events (subluxations and dislocations) undergoing operative management between 2013 and 2020 were included. The exclusion criteria included multiple dislocations and multidirectional shoulder instability. Baseline demographic characteristics, imaging data, examination findings, and intraoperative findings were retrospectively collected. Patients were contacted to collect postoperative patient-reported outcomes including American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy activity index score, and Subjective Shoulder Value, in addition to return-to-work and -sport, recurrent dislocation, and revision rates. RESULTS: A total of 256 patients met the inclusion criteria, of whom 178 (70%) were non-overhead athletes. The mean age of the entire population was 23.1 years. There was no significant difference in concomitant shoulder pathology, preoperative range of motion, or preoperative strength between cohorts. A greater proportion of overhead athletes presented with instability events not requiring manual reduction (defined as subluxations; 64.1% vs. 50.6%; P < .001) and underwent arthroscopic surgery (97% vs. 76%, P < .001) compared with non-overhead athletes. A smaller proportion of overhead athletes underwent open soft-tissue stabilization compared with non-overhead athletes (1% vs. 19%, P < .001). Outcome data were available for 60 patients with an average follow-up period of 6.7 years. No significant differences were found between groups with respect to recurrent postoperative instability event rate (13.0% for overhead athletes vs. 16.8% for non-overhead athletes), revision rate (13.0% for overhead athletes vs. 11.1% for non-overhead athletes), American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy score, Subjective Shoulder Value, or rates of return to work or sport. CONCLUSION: Overhead athletes who underwent surgery after an initial instability event were more likely to present with subluxations compared with non-overhead athletes. With limited follow-up subject to biases, this study found no differences in recurrence or revision rates, postoperative patient-reported outcomes, or return-to-work or -sport rates between overhead and non-overhead athletes undergoing shoulder stabilization surgery following first-time instability events. Although larger prospective studies are necessary to draw firmer conclusions, the findings of this study suggest that overhead athletes can be considered in the same treatment pathway for first-time dislocation as non-overhead athletes.

Is preoperative glenoid defect size a reliable indicator of postoperative recurrence after arthroscopic Bankart repair in teenage competitive athletes?

BACKGROUND: Being younger than 20 years of age at the time of arthroscopic Bankart repair (ABR) is known to be one of the most important risk factors for postoperative recurrence of instability. When deciding on the appropriate surgical approach, surgeons generally consider only the size of a critical glenoid defect, and most of them do not take into account factors such as the size of bone fragments and possible bone union after arthroscopic bony Bankart repair (ABBR). Therefore, this retrospective study aimed to clarify the risk factors for postoperative recurrence after ABR in teenage competitive athletes by focusing on glenoid rim morphologies and bone union. METHODS: Participants were 115 teenage competitive athletes without a capsular injury who underwent primary ABR for chronic traumatic anterior instability and were followed up for a minimum of 2 years. Possible risk factors for postoperative recurrence were investigated by univariate and multivariate analysis. In shoulders with a glenoid defect and bone fragment, the influence of glenoid defect size and bone fragment size on bone union after ABBR was also investigated. RESULTS: Postoperative recurrence was seen in 16 patients (13.9%). Regarding glenoid defect size, recurrence was seen in 1 (3.2%) of 31 shoulders with a glenoid defect smaller than 5% (including those with a normal glenoid), 15 (22.1%) of 68 shoulders with a glenoid defect of 5%-20%, and 0 (0%) of 16 shoulders with a glenoid defect of 20% or larger (P = .009). Regarding bone union, recurrence was seen in 4 (6.9%) of 58 shoulders with complete or partial bone union after ABBR and 8 (40%) of 20 shoulders with nonunion or disappearance of the bone fragment (P = .001). Regarding bone fragment size, recurrence was seen in 12 (20.7%) of 58 shoulders with a small or no bone fragment (<7.5%) and in 3 (8.6%) of 35 shoulders with a large bone fragment (≥7.5%; P = .154). Multivariate analysis identified non-union or disappearance of the bone fragment after ABBR as a significant risk factor for recurrence. Complete or partial bone union was seen in 25 (58.1%) of 43 shoulders with a small bone fragment (<7.5%) and 33 (94.3%) of 35 shoulders with a large bone fragment (≥7.5%; P < .001). CONCLUSIONS: In teenage competitive athletes, bone union after ABBR affects postoperative recurrence after ABR, regardless of the preoperative glenoid defect size, and bone union rate after ABBR is significantly influenced by bone fragment size.

Glenoid bone loss in anterior shoulder dislocation: a multicentric study to assess the most reliable imaging method.

PURPOSE: The aim of this multicentric study was to assess which imaging method has the best inter-reader agreement for glenoid bone loss quantification in anterior shoulder instability. A further aim was to calculate the inter-method agreement comparing bilateral CT with unilateral CT and MR arthrography (MRA) with CT measurements. Finally, calculations were carried out to find the least time-consuming method. METHOD: A retrospective evaluation was performed by 9 readers (or pairs of readers) on a consecutive series of 110 patients with MRA and bilateral shoulder CT. Each reader was asked to calculate the glenoid bone loss of all patients using the following methods: best fit circle area on both MRA and CT images, maximum transverse glenoid width on MRA and CT, CT PICO technique, ratio of the maximum glenoid width to height on MRA and CT, and length of flattening of the anterior glenoid curvature on MRA and CT. Using Pearson's correlation coefficient (PCC), the following agreement values were calculated: the inter-reader for each method, the inter-method for MRA with CT quantifications and the inter-method for CT best-fit circle area and CT PICO. Statistical analysis was carried out to compare the time employed by the readers for each method. RESULTS: Inter-reader agreement PCC mean values were the following: 0.70 for MRA and 0.77 for CT using best fit circle diameter, 0.68 for MRA and 0.72 for CT using best fit circle area, 0.75 for CT PICO, 0.64 for MRA and 0.62 for CT anterior straight line and 0.49 for MRA and 0.43 for CT using length-to-width ratio. CT-MRA inter-modality PCC mean values were 0.9 for best fit circle diameter, 0.9 for best fit circle area, 0.62 for anterior straight line and 0.94 for length-to-width methods. PCC mean value comparing unilateral CT with PICO CT methods was 0.8. MRA best fit circle area method was significantly faster than the same method performed on CT (p = 0.031), while no significant difference was seen between CT and MRA for remaining measurements. CONCLUSIONS: CT PICO is the most reliable imaging method, but both CT and MRA can be reliably used to assess glenoid bone loss. Best fit circle area CT and MRA methods are valuable alternative measurement techniques.