Studies on Bankart Repair for Anterior Shoulder Instability Show Poor Reporting of Data and Reflect Low Level of Evidence: A Systematic Review.

PURPOSE: To assess the quality and level of evidence of studies reporting on Bankart repair for anterior shoulder instability. 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" with all results were analyzed via strict inclusion and exclusion criteria. Two independent investigators scored each included study based on the 10 criteria of the Modified Coleman Methodology Score (CMS) out of 100 and gave each study a score out of 25 based on the Anterior Shoulder Instability (ASI) Methodology criteria. RESULTS: Two hundred sixty-six studies were included in the analysis and encompassed a total of 19,156 patients and 19,317 surgical procedures for Bankart repair for shoulder instability. Overall, 81.6% of studies were Level III or IV evidence. The mean CMS score for the studies was 55.3 out of 100, and the mean ASI Methodology score for the studies was 12.1 out of 25. Weaknesses in the studies were identified in sample size, description of preoperative investigations and diagnoses, reporting of mean glenoid bone loss, nonsubjective clinical outcome reporting, and description of associated pathologies. CONCLUSIONS: A large proportion of studies reporting the clinical outcomes of Bankart repair for anterior shoulder instability are of low methodological quality and have a low level of evidence. CLINICAL RELEVANCE: This study emphasizes need for greater reporting of many variables such as body mass index, mean glenoid bone loss, and patient-reported outcomes and provides a framework for future studies reporting.

Editorial Commentary: For Patients With Shoulder Instability, On-Track Hill-Sachs Lesion Plus Subcritical Glenoid Bone Loss May Be the Best Indication for Dynamic Anterior Stabilization Using the Long Head of the Biceps Tendon.

As the definition of shoulder glenoid critical bone loss has evolved and decreased from 25% to 17% to 13.5%, indications for bone block procedures for shoulder instability with glenoid bone loss have expanded. While the bone block procedure is an effective treatment for almost all cases of anterior shoulder instability, regardless of the amount of bone loss, many surgeons prefer to perform a bone block procedure only in cases of critical bone loss due to risk of complications. Thus, for cases of minimal (subcritical) bone loss, Remplissage has been recommended to enhance Bankart repair. As an alternative, dynamic anterior stabilization (DAS) using the long head of the biceps tendon has been recommended as a surgical option in patients with shoulder instability and subcritical bone loss. How do we decide? A biomechanical study shows DAS is an effective method for on-track Hill-Sachs lesions with subcritical bone loss, and Remplissage is more effective for off-track Hill-Sachs lesions. Clinical studies are required to complement biomechanical findings.

Biomechanical Analysis Reveals Shoulder Instability With Bipolar Bone Loss Is Best Treated With Dynamic Anterior Stabilization for On-Track Lesions and With Remplissage for Off-Track Lesions.

PURPOSE: To compare the biomechanical effects of augmenting Bankart repair (BR) with either remplissage or dynamic anterior stabilization (DAS) in the treatment of anterior shoulder instability with on-track or off-track bipolar bone loss. METHODS: Eight fresh-frozen cadaveric shoulders were tested at 60° of glenohumeral abduction in the intact, injury, and repair conditions. Injury conditions included 15% glenoid bone loss with an on-track or off-track Hill-Sachs lesion as previously recommended. Repair conditions included isolated BR, BR with remplissage, and BR with DAS (long head of biceps transfer). The glenohumeral stability was assessed by measuring the anterior translation under 0, 10, 20, 30, 40, 50 N load and maximum load without causing instability at mid-range (60°) and end-range (90°) external rotation (ER). Maximum range of motion (ROM) was measured by applying a 2.2-N·m torque in passive ER and internal rotation. RESULTS: Isolated BR failed to restore native glenohumeral stability in both on-track and off-track bipolar bone loss models. Both remplissage and DAS significantly decreased the anterior instability in the bipolar bone loss models, showing better restoration than the isolated BR. In the on-track lesions, DAS successfully restored native glenohumeral stability and mobility, whereas remplissage significantly decreased anterior translation without load (-2.12 ± 1.07 mm at 90° ER, P = .003; -1.98 ± 1.23 mm at 60° ER, P = .015). In the off-track lesions, remplissage restored native glenohumeral stability but led to significant ROM limitation (-8.6° ± 2.3° for internal rotation, P < .001; -13.9° ± 6.2° for ER, P = .003), whereas DAS failed to restore native stability at 90° ER regarding the increased anterior translation under 50 N (4.10 ± 1.53 mm, P < .001) and decreased maximum load (-13.8 ± 9.2 N, P = .021). CONCLUSIONS: At time-zero, both remplissage and DAS significantly reduced residual anterior instability compared with isolated BR in the bipolar bone loss models and restored the native glenohumeral stability under most translational loads. However, remplissage could decrease the anterior translation without load for on-track lesions and may restrict ROM for off-track lesions, whereas DAS failed to restore native stability under high translational loads for off-track lesions. CLINICAL RELEVANCE: DAS could be recommended to treat on-track bipolar bone loss with less biomechanical adverse effects, whereas remplissage might be the preferred procedure to address off-track bipolar bone loss for better stability.

Editorial Commentary: Anterior Shoulder Stabilization Combining Arthroscopic Bankart and Inferior Capsular Shift Avoids Open Surgery in Athletes Without Critical Glenoid Bone Loss.

Traumatic anterior shoulder dislocations can cause a myriad of injuries, each with their own unique set of challenges with respect to surgical management. The debate of whether open or arthroscopic management is the superior approach is one that predates most currently practicing orthopaedic surgeons yet remains one of the most actively researched areas of orthopaedics. Current trends favor arthroscopic management for anterior instability secondary to a Bankart lesion in patients without other risk factors for instability, such as critical glenoid bone loss. However, excellent results are not guaranteed following arthroscopic Bankart repair, particularly in athletes, due to high rates of recurrence. While the technique of inferior to superior capsular shift is not new, transitioning a historically open technique to the arthroscopic world may represent another tool in the glenohumeral instability management toolbox. While perspectives are evolving, more evidence supporting arthroscopic techniques like the capsular shift are needed to better identify appropriate patient populations.

Humeral Head Reconstruction of Reverse Hill-Sachs Lesions.

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

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.

Glenohumeral morphological predictors of recurrent shoulder instability following arthroscopic Bankart repair.

PURPOSE: The purpose of this study was to evaluate glenohumeral morphological features on a magnetic resonance arthrogram (MRA) to determine risk factors for recurrence of anterior shoulder instability following arthroscopic Bankart repair (ABR). METHODS: A retrospective review of patients who underwent ABR between 2012 and 2017 was performed to identify patients who had recurrence of instability following stabilisation (Group 1). These were pair-matched in a 2:1 ratio for age, gender and sport with a control (Group 2) who underwent ABR without recurrence. Preoperative MRAs were evaluated for risk factors for recurrence, with glenoid bone loss and Hill-Sachs lesions also measured. Multilinear and multilogistic regression models were used to evaluate factors affecting recurrence. RESULTS: Overall, 72 patients were included in this study, including 48 patients without recurrence and 24 patients with recurrent instability. There was a significant difference between the two groups in mean glenoid bone loss (Group 1: 7.3% vs. Group 2: 5.7%, p < 0.0001) and the rate of off-track Hill-Sachs lesions (Group 1: 20.8% vs. Group 2: 0%, p = 0.0003). Of the variables analysed in logistic regression, increased glenoid anteversion (p = 0.02), acromioclavicular (AC) degeneration (p = 0.03) and increased Hill-Sachs width were associated with increased risk of failure. Increased chondral version (p = 0.01) and humeral head diameter in the anteriorposterior view were found to be protective and associated with a greater likelihood of success. CONCLUSION: Glenoid anteversion was a risk factor for recurrent instability, whereas increased chondral version and humeral head diameter were associated with higher rates of success following ABR. Glenoid bone loss, presence of an off-track Hill-Sachs lesion, increased Hill-Sachs width and AC degeneration were also associated with failure. These findings should be used by surgeons to stratify risk for recurrence following ABR. LEVEL OF EVIDENCE: Level III.

Biomechanical comparison of open Bankart repair vs. conjoint tendon transfer in a 10% anterior glenoid bone loss shoulder instability model.

BACKGROUND: The treatment of shoulder instability in patients with subcritical glenoid bone loss poses a difficult problem for surgeons as new evidence supports a higher failure rate when a standard arthroscopic Bankart repair is used. The purpose of this study was to compare a conjoint tendon transfer (soft-tissue Bristow) to an open Bankart repair in a cadaveric instability model of 10% glenoid bone loss. METHODS: Eight cadaveric shoulders were tested using a custom testing system that allows for a 6-degree-of-freedom positioning of the glenohumeral joint. The rotator cuff muscles were loaded to simulate physiologic muscle conditions. Four conditions were tested: (1) intact, (2) Bankart lesion with 10% bone loss, (3) conjoint tendon transfer, and (4) open Bankart repair. Range of motion, glenohumeral kinematics, and anterior-inferior translation at 60° of external rotation with 20 N, 30 N, and 40 N were measured in the scapular and coronal planes. Glenohumeral joint translational stiffness was calculated as the linear fit of the translational force-displacement curve. Force to anterior-inferior dislocation was also measured in the coronal plane. Repeated measures analysis of variance with a Bonferroni correction was used for statistical analysis. RESULTS: A Bankart lesion with 10% bone loss increased the range of motion in both the scapular (P = .001) and coronal planes (P = .001). The conjoint tendon transfer had a minimal effect on the range of motion (vs. intact P = .019, .002), but the Bankart repair decreased the range of motion to intact (P = .9, .4). There was a significant decrease in glenohumeral joint translational stiffness for the Bankart lesion compared with intact in the coronal plane (P = .021). The conjoint tendon transfer significantly increased stiffness in the scapular plane (P = .034), and the Bankart repair increased stiffness in the coronal plane (P = .037) compared with the Bankart lesion. The conjoint tendon transfer shifted the humeral head posteriorly at 60° and 90° of external rotation in the scapular plane. The Bankart repair shifted the head posteriorly in maximum external rotation in the coronal plane. There was no significant difference in force to dislocation between the Bankart repair (75.8 ± 6.6 N) and the conjoint tendon transfer (66.5 ± 4.4 N) (P = .151). CONCLUSION: In the setting of subcritical bone loss, both the open Bankart repair and conjoint tendon transfer are biomechanically viable options for the treatment of anterior shoulder instability; further studies are needed to extrapolate these data to the clinical setting.

An assessment of SLAP type 5 lesions using proton density oblique sagittal imaging in magnetic resonance arthrography.

BACKGROUND: Bankart lesions accompany superior labrum anteroposterior (SLAP) lesions; these are called SLAP type 5. PURPOSE: To compare SLAP type 5 lesions using routine magnetic resonance arthrography (MRA) and thin-slice oblique sagittal proton density (PDW) sequences and correlation operation results. MATERIAL AND METHODS: In total, 181 patients were admitted with shoulder instability. The study was completed with 44 patients. The presence or absence of isolated Bankart and SLAP type 5 lesions in routine MRA and PDW oblique sagittal images were evaluated separately. Absence of rupture scored 0 points, suspected ruptures scored 1 point, and apparent ruptures scored 2 points. The two scores were compared with the shoulder arthroscopy findings. RESULTS: According to the findings in the shoulder arthroscopy, 40 patients had Bankart lesions and 17 patients had accompanying SLAP type 5 lesions. To detect a Bankart lesion, there was no significant difference between routine MRA sequences and PDW oblique sagittal images (P = 0.061). Routine MRA sensitivity was 95%, specificity 25%, positive predictive value (PPV) 92%, negative predictive value (NPV) 33%, while for PDW oblique sagittal images, sensitivity was 75%, specificity 100%, PPV 100%, and NPV 28.5%. In 8/17 type 5 SLAP lesions, routine MRA detected sensitivity 47%, specificity 92.6%, PPV 80%, and NPV 73.5%; in 14/17 SLAP type 5 lesions, PDW oblique sagittal images detected sensitivity 82%, specificity 100%, PPV 100%, and NPV 90% (P = 0.015). CONCLUSION: The PDW oblique sagittal images may play a significant role in assessing the anterior and superior extent of the tears.

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

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

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

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

Remplissage in Addition to Arthroscopic Bankart Repair for Shoulder Instability With On-Track Hill-Sachs Lesions Reduces Residual Apprehension Without External Rotation Limitation.

PURPOSE: To evaluate the role of remplissage as an adjunct to Bankart repair in patients with recurrent anterior shoulder dislocation combined with on-track Hill-Sachs lesion. METHODS: Arthroscopic Bankart repair with remplissage data (December 2018-2020) were collected (BR group). Inclusion criteria were (1) recurrent anterior shoulder dislocation, (2) on-track Hill-Sachs lesion, (3) minimal/subcritical glenoid bone loss (<17%), and (4) postoperative follow-up >1 year. Exclusion criteria were (1) revision surgery, (2) first dislocation with acute glenoid rim fracture, and (3) combined with other surgery. The control group was identified in Bankart repair-only cohort (B group). All patients were evaluated preoperatively, and at 3 weeks, 6 weeks, 3 months, 6 months, and then annually postoperatively. Visual analogue scale for pain, Self-Assessment Numerical Evaluation, American Shoulder and Elbow Surgeons Shoulder score, ROWE, and Western Ontario Shoulder Instability were evaluated at preoperative and final follow-up. Residual apprehension experience and external rotation deficit were evaluated. Patients, who were followed-up for more than 1 year, were asked how often they experienced any subjective apprehension in 4 grades (1: always, 2: frequently, 3: occasionally, 4: never). Patients who had a history of recurrent dislocation or revision surgery were investigated. RESULTS: In total, 53 patients (B, 28; BR, 25) were included. At final follow-up, both groups showed improvement in 5 clinical scores postsurgery (P < .001). The BR group showed greater ROWE scores than the B group (B: 75.2 ± 13.6, BR: 84.4 ± 10.8; P = .009). Residual apprehension patient ratio (B: 71.4% [20/28], BR: 32% [8/25]; P = .004) and the mean subjective apprehension grade (B: 3.1 ± 0.6, BR: 3.6 ± 0.6; P = .005) showed statistically significant difference, whereas no patients in either group experienced external rotation deficit (B: 14.8 ± 12.9°, BR: 18.0 ± 15.2°, P = .420). Only 1 patient in the B group had not responded to surgery, with dislocation recurrence (P = .340). CONCLUSIONS: Remplissage with arthroscopic Bankart repair in on-track Hill-Sachs lesion has a role in reducing residual apprehension without external rotation limitation. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Editorial Commentary: Glenoid Reconstruction With Autologous Tricortical Iliac Crest Represents an Alternative to Bankart Repair and Remplissage for Anterior Shoulder Instability With Subcritical Bone Loss.

Traumatic anterior shoulder dislocations are estimated to occur in approximately 2% of the population, frequently with concomitant anterior-inferior labral tears and associated Hill-Sachs lesions of the humeral head. So-called bipolar (or engaging) lesions with attritional bone loss may be exacerbated by recurrent instability, in terms of both prevalence and severity. The glenoid track concept and distance to dislocation have offered context for evaluating bipolar lesions, and increasingly, options for bone block reconstruction are considered for definitive treatment. Recently, concerns have been raised regarding coracoid transfer or Latarjet treatment, particularly with screw constructs in which catastrophic failure, hardware breakage, and secondary arthritis may develop. The Eden-Hybinette procedure, or tricortical iliac crest autograft bone augmentation, may represent a promising alternative to existing options while also restoring native glenoid bone stock. Additionally, suture button fixation may obviate the traditional pitfalls of prior bone block procedures while also achieving reproducible functional outcomes and low rates of recurrence. However, this must be considered alongside other contemporary arthroscopic treatments, such as combined arthroscopic Bankart repair and remplissage.

Arthroscopic Autologous Iliac Crest Grafting Results in Similar Outcomes and Low Recurrence Compared to Remplissage Plus Bankart Repair for Anterior Shoulder Instability With Bipolar Bone Defects.

PURPOSE: To compare the functional outcomes, range of motion (ROM), recurrence rates, and complication rates of arthroscopic autologous iliac crest grafting (AICG) and Remplissage plus Bankart repair (RB) for anterior shoulder instability with bipolar bone defects. METHODS: This study enrolled patients undergoing arthroscopic AICG or RB with 13.5-25% glenoid bone defect combined with Hill-Sachs lesion between January 2013 and April 2020, who had a minimum 2-year follow-up. Patient-reported outcomes were evaluated by Subjective Shoulder Value (SSV), Oxford Shoulder Instability Score (OSIS), Rowe score, Constant score, and visual analog scale (VAS) for pain. Active ROM, return to sports, recurrence, self-reported apprehension, and complications were recorded. RESULTS: This study included 60 patients, including 28 AICG (Group A) and 32 RB (Group R). Mean glenoid bone defect was similar (17.7% ± 3.1% vs 16.6% ± 2.4%; P = .122). Both groups showed significant postoperative improvement in Rowe score, SSV, OSIS, and Constant score. No significant difference was found in postoperative Rowe Score (87.7 vs 85.2; P = .198). A total of 20/28 (71.4%) patients in Group A versus 26/32 (81.3%) patients in Group R met the Patient Acceptable Symptomatic State determined by VAS pain score (P = .370). Both groups showed high return-to-sports rates (67.8% vs 71.8%; P = .735) and slightly decreased ROM. There were two cases of recurrence in Group A versus one in Group R (P = .594). Group R had insignificantly higher positive self-reported apprehension rate (40.6% vs 17.9%; P = .055). CONCLUSIONS: For anterior shoulder instability with bipolar bone defects, both arthroscopic AICG and RB can result in satisfactory clinical outcomes, good postoperative ROM, and low recurrence and complication rates. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Increased rates of subjective shoulder instability after Bankart repair with remplissage compared to Latarjet surgery.

HYPOTHESIS AND BACKGROUND: Controversy exists as to the ideal management of young active patients with subcritical glenoid bone loss and an off-track Hill-Sachs lesion, and the Latarjet and arthroscopic Bankart with remplissage are effective surgical options. The purpose of this study was to compare rates of recurrent instability and reoperation, as well as patient-reported outcome measures, between Latarjet and arthroscopic Bankart repair with remplissage surgery patients. The authors hypothesized that there would be no difference in rates of recurrent instability, reoperation, and postoperative outcomes between patients who underwent Latarjet surgery and patients who underwent Bankart repair with concomitant remplissage postoperatively. MATERIALS AND METHODS: All patients who underwent primary shoulder stabilization for shoulder instability from 2014 to 2019 were screened. Latarjet and Bankart repair with remplissage patients were included if arthroscopic surgery was performed in response to anterior shoulder instability. Recurrent instability, revision, shoulder range of motion, return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores) were compared between groups. RESULTS: Overall, 43 Latarjet patients (age: 29.8 ± 12.1 years, 36 males 7 females) and 28 Bankart repair with remplissage patients (age: 28.2 ± 8.8 years, 25 males 3 females) were included with a mean follow-up of 3.3 ± 1.9 years. Patients who underwent Latarjet surgery had larger amounts of bone loss (19% vs. 11%, P < .001), a lower rate of off-track Hill-Sachs lesions (47% vs. 82%, P < .001), and more frequently had a history of chronic shoulder dislocations (88% vs. 43%, P < .001) compared to Bankart repair with remplissage patients. Latarjet patients less frequently reported feeling subjective shoulder instability after surgery (21% vs. 50%, P = .022), which was defined as feeling apprehension or experiencing a shoulder subluxation or dislocation event. There were no differences in rates of postoperative dislocation, revision, reoperation, or RTS, as well as patient-reported outcome scores, between groups (all P > .05). CONCLUSION: Despite differences in osseous defects, Latarjet and Bankart repair with remplissage patients had similar rates of clinical, patient-reported, and RTS outcomes at a mean of 3.3 years postoperatively. Latarjet surgery patients may be less likely to experience subjective shoulder instability postoperatively than patients who undergo Bankart repair with concomitant remplissage.

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.

Arthroscopic findings of the glenohumeral joint in symptomatic anterior instabilities: comparison between overhead throwing disorders and traumatic shoulder dislocation.

BACKGROUND: The term shoulder instability refers to a variety of mechanisms and clinical presentations. One of the common pathologies of throwing disorders is internal impingement with anterior instability. Most throwing athletes with symptomatic internal impingement with anterior instability exhibit positive apprehension and relocation test results, whereas those with recurrent anterior shoulder instability display positive apprehension test results. While the glenoid labrum-inferior glenohumeral ligament complex is a significant critical stabilizer for the prevention of anterior shoulder dislocation, the characteristics of the essential lesion in internal impingement with anterior instability have not been determined yet. This study aimed to compare the intra-articular lesion of athletes with internal impingement related to the overhead throwing motion in athletes with a traumatic shoulder dislocation. METHODS: Sixty-one athletes (all men; mean age, 25.2 ± 12.6 yr) who underwent an arthroscopic procedure were divided into 2 groups: 25 in the throwing group and 36 in the dislocation group. All shoulders had subtle glenohumeral instability defined by a positive anterior apprehension test and a relocation test. Those with voluntary and multidirectional instability and large glenoid bone loss (more than 25%) were excluded from the current study. All shoulders were evaluated for the following evidence: rotator cuff injury, superior labrum tear anterior and posterior lesions, labral pathologies including Bankart lesions, osteochondral lesions to the humeral head, biceps tendon fraying or rupture, and inferior glenohumeral ligament and middle glenohumeral ligament (MGHL) conditions. RESULTS: Arthroscopic findings of the throwing group showed more supraspinatus injuries (92% and 25%, P < .001), type II superior labrum tear anterior and posterior lesions (60% and 3%, P < .001), posterosuperior labral lesions (92% and 39%, P < .001), and hypoplastic MGHLs (56% and 6%, P < .001) and lesser Bankart lesions (8% and 92%, P < .05) than those of the dislocation group. CONCLUSIONS: These results indicate that the characteristic lesions of internal impingement with anterior instability in throwing athletes include partial thickness rotator cuff tears, superior labrum tear anterior and posterior lesions, posterosuperior labral tears, and hypoplastic MGHLs. As expected, the physiopathology of internal impingement with anterior instability in throwing athletes may be related to the dysfunction of the anterosuperior glenohumeral capsular ligament, including the MGHL, rather than the inferior glenohumeral ligament as in traumatic anterior shoulder dislocations. These findings would be useful for defining treatment strategies for internal impingement with anterior instability in overhead throwing athletes.

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.

Remplissage reduces recurrent instability in high-risk patients with on-track Hill-Sachs lesions.

BACKGROUND: The purpose of this study was to compare recurrent instability rates between patients with on-track Hill-Sachs lesions who underwent arthroscopic labral repair (ALR) alone and those who underwent ALR with remplissage (ALR-R). Our hypothesis was that ALR-R would decrease the rate of recurrent instability, especially among patients at high risk of recurrent instability after ALR, such as contact athletes with near-track Hill-Sachs lesions. METHODS: We performed a multicenter, retrospective analysis of patients aged 14-50 years with on-track Hill-Sachs lesions who underwent ALR-R or ALR without remplissage between January 2014 and December 2019 with minimum 2-year follow-up. The exclusion criteria included prior ipsilateral shoulder surgery, >15% glenoid bone loss (GBL), off-track Hill-Sachs lesion, concomitant shoulder procedure, and connective tissue disorder. Age, sex, follow-up, and contact sports participation were recorded. GBL, Hills-Sachs interval (HSI), glenoid track, and distance to dislocation (DTD) were determined from preoperative magnetic resonance imaging scans. Affected-shoulder range of motion, Western Ontario Shoulder Instability Index scores, Subjective Shoulder Value scores, and recurrent dislocation and/or revision surgery status were also collected. A subgroup analysis was performed on "high-risk" patients (defined as participants in contact sports with DTD <10 mm) from each cohort. RESULTS: The ALR-R cohort included 56 patients, and the ALR cohort included 127. ALR-R patients had greater GBL (P = .004) and a greater HSI (P < .001). In the ALR-R cohort, only 1 patient (1.8%) had a recurrent dislocation and there were no revision operations. In comparison, in the ALR cohort, 14 patients (11.0%) had recurrent dislocations (P = .040) and 8 (6.3%) underwent revision operations (P = .11). Univariate analysis showed that remplissage protected against recurrent dislocation (P = .040) whereas younger age (P = .004), contact sports participation (P = .001), and increased GBL (P = .048) were associated with recurrent dislocation. Multivariate analysis showed that HSI (P = .001) and contact sports participation (P = .002) predicted recurrent dislocation. Among high-risk patients, only 1 patient (4.2%) in the ALR-R group had a recurrent instability event vs. 6 (66.7%) in the ALR group (P < .001). The high-risk ALR-R subgroup also had significantly better final Western Ontario Shoulder Instability Index (P = .008) and Subjective Shoulder Value (P = .001) scores than the high-risk ALR subgroup. CONCLUSIONS: Anterior shoulder instability patients with on-track Hill-Sachs lesions have lower recurrent dislocation rates after ALR plus remplissage when compared with ALR alone. This is especially true for high-risk patients, such as contact athletes with a DTD <10 mm.

Does glenoid bone loss accompany posterior shoulder instability with only labral tear? A magnetic resonance imaging-based study.

BACKGROUND: The primary aim of this study was to investigate bone loss in the glenoid with magnetic resonance imaging in posterior shoulder instability with only a labral tear. METHODS: A total of 76 patients operated on because of posterior and anteroposterior shoulder instability only with a labral tear between 2006 and 2019 (n = 40 and n = 36, respectively) were included in this study. The instability type, a presence of an additional superior labrum anteroposterior (SLAP) lesion, the number of dislocations, and the magnetic resonance imaging-based measurements (the glenoid diameter and the bone defect size in the glenoid, the Hill-Sachs lesion [HSL] and the reverse HSL [rHSL] length, the angle and the arc length of HSL and rHSL, and the humerus head diameter and its area) were analyzed. RESULTS: The size of the anterior glenoid defect, the rHSL measurements (length, angle, and arc length), and the ratio of the anterior glenoid defect size to the glenoid diameter were significantly higher for anteroposterior instability (P < .01) cases. There was no significant difference (P = .49, .64, and .82, respectively) for the presence of an additional SLAP pathology, the glenoid diameter, the posterior glenoid defect, and the ratio of the posterior glenoid defect size to the glenoid diameter in posterior and anteroposterior instability groups. The increased number of dislocations was associated with increased rHSL length and total arc length (P = .04 and .03, respectively). An additional SLAP lesion in posterior shoulder instabilities was not associated with the bone defect size (P = .29). CONCLUSION: Although the posterior shoulder instability with only a labral tear is likely to cause a bone defect, we have shown that the instability is not expected to be caused by the bone defect. Therefore, this study points out that only soft tissue repair without considering the bone defect could be promising in this patient group.