Arthroscopic Bankart repair: how many knotless anchors do we need for anatomic reconstruction of the shoulder?-a prospective randomized controlled study.

PURPOSE: The optimal strategy for surgical repair of traumatic anterior shoulder instability remains controversial. While several study groups have reported that the clinical and radiological outcomes of arthroscopic procedures performed with two anchors are not fully adequate, these conclusions are not supported by the findings published in other studies. A prospective randomized study was conducted to compare the structural and clinical outcomes of surgical procedures involving two vs. three anchors. METHODS: Patients who underwent arthroscopic Bankart repair were randomly assigned to either Group I, which underwent procedures involving two double-loaded 3.5-mm knotless anchors, or Group II, which underwent procedures involving three single-loaded 2.9-mm knotless anchors. All patients underwent bilateral MRI assessments at a minimum of 12 months and clinical assessment at a minimum of 24 months postoperatively. To evaluate the reconstruction of the labral capsular ligamentous complex (LCLC), the labrum-glenoid height index (LGHI), restored labral height (LH), and labral slope (LS) were measured for both shoulders. For clinical assessment, the redislocation rate and functional outcome scores (Constant score (CS), American Shoulder and Elbow Surgeon score (ASES), Walch Duplay score (WDS), and Rowe score (RS)) were evaluated at follow-up visits. RESULTS: Bankart repair with two knotless anchors showed lower values for anterior reconstruction of the LCLC compared to the uninjured contralateral shoulder. Likewise, significant differences were noted when comparing these measurements to those from patients who underwent reconstruction with three anchors. No differences were demonstrated with regard to the reconstruction of the inferior LCLC. Clinical assessment showed good to excellent results in both groups. In total, three patients experienced redislocation of the shoulder: two in group I and one in group II. No significant differences were found with respect to clinical outcomes and redislocation rates. CONCLUSION: Bankart repair with both two and three knotless anchors results in effective anatomical reconstruction of the labral capsular ligamentous complex. Although the two-anchor technique yields significantly lower values for the anterior portion compared with the contralateral side, none of these differences reach clinical relevance as per our original definition.

Effectiveness of a home-based re-injury prevention program on motor control, return to sport and recurrence rates after anterior cruciate ligament reconstruction: study protocol for a multicenter, single-blind, randomized controlled trial (PReP).

BACKGROUND: Although anterior cruciate ligament (ACL) tear-prevention programs may be effective in the (secondary) prevention of a subsequent ACL injury, little is known, yet, on their effectiveness and feasibility. This study assesses the effects and implementation capacity of a secondary preventive motor-control training (the Stop-X program) after ACL reconstruction. METHODS AND DESIGN: A multicenter, single-blind, randomized controlled, prospective, superiority, two-arm design is adopted. Subsequent patients (18-35 years) with primary arthroscopic unilateral ACL reconstruction with autologous hamstring graft are enrolled. Postoperative guideline rehabilitation plus Classic follow-up treatment and guideline rehabilitation plus the Stop-X intervention will be compared. The onset of the Stop-X program as part of the postoperative follow-up treatment is individualized and function based. The participants must be released for the training components. The endpoint is the unrestricted return to sport (RTS) decision. Before (where applicable) reconstruction and after the clearance for the intervention (aimed at 4-8 months post surgery) until the unrestricted RTS decision (but at least until 12 months post surgery), all outcomes will be assessed once a month. Each participant is consequently measured at least five times to a maximum of 12 times. Twelve, 18 and 24 months after the surgery, follow-up-measurements and recurrence monitoring will follow. The primary outcome assessement (normalized knee-separation distance at the Drop Jump Screening Test (DJST)) is followed by the functional secondary outcomes assessements. The latter consist of quality assessments during simple (combined) balance side, balance front and single-leg hops for distance. All hop/jump tests are self-administered and filmed from the frontal view (3-m distance). All videos are transferred using safe big content transfer and subsequently (and blinded) expertly video-rated. Secondary outcomes are questionnaires on patient-reported knee function, kinesiophobia, RTS after ACL injury and training/therapy volume (frequency - intensity - type and time). All questionnaires are completed online using the participants' pseudonym only. Group allocation is executed randomly. The training intervention (Stop-X arm) consists of self-administered home-based exercises. The exercises are step-wise graduated and follow wound healing and functional restoration criteria. The training frequency for both arms is scheduled to be three times per week, each time for a 30 min duration. The program follows current (secondary) prevention guidelines. Repeated measurements gain-score analyses using analyses of (co-)variance are performed for all outcomes. TRIAL REGISTRATION: German Clinical Trials Register, identification number DRKS00015313 . Registered on 1 October 2018.

Stabilization of Acute High-Grade Acromioclavicular Joint Separation: A Prospective Assessment of the Clavicular Hook Plate Versus the Double Double-Button Suture Procedure.

BACKGROUND: The stabilization strategy for acute high-grade acromioclavicular (AC) joint separations with AC-stabilizing clavicular hook plate (cHP) or coracoclavicular (CC)-stabilizing double double-button suture (dDBS) is still under consideration. HYPOTHESIS: The CC-stabilizing dDBS is superior to the cHP according to an AC-specific radiologic assessment and score system. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Seventy-three consecutive patients with acute high-grade AC joint separation were prospectively followed in 2 treatment groups (64.4% randomized, 35.6% patient-selected treatment): open reduction and cHP (cHP group) or arthroscopically assisted dDBS (dDBS group) performed within 14 days of injury. Patients were prospectively analyzed by clinical scores (Taft, Constant score [CS], numeric analog scale for pain) and AC-specific radiographs (AC distance, CC distance [CCD], relative CCD [rCCD; 100 / AC distance × CCD]) at points of examination (preoperative and 6, 12, and 24 months). The minimal clinically important differences (MCIDs) were assessed by the anchor-based method. RESULTS: Twenty-seven of 35 patients (mean age ± SD: 37.7 ± 9.7 years) after cHP implantation and 29 of 38 patients (34.2 ± 9.7 years) after dDBS implantation were continuously followed until the 24-month follow-up. All patients showed significantly increased scores after surgery as compared with preoperative status (all P < .05). As compared with GI, GII had significantly better outcomes at 24 months (Taft: cHP = 9.4 ± 1.7 vs dDBS = 10.9 ± 1.1, P < .05, MCID = 2.9; CS: cHP = 90.2 ± 7.8 vs dDBS = 95.3 ± 4.4, P < .02, MCID = 16.6) and at 24 months for Rockwood IV/V (Taft: cHP = 9.4 ± 1.7 vs dDBS = 11.1 ± 0.8, P < .0005; CS: cHP = 90.1 ± 7.7 vs dDBS = 95.5 ± 3.1, P < .04). Clinically assessed horizontal instability persisted in 18.52% (GI) and 6.89% (GII; P = .24). The rCCD showed equal loss of reduction at 24 months (GII = 130.7% [control = 111%] vs GI = 141.8% [control = 115%], MCID = 11.1%). CONCLUSION: This prospective study showed significantly superior outcomes in all clinical scores between GII and GI. The subanalysis of the high-grade injury type (Rockwood IV/V) revealed that these patients showed significant benefits from the dDBS procedure in the clinical assessments. The cHP procedure resulted in good to excellent clinical outcome data and displayed an alternative procedure for patients needing less restrictive rehabilitation protocols.

Back to Sports After Arthroscopic Revision Bankart Repair.

BACKGROUND: Recurrent instability following primary arthroscopic stabilization of the shoulder is a common complication. Young, athletic patients are at the greatest risk of recurring instability. To date, the literature contains insufficient description regarding whether return to sports is possible after revision arthroscopic Bankart repair. HYPOTHESIS: Patients presenting with recurrent instability after primary arthroscopic stabilization should expect limitations in terms of their ability to partake in sporting activities after revision surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty athletes who underwent arthroscopic revision stabilization of the shoulder after failed primary arthroscopic Bankart repair were included in the study after completing inclusion and exclusion criteria surveys. Athletic Shoulder Outcome Scoring System (ASOSS), Shoulder Sport Activity Score (SSAS), and the Subjective Patient Outcome for Return to Sports (SPORTS) scores were determined to assess the participants' ability to partake in sporting activities. Furthermore, sport type and sport level were classified and recorded. To assess function and stability, Rowe, American Shoulder and Elbow Surgeons, Constant-Murley, and Walch-Duplay scores were measured and recorded. RESULTS: Follow-up consultations were carried out after a mean of 28.7 months. The mean age at follow-up examination was 27.75 years. At the time of follow-up, 70% of the patients were able to return to their original sporting activities at the same level. However, 90% of patients described a limitation in their shoulder when participating in their sports. At 28.7 months after surgery, the mean ASOSS score was 76.8; the SSAS score decreased from 7.85 before first-time dislocation to 5.35 at follow-up (P < .005). The SPORTS score was 5.2 out of 10 at the follow-up consultation. Function- and instability-specific scores showed good to excellent results. The mean external rotational deficit for high external rotation was 9.25°, and for low external rotation it was 12°. CONCLUSION: Patients can return to their original type and level of sport after arthroscopic revision Bankart repair, but they must expect persistent deficits and limitations to the shoulder when put under the strains of sporting activity. Patients with shoulder injuries who partake in sports that put greater demand on the shoulder show the smallest probabilities of returning to sporting activity.

Rotator cuff muscular integrity after arthroscopic revision of a Bankart repair.

INTRODUCTION: Recurrent shoulder instability after arthroscopic Bankart repair is still a common complication. For primary Bankart repair studies have shown that the rotator cuff can recover completely. The ability of muscles to regenerate after arthroscopic revision Bankart repair (ARBR) has not been studied. Does the ARBR using a three-portal method allows complete muscle integrity compared with an uninjured imaging control group (ICG)? MATERIALS AND METHODS: Twenty-two (1 female, 21 males) physically active patients (mean age at follow-up 28.5 ± 7.1 years; mean follow-up 27.5 months ± 8.5) were assessed. ARBR with a three-portal method was carried out in all patients according to previous primary arthroscopic stabilization of the shoulder (revision Bankart group). Muscle atrophy of the subscapularis muscle (SSC), supraspinatus muscle (SSP) and infraspinatus muscle (ISP) was assessed by making lateral and vertical measurements by magnetic resonance imaging (MRI). Fatty infiltration was detected by standardized assessment from variations in intensity. Detailed clinical examination of the rotator cuff was carried out. MRI assessment was compared with that of a control group of 22 healthy volunteers of same age and activity level (ICG). RESULTS: For the SSC, no muscle impairment was noted compared with the ICG [superior atrophy index (sAISSC), p = 0.439; inferior atrophy index (iAISSC), p = 0.555; superior fatty infiltration index (sFDISSC), p = 0.294; inferior fatty infiltration index (iFDISSC), p = 0.62]. In investigation of the SSP and ISP, fatty infiltration was not shown (FDISSP, p = 0.454; sFDIISP, p = 0.504), though persistent muscle atrophy was found even > 2 years after surgery compared with the ICG (AISSP, p = 0.0025; sAIISP, p = 0.0009; iAIISP, p = 0.0004). CONCLUSION: ARBR using a three-portal method allowed good muscular integrity compared with the ICG, but with persistent slight muscular atrophy of the SSP and ISP.

Tibiofemoral and patellofemoral joint 3D-kinematics in patients with posterior cruciate ligament deficiency compared to healthy volunteers.

BACKGROUND: The posterior cruciate ligament (PCL) plays an important role in maintaining physiological kinematics and function of the knee joint. To date mainly in-vitro models or combined magnetic resonance and fluoroscopic systems have been used for quantifying the importance of the PCL. We hypothesized, that both tibiofemoral and patellofemoral kinematic patterns are changed in PCL-deficient knees, which is increased by isometric muscle flexion. Therefore the aim of this study was to simultaneously investigate tibiofemoral and patellofemoral 3D kinematics in patients suffering from PCL deficiency during different knee flexion angles and under neuromuscular activation. METHODS: We enrolled 12 patients with isolated PCL-insufficiency as well as 20 healthy volunteers. Sagittal MR-images of the knee joint were acquired in different positions of the knee joint (0°, 30°, 90° flexion, with and without flexing isometric muscle activity) on a 0.2 Tesla open MR-scanner. After segmentation of the patella, femur and tibia local coordinate systems were established to define the spatial position of these structures in relation to each other. RESULTS: At full extension and 30° flexion no significant difference was observed in PCL-deficient knee joints neither for tibiofemoral nor for patellofemoral kinematics. At 90° flexion the femur of PCL-deficient patients was positioned significantly more anteriorly in relation to the tibia and both, the patellar tilt and the patellar shift to the lateral side, significantly increased compared to healthy knee joints. While no significant effect of isometric flexing muscle activity was observed in healthy individuals, in PCL-deficient knee joints an increased paradoxical anterior translation of the femur was observed at 90° flexion compared to the status of muscle relaxation. CONCLUSIONS: Significant changes in tibiofemoral and patellofemoral joint kinematics occur in patients with isolated PCL-insufficiency above 30 degrees of flexion compared to healthy volunteers. Since this could be one reasonable mechanism in the development of osteoarthritis (OA) our results might help to understand the long-term development of tibiofemoral and/or patellofemoral OA in PCL-insufficient knee joints.

Shoulder sport-specific impairments after arthroscopic Bankart repair: a prospective longitudinal assessment.

BACKGROUND: Reports of return to shoulder-dependent sport after surgical stabilization previously underestimated impairments, which were not reflected in the score systems used. HYPOTHESIS: Return to shoulder-dependent sport depends on the type of sport performed. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Forty-seven athletes (26.9 years of age at surgery) who underwent isolated arthroscopic Bankart repair were longitudinally monitored by shoulder-dependent sport-specific activity (Shoulder Sport Activity Score [SSAS]) and ability (Athletic Shoulder Outcome Scoring System [ASOSS]) scores and visual analog scales for reachieved proficiency level, sport-specific shoulder pain, and functional deficits. Data were assessed at 4 points of treatment: preoperatively, and postoperatively after 6, 16, and 32 months (P0-P3). Athletes were analyzed separately according to shoulder sport: noncollision/nonoverhead (G1), collision (G2), overhead (G3), and martial arts (G4). RESULTS: The G1 and G2 athletes had re-achieved the preinjury sport activity and sport proficiency status and excellent ASOSS scores after 32 months (SSAS(G1) = 7.2, SSAS(G2) = 8.1, ASOSS(G1) = 94.4, ASOSS(G2) = 95.2), whereas G3 and G4 athletes remained at an inferior activity level (SSAS(G3) = 8.0, SSAS(G4) = 8.3) and proficiency level. The ASOSS documented a prolonged period of shoulder rehabilitation for G3 and G4 athletes to reach a good shoulder-dependent sport ability outcome after 32 months (ASOSS(G3) = 89.0, ASOSS(G4) = 93.1). All groups recorded persisting limitations in visual analog scales for sport-specific shoulder function and pain. The established scores (Rowe = 95.9, Walch-Duplay = 93.3, Constant = 94.0) did not reflect these sport-specific impairments. Athletes with 5 or more preoperative dislocations had significantly longer surgery-to-sport resumption intervals with a prolonged proficiency recovery. CONCLUSION: The athletes' shoulder stabilization resulted in a prolonged rehabilitation depending on the functional demand of the performed shoulder-dependent sport, as shown by the specific shoulder sport score systems.

Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears.

BACKGROUND: The influence of standard meniscus treatment strategies regarding osteoarthritic progress, function, and sports activity has not been estimated in a direct long-term comparison. HYPOTHESIS: Meniscal repair compared with partial meniscectomy (partial meniscal resection) decreases osteoarthritic changes and reduces the effect on sports activity in the long-term follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Eighty-one patients with an arthroscopic meniscus shape-preserving surgery after isolated traumatic medial meniscal tear (repair: n = 42; meniscectomy: n = 39) were examined clinically (Lysholm score, Tegner score) and radiologically (Fairbank score, compared with the uninjured knee); the follow-up was divided into midterm (3.4 years; n = 35) and long term (8.8 years; n = 46). Additionally, the influences of the preoperative sports activity level and age at surgery were evaluated. RESULTS: In the long-term follow-up, no osteoarthritic progress was detectable in 80.8% after repair compared with 40.0% after meniscectomy (P = .005) with significant benefit for the "young" subgroup (P = 0.01). The preinjury activity level was obtained in 96.2% after repair compared with 50% after meniscectomy (P = .001). The function score revealed no significant difference between these strategies (P = .114). The athletes showed a significantly reduced loss of sports activity after repair compared with the athletes after meniscectomy (P = .001). CONCLUSION: Arthroscopic meniscal repair offers significantly improved results for isolated traumatic meniscal tears regarding the long-term follow-up in osteoarthritis prophylaxis and sports activity recovery compared with partial meniscectomy.

Postoperative functional outcome and stability in recurrent traumatic anteroinferior glenohumeral instability: comparison of two different surgical capsular reconstruction techniques.

INTRODUCTION: Patients (n=62) with recurrent traumatic anterior or anteroinferior glenohumeral instability were prospectively evaluated with reference to the surgical reconstruction technique performed. MATERIALS AND METHODS: Neer's T-plasty procedure was performed in group I (n=31) while a modified, anatomically orientated, anteroinferior capsular shift was performed in group II (n=31). All patients underwent an additional Bankart repair. After 18.1 (group II) and 22.2 (group I) months, patients were assessed in terms of subjective satisfaction, objective stability, range of motion, and functional outcome. RESULTS: No significant differences (91.5% group II, 87.8% group I) were noted between the study groups regarding the patient's subjective evaluation (p=0.17106). Results of Rowe's (93.1% group II, 87.9% group I; p=0.14419) and Constant's Score (96.5% group II, 93.8% group I; p=0.16582) showed no significant differences for both collectives. Postoperative lack of external rotation remained significantly smaller in group II (5.6 degrees +/-2.5 degrees ) compared with group I (9.8 degrees +/-2.5; p=0.00028). Although no significant differences (p=0.612) were found, the rate of recurrence was obviously smaller in group II (group II vs group I: 6 patients). CONCLUSIONS: Our results demonstrate no significant differences between the two capsular reconstruction techniques regarding patient's satisfaction, Rowe and Constant Scores. However, the anatomically orientated anteroinferior capsular shift leads to a significantly smaller external rotation deficit and seems to offer a more reliable postoperative stability.

Mid-term results and quantitative comparison of postoperative shoulder function in traumatic and non-traumatic rotator cuff tears.

INTRODUCTION: The objective of this study was to compare the postoperative range of motion (ROM) and patient satisfaction after surgical reconstruction of traumatic and non-traumatic rotator cuff tears. MATERIALS AND METHODS: The cases of 46 consecutive patients who underwent the same standardised surgical reconstruction and postoperative rehabilitation protocol between 1993 and 1998 were reviewed. Traumatic (group I, n=20, average age 34.2 years, range 15-49 years) and non-traumatic tears (group II, n=26, average age 54.1 years, range 50-68 years) formed the two study groups. Mean follow-up lasted 47.1 months (range 13-105 months) in group I and 41.4 months (range 11-94 months) in group II. Assessment included postoperative shoulder function with Constant and Murley's score and visual analogue scale (VAS). RESULTS: Significantly ( p=0.0019) better results were observed in group I with an average of 94.1 points for Constant's score, compared with 75.3 points in group II. Postoperative shoulder function was not affected regarding full-thickness or partial tears ( p=0.239) in group I. VAS revealed an excellent or good result in all patients of group I ( n=20) and 50% of group II ( n=13/26). Quantitative comparison of postoperative ROM demonstrated significantly better results in forward flexion ( p=0.013), abduction ( p=0.0019) and external rotation ( p=0.0042) for group I. The remaining postoperative external rotation deficit for group II with a loss of 31% compared with group I (38.9 degrees vs 56.6 degrees ) was statistically and clinically relevant. CONCLUSION: The results demonstrate that surgical reconstruction of traumatic and non-traumatic rotator cuff tears is a successful procedure. Comparison of both groups revealed significantly better postoperative results in the younger, traumatic collective.