Anterior Shoulder Instability Part III – Revision Surgery, Rehabilitation and Return to Play, and Clinical Follow-Up – An International Consensus Statement

2021 ◽  
Author(s):  
Bogdan A. Matache ◽  
Eoghan T. Hurley ◽  
Ivan Wong ◽  
Eiji Itoi ◽  
Eric J. Strauss ◽  
...  
Keyword(s):  
Revision Surgery ◽  
Shoulder Instability ◽  
Consensus Statement ◽  
Return To Play ◽  
Anterior Shoulder Instability ◽  
International Consensus ◽  
International Consensus Statement

Anterior Shoulder Instability in Throwers and Overhead Athletes: Long-term Outcomes in a Geographic Cohort

2021 ◽  
pp. 036354652110591
Author(s):  
Ryan R. Wilbur ◽  
Matthew B. Shirley ◽  
Richard F. Nauert ◽  
Matthew D. LaPrade ◽  
Kelechi R. Okoroha ◽  
...  
Keyword(s):  
Revision Surgery ◽  
Shoulder Instability ◽  
Treatment Strategies ◽  
Return To Play ◽  
Anterior Shoulder Instability ◽  
Recurrent Instability ◽  
Long Term Outcome ◽  
Overhead Athletes

Background: Athletes of all sports often have shoulder instability, most commonly as anterior shoulder instability (ASI). For overhead athletes (OHAs) and those participating in throwing sports, clinical and surgical decision making can be difficult owing to a lack of long-term outcome studies in this population of athletes. Purpose/Hypothesis: To report presentation characteristics, pathology, treatment strategies, and outcomes of ASI in OHAs and throwers in a geographic cohort. We hypothesized that OHAs and throwers would have similar presenting characteristics, management strategies, and clinical outcomes but lower rates of return to play (RTP) when compared with non-OHAs (NOHAs) and nonthrowers, respectively. Study Design: Cohort study; Level of evidence, 3. Methods: An established geographic medical record system was used to identify OHAs diagnosed with ASI in the dominant shoulder. An overall 57 OHAs with ASI were matched 1:2 with 114 NOHAs with ASI. Of the OHAs, 40 were throwers. Sports considered overhead were volleyball, swimming, racquet sports, baseball, and softball, while baseball and softball composed the thrower subgroup. Records were reviewed for patient characteristics, type of sport, imaging findings, treatment strategies, and surgical details. Patients were contacted to collect Western Ontario Shoulder Instability index (WOSI) scores and RTP data. Statistical analysis compared throwers with nonthrowers and OHAs with NOHAs. Results: Four patients, 3 NOHAs and 1 thrower, were lost to follow-up at 6 months. Clinical follow-up for the remaining 167 patients (98%) was 11.9 ± 7.2 years (mean ± SD). Of the 171 patients included, an overall 41 (36%) NOHAs, 29 (51%) OHAs, and 22 (55%) throwers were able to be contacted for WOSI scores and RTP data. OHAs were more likely to initially present with subluxations (56%; P = .030). NOHAs were more likely to have dislocations (80%; P = .018). The number of instability events at presentation was similar. OHAs were more likely to undergo initial operative management. Differences in rates of recurrent instability were not significant after initial nonoperative management (NOHAs, 37.1% vs OHAs, 28.6% [ P = .331] and throwers, 21.2% [ P = .094]) and surgery (NOHAs, 20.5% vs OHAs, 13.0% [ P = .516] and throwers, 9.1% [ P = .662]). Rates of revision surgery were similar (NOHAs, 18.0% vs OHAs, 8.7% [ P = .464] and throwers, 18.2% [ P > .999]). RTP rates were 80.5% in NOHAs, as compared with 71.4% in OHAs ( P = .381) and 63.6% in throwers ( P = .143). Median WOSI scores were 40 for NOHAs, as compared with 28 in OHAs ( P = .425) and 28 in throwers ( P = .615). Conclusion: In a 1:2 matched comparison of general population athletes, throwers and OHAs were more likely to have more subtle instability, as evidenced by higher rates of subluxations rather than frank dislocations, when compared with NOHAs. Despite differences in presentation and the unique sport demands of OHAs, rates of recurrent instability and revision surgery were similar across groups. Similar outcomes in terms of RTP, level of RTP, and WOSI scores were achieved for OHAs and NOHAs, but these results must be interpreted with caution given the limited sample size.

Functional Rehabilitation and Return to Play After Arthroscopic Surgical Stabilization for Anterior Shoulder Instability

2021 ◽  
pp. 194173812110628
Author(s):  
Timothy D. Kelley ◽  
Stephanie Clegg ◽  
Paul Rodenhouse ◽  
Jon Hinz ◽  
Brian D. Busconi
Keyword(s):  
Shoulder Instability ◽  
Return To Sport ◽  
Rehabilitation Program ◽  
Return To Play ◽  
Bankart Repair ◽  
Anterior Shoulder Instability ◽  
Functional Rehabilitation ◽  
Arthroscopic Bankart Repair ◽  
Redislocation Rate

Background: There exists limited objective functional return-to-play criteria after surgical stabilization for anterior shoulder instability in the competitive athlete. Hypothesis: The proposed functional rehabilitation program and psychological evaluation after arthroscopic Bankart repair will help athletes return to sport with a decreased redislocation rate on return. Study Design: Case series. Level of Evidence: Level 4. Methods: Participants were contact or overhead athletes at the high school or collegiate level. Each underwent arthroscopic Bankart repair after a single dislocation event, with less than 10% glenoid bone loss. Western Ontario Shoulder Instability Index (WOSI) scores, Single Assessment Numeric Evaluation (SANE) scores, and American Shoulder and Elbow Surgeons (ASES) scores were evaluated pre- and postoperatively. Athletes were only allowed to return to competition after completing the proposed functional and psychological rehabilitation protocol. Results: A total of 62 participants were enrolled (52 male, 10 female; average age, 18.7 years (range 16-24 years); mean Instability Severity Index Score, 5.63 ± 0.55). All returned to sport for 1 full season and completed a minimum of 2 years of follow-up. The average time to pass functional testing was 6.2 ± 0.7 months, psychological testing was 5.2 ± 0.5 months, and return to sport was 6.5 ± 0.7 months. SANE scores improved from 44.3 to 90.0, ASES from 45.5 to 89.3, and WOSI from 1578.0 to 178.9 (all P < 0.001). Redislocation rate was 6.5% (4 of 62). Conclusion: The proposed functional rehabilitation and psychological assessment protocol is safe and effective in returning athletes to sport after arthroscopic surgical intervention for anterior shoulder instability. This demonstrated a low redislocation rate after 2-year follow-up. Clinical Relevance: Most return-to-play protocols after arthroscopic Bankart repair are centered on recovery time alone, with limited focus on functional rehabilitation, psychological assessment, and return-to-play testing parameters. To our knowledge, this is the first study to propose a dedicated rehabilitation program incorporating functional testing, psychological readiness, and return-to-play criteria for competitive athletes recovering from arthroscopic shoulder stabilization.

Traveller’s thrombosis: International consensus statement

VASA ◽  
2008 ◽  
Vol 37 (4) ◽  
pp. 311-317 ◽  
Author(s):  
Schobersberger ◽  
Toff ◽  
Eklöf ◽  
Fraedrich ◽  
Gunga ◽  
...  
Keyword(s):  
Literature Search ◽  
Consensus Statement ◽  
Current Knowledge ◽  
Individual Risk ◽  
International Consensus ◽  
Writing Group ◽  
Consensus Group ◽  
International Consensus Statement

In 2001, consensus meetings on traveller’s thrombosis were held in Vienna and Berlin. The results of these conferences were subsequently published in VASA 2002. In 2006 a follow-up conference was organized in Hall, Tirol, Austria, in order to review new and emerging data and to update the conclusions and recommendations of the 2001 meetings. Prior to the conference key papers from peer-reviewed journals were pre-circulated to all participants. The consensus group discussed the data and drafted an updated statement. Thereafter, the writing group summarised the results including the pre-circulated material and additional papers identified by a formal literature search up to December 2007. In this article current knowledge on the incidence, pathophysiology and prevention of traveller’s thrombosis is summarised. The assessment of individual risk is described and recommendations for prevention of traveller’s thrombosis are given, based upon the conclusions of the Hall Conference.

scholarly journals Clinical Outcomes of Primary versus Revision Surgery using Arthroscopic Anatomic Glenoid Reconstruction for Anterior Shoulder Instability. (244)

2021 ◽  
Vol 9 (10_suppl5) ◽  
pp. 2325967121S0035
Author(s):  
Ivan Wong ◽  
Ryland Murphy ◽  
Sara Sparavalo ◽  
Jie Ma
Keyword(s):  
Bone Loss ◽  
Clinical Outcomes ◽  
Revision Surgery ◽  
Shoulder Instability ◽  
Anterior Shoulder Instability ◽  
Primary Group ◽  
Recurrent Instability ◽  
Exclusion Criteria ◽  
Glenoid Reconstruction

Objectives: Revision surgeries after prior shoulder stabilization are known to have worse outcomes as compared to their primary counterparts. To date, no studies have looked at the utility of arthroscopic anatomic glenoid reconstruction (AAGR) as a revision surgery. The purpose of this study was to assess the clinical outcomes of primary versus revision AAGR for anterior shoulder instability with bone loss. Methods: We performed a retrospective review on consecutive patients with prospectively collected data who underwent AAGR from 2012 to 2018. 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 rotator cuff pathology, multidirectional instability and glenoid fractures. There were 68 patients (48 primary and 20 revision) who met inclusion/exclusion criteria. Our primary outcome was measured using the Western Ontario Shoulder Instability Index (WOSI) and Disabilities of Arm, Shoulder, Hand (DASH) scores. Secondary outcomes included post-operative complications and post-operative recurrent instability. Results: The primary group showed a significant improvement in most-recent post-operative WOSI from 62.7 to 20.7 (P<0.001, α=0.05) and in DASH from 26.89 to 6.7 (p<0.001, α=0.05). The revision group also showed a significant improvement in WOSI from 71.5 to 34.6 (p<0.001, α=0.05) and in DASH from 39.5 to 17.0 (p<0.05, α=0.05). When comparing between groups, the revision group had worse WOSI scores (34.6) at most recent follow-up compared to the primary group (20.7); p<0.05. The most-recent DASH scores also showed the revision group (17.0) having worse outcomes than the primary group (6.7); p<0.05. Important to note that the minimal clinically important difference (MCID) was met for WOSI (MCID=10.4) but not DASH (MCID=10.83). There were no post-operative reports of instability in either group. For complications, one hardware failure (suture anchor) was seen in the primary group, and two hardware removals were seen in the revision group. Conclusions: While patient reported scores indicated worse outcomes in the revision group, the significant clinical improvement in DASH and WOSI, along with the lack of recurrent instability provides evidence that AAGR is a suitable option for revision patients.

scholarly journals Long Term Outcomes of Anterior Shoulder Instability in Throwers and Overhead Athletes at a Mean Follow-up of 15 years (240)

2021 ◽  
Vol 9 (10_suppl5) ◽  
pp. 2325967121S0034
Author(s):  
Matthew Shirley ◽  
Richard Nauert ◽  
Ryan Wilbur ◽  
Matthew LaPrade ◽  
Christopher Bernard ◽  
...  
Keyword(s):  
Shoulder Instability ◽  
Treatment Strategies ◽  
Return To Sport ◽  
Population Based ◽  
Return To Play ◽  
Anterior Shoulder Instability ◽  
Geographic Population ◽  
Overhead Athletes ◽  
Patient Reported

Objectives: There is a paucity of literature regarding outcomes of anterior shoulder instability (ASI) in throwers and overhead athletes (OHA). The purpose of this study was to report the pathology, treatment strategies, and outcomes of ASI in throwers and overhead athletes utilizing an established US geographic population-based cohort. Methods: An established geographic database of more than 500,000 patients was used to identify athletes <40 years of age with ASI between 1994 and 2016. Medical records were reviewed to obtain demographics, type of sport, surgical details, and clinical outcomes. Patients were contacted after final clinical follow-up for patient reported outcomes (PRO). The Western Ontario Shoulder Instability (WOSI) score, return to sport at previous level of performance (RPP), rate of return to play (RTP) and time to RTP were recorded. Statistical analysis was performed comparing throwers to non-throwers and OHA to non-overhead athletes (NOHA). Results: The study population consisted of 171 patients, 114 NOHA and 57 OHA. Of the OHA, 40 were throwers. The mean follow-up was 14.7 ± 5.6 years for PRO’s and 11.7 ± 7.3 years for last clinical evaluation. No difference in overall instability events was seen in either group. Throwers were more likely to present with subluxations while non-throwers were more likely to present with frank dislocations. NOHA and non-throwers were more likely than OHA and throwers to have a history of trauma related to ASI, respectively ( P = <.001, P = .002). Throwers were more likely to undergo an open surgical procedure (45%) than non-throwers (15%) ( P = .038). The rate of recurrent instability between groups was similar. Throwers returned to sport at a lower rate than non-throwers, however this did not reach significance (64% vs 83%, P = .100). Throwers and OHA reported similar WOSI scores, RPP and time to RTP grouped by surgical or conservative management compared to non-throwers and NOHA, respectively. Conclusions: In a US cohort of patients, throwers and OHA had a similar number of instability events compared to non-throwers and NOHA, respectively. Non-throwers and NOHA were more likely to present with frank dislocation which is supported by the significantly higher rates of trauma in both groups. Notably, the WOSI score, RPP, rate of RTP and time to RTP showed no difference between throwers and OHA when compared to their non-throwing and NOHA counterparts.

Management of the Failed Latarjet Procedure: Outcomes of Revision Surgery With Fresh Distal Tibial Allograft

2019 ◽  
Vol 47 (12) ◽  
pp. 2795-2802 ◽  
Author(s):  
Matthew T. Provencher ◽  
Liam A. Peebles ◽  
Zachary S. Aman ◽  
Andrew S. Bernhardson ◽  
Colin P. Murphy ◽  
...  
Keyword(s):  
Bone Loss ◽  
Physical Examination ◽  
Ct Scan ◽  
Revision Surgery ◽  
Shoulder Instability ◽  
Anterior Shoulder Instability ◽  
Latarjet Procedure ◽  
Recurrent Shoulder Instability ◽  
Recurrent Anterior Shoulder Instability

Background: Patients with recurrent anterior glenohumeral instability after a failed Latarjet procedure remain a challenge to address. Complications related to this procedure include large amounts of bone loss, bone resorption, and issues with retained hardware that necessitate the need for revision surgery. Purpose: To determine the outcomes of patients who underwent revision surgery for a recurrent shoulder instability after a failed Latarjet procedure with fresh distal tibial allograft. Study Design: Case series; Level of evidence, 4. Methods: All consecutive patients who underwent revision of a failed Latarjet procedure with distal tibial allograft were prospectively enrolled. Patients were included if they had physical examination findings consistent with recurrent anterior shoulder instability. Patients were excluded if they had prior neurologic injury, a seizure disorder, bone graft requirements to the humeral head, or findings of multidirectional or posterior instability. History of shoulder instability was documented, including initial dislocation history, duration of instability, number of prior surgeries, examination findings, plain radiographic and computed tomography (CT) data, and arthritis graded with Samilson and Prieto (SP) classification. All patients were treated with hardware removal, capsular release with subsequent repair, and fresh distal tibial allograft to the glenoid. Outcomes before and after revision were assessed according to the American Shoulder and Elbow Score (ASES), Single Assessment Numerical Evaluation (SANE), and Western Ontario Shoulder Index (WOSI) and statistically compared. All patients underwent a CT scan of the distal tibial allograft at a minimum 4 months after surgery. Results: There were 31 patients enrolled (all males), with a mean age of 25.5 years (range, 19-38 years) and a mean follow-up time of 47 months (range, 36-60 months) after revision with distal tibial allograft. Before distal tibial allograft augmentation, the mean percentage glenoid bone loss was 30.3% (range, 25%-49%). All patients after their Latarjet stabilization had recurrent shoulder dislocation (11/31, 35.5%) or subluxation (20/31, 64.5%), and all patients had symptoms consistent with recurrent shoulder instability upon physical examination. Radiographs demonstrated 2 fixation screws in all cases, mean SP grade was 0.5 (range, 0-3), and CT scans revealed that a mean 78% of the Latarjet coracoid graft had resorbed (range, 37%-100%). Patient-reported outcome scores improved significantly pre- to postoperatively for ASES (40 to 92, P = .001), SANE (44 to 91, P = .001), and WOSI (1300 to 310, P = .001). There were no cases of recurrence, and a final CT scan of the distal tibial revision demonstrated a complete union at the glenoid–distal tibial allograft interface in 92% of patients. Conclusion: The majority of the failed Latarjet procedures included in this study had near-complete resorption of the coracoid graft and hardware complications. At a minimum follow-up time of 36 months, patients who underwent revision treatment for a failed Latarjet procedure with a fresh distal tibial allograft demonstrated excellent clinical outcomes and near-complete osseous union at the glenoid-allograft interface. Although patients evaluated with recurrent anterior shoulder instability after a failed Latarjet procedure remain a challenge to address, fresh distal tibial allograft augmentation is a viable and highly effective revision procedure to treat this patient population.

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