scholarly journals Multidirectional Shoulder Instability With Circumferential Labral Tear and Bony Reverse Hill Sachs: Treatment with 270° Labral Repair and Fresh Talus Osteochondral Allograft to the Humeral Head

2021 ◽  
Vol 10 (3) ◽  
pp. e781-e787
Author(s):  
Zachary S. Aman ◽  
Liam A. Peebles ◽  
Donovan W. Johnson ◽  
Jared A. Hanson ◽  
Matthew T. Provencher
Keyword(s):  
Shoulder Instability ◽  
Humeral Head ◽  
Labral Tear ◽  
Labral Repair ◽  
Osteochondral Allograft

scholarly journals The Influence of Glenoid Retroversion on Posterior Shoulder Instability: A Cadaveric Study (214)

2021 ◽  
Vol 9 (10_suppl5) ◽  
pp. 2325967121S0032
Author(s):  
James Levins ◽  
Rohit Badida ◽  
Edgar Garcia-Lopez ◽  
Steven Bokshan ◽  
Steven DeFroda ◽  
...  
Keyword(s):  
Coordinate System ◽  
Humeral Head ◽  
Labral Tear ◽  
Labral Repair ◽  
Intact State ◽  
Percent Change ◽  
Increased Risk ◽  
Bone Tunnels ◽  
Glenoid Retroversion ◽  
Peak Resistance

Objectives: Increased glenoid retroversion has been associated with an increased risk of posterior glenohumeral instability. Normal mean glenoid version is between 0-7° of retroversion depending on the population and measurement method. Retroversion can range above 20°, notably in patients with glenoid dysplasia. Increased glenoid retroversion has also been proposed as a risk factor for failure after primary soft tissue repair. Arthroscopic repair is the most common surgical treatment; however, this does not address cases of increased glenoid retroversion. What has not been identified is the degree of glenoid retroversion associated with recurrent instability or failed repair. The goal of our work is to (1) measure how resistance to posterior translation changes as retroversion increases, (2) examine if labral tear results in a greater decrease to resistance at increasing degrees of retroversion, and (3) to determine the degree of retroversion at which labral repair fails to restore the resistance of the intact, neutral version state. Methods: Eight fresh frozen cadaveric shoulder specimens (age 50-64, 4 male) were prepared, maintaining bone and capsulolabral tissue. The scapula and humerus were potted using quick-set polyurethane. CT scans were obtained to establish a scapular 3D coordinate system relative to the potting. Specimens were mounted on a 6 degree of freedom musculoskeletal simulation robotic arm (KUKA KR 6 R700, Augsburg, Germany) and referenced to the coordinate system. The humeral head was centered on the glenoid using a 50N compressive force, and the humerus was translated posterior-inferiorly (30° inferior to the midline) at 1mm/sec in neutral rotation for 10mm. The shoulder was positioned in 30° of abduction and 30° of flexion, based on prior protocol. Custom simVITRO (Cleveland Clinic, Ohio, US) labview-based control software measured peak resistance at 0° of version and then in 5° increments of retroversion until the specimen dislocated, up to 30° of retroversion. Version was adjusted through use of a multiplanar vice. A posterior labral tear was created from the 2 to 6 o’clock position on a left shoulder, and the same testing parameters were performed. Vertical mattress sutures using 4 independent bone tunnels were used to repair the labrum and the same version iterations were tested. Generalized estimating equations were used to compare the peak resistance to translation for each degree of version in the intact, cut and repaired states. The maximum likelihood estimators of the model were adjusted for any model misspecification using classical sandwich estimation. Post hoc pairwise comparisons between conditions were conducted via orthogonal contrasts. The Holm-test was used to calculate adjusted p-values and confidence intervals. Statistical significance was established at the P<0.05 level and all interval estimates were calculated for 95% confidence. Results: The mean peak resistance for the intact labral state decreased significantly for each interval increase in retroversion when the humerus was translated posterior-inferiorly (Figure 1). On average, a 1° increase in retroversion correlated with a 3.5% decrease in resistance to translation. Dislocation with an intact labrum without any posterior force occurred at a mean of 22.7° (range 15-30°) of retroversion. After labral tear, resistance forces to posterior-inferior translation decreased but not significantly from the intact state. However, the percent change of resistance force decreased 41% at 25° of retroversion; this was notably higher than the percent change at 0-15° of retroversion (range 2.7-6.5% decrease) but was not statistically significant (Figure 2). Compared to the intact state at 0° version, there was a 45% and 81% decrease in resistance after labral repair at 20° and 25° of retroversion, respectively (p=0.04 and p=0.004). Conclusions: Glenoid retroversion has a significant effect on resistance to posterior humeral head translation, with each degree increase accounting for 3.5% of resistance to translation. Cutting the labrum at 0-15° of retroversion does not have a significant effect on resistance to posterior inferior humeral translation; however, at 25° of retroversion cutting the labrum results in a 41% decrease in resistance. Similarly, labral repair at 20-25° of retroversion does not recreate peak resistance values of the intact state at 0-5° of retroversion. These findings point to the bony anatomy (retroversion) playing a larger role in preventing posterior instability than the labrum. It also provides evidence that the labrum plays a more significant role in stability at higher degrees of retroversion, and labral repair in patients with >20° of retroversion may be subjected to a relatively greater percentage of force than those at lesser degrees of retroversion.

scholarly journals Arthroscopic Repair of a Posterior Midcapsular Rupture Causing Posterior Shoulder Instability

2021 ◽  
Vol 1 (6) ◽  
pp. 263502542110319
Author(s):  
Gautam P. Yagnik ◽  
Kevin West ◽  
Bhavya K. Sheth ◽  
Luis Vargas ◽  
John W. Uribe
Keyword(s):  
Shoulder Instability ◽  
Arthroscopic Repair ◽  
Labral Tear ◽  
Labral Repair ◽  
Posterior Capsule ◽  
Posterior Shoulder Instability ◽  
Posterior Instability ◽  
Difficult Condition ◽  
Posterior Shoulder ◽  
Diagnostic Arthroscopy

Background: Gross posterior instability is rare and when found likely has an injury or deficiency to the posterior static restraints of shoulder associated with it. Traditionally, injuries to the posterior capsule have been difficult to diagnose and visualize with magnetic resonance imaging preoperatively, and very little literature regarding arthroscopic repair of posterior capsular tears exists currently. Indications: We present a repair of a posterior midcapsular and posterior labral tear in a 26-year-old man with recurrent left posterior shoulder instability using a novel all–arthroscopic technique. Technique Description: We performed a shoulder arthroscopy in a lateral decubitus position with the arm at 45° of abduction using standard posterior viewing and anterior working portals. Diagnostic arthroscopy revealed a large posterior midcapsular rupture approximately 2 cm lateral to the glenoid with an associated posterior labral tear. We created an accessory posterolateral portal with needle localization that was outside the capsular defect yet allowed access to the posterior labrum. Anatomic closure of the capsular tear was achieved arthroscopically with 3 interrupted No. 2 nonabsorbable sutures in a side–to–side fashion. Posterior labral repair and capsular shift were done to further address the instability using 2 knotless all–suture anchors percutaneously placed at the 7 o'clock and 9 o'clock position. We closed the posterior portal with a combination of curved and penetrating suture passers. Incisions were closed with interrupted 4-0 nylon. Postoperatively, the patient was placed in an ultra–sling for 4 weeks before physical therapy. We allowed light strengthening at 8 weeks, full strengthening at 12 weeks, and estimated return to sport at 4 months. Results: At 6 months postoperatively, the patient has regained symmetric motion, full strength, and has no residual pain or instability. Conclusion: Gross posterior instability is a rare and difficult condition to diagnose and manage. If no significant labral injuries are identified, injury to the posterior capsule must be considered and full assessment should be done when visualizing from the anterior portal. Repair of the posterior capsule is necessary and can be achieved all arthroscopically with this technique.

scholarly journals Minimum 2-Year Outcomes of All-Arthroscopic Capsular Autograft Labral Reconstruction

2021 ◽  
Vol 9 (7_suppl4) ◽  
pp. 2325967121S0024
Author(s):  
Michael Kucharik ◽  
Paul Abraham ◽  
Mark Nazal ◽  
Nathan Varady ◽  
Wendy Meek ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Body Mass ◽  
Donor Site ◽  
Donor Site Morbidity ◽  
Labral Tear ◽  
Labral Repair ◽  
Inclusion Criteria ◽  
The Mean ◽  
Tönnis Grade

Objectives: Acetabular labral tears distort the architecture of the hip and result in accelerated osteoarthritis and increases in femoroacetabular stress. Uncomplicated tears with preserved, native fibers can be fixed to acetabular bone using labral repair techniques, which have shown improved outcomes when compared to the previous gold standard, labral debridement and resection. If the tear is complex or the labrum is hypoplastic, labral reconstruction techniques can be utilized to add grafted tissue to existing, structurally intact tissue or completely replace a deficient labrum. The ultimate goal is to reconstruct the labrum to restore the labral seal and hip biomechanics. Clinical outcomes using autografts and allografts from multiple sources for segmental and whole labral reconstruction have been reported as successful. However, reconstruction using autografts has been associated with substantial donor-site morbidity. More recently, all-arthroscopic capsular autograft labral reconstruction has been proposed as a way to repair complex or irreparable tears without the downside of donor-site morbidity. Since all-arthroscopic capsular autograft labral reconstruction is a novel technique, there is limited data in the literature on patient outcomes. The purpose of this study is to report outcomes in patients who have undergone this procedure at a minimum 2-year follow-up. Methods: This is a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by a senior surgeon between December 2013 and May 2017. Patients who failed at least 3 months of conservative therapy and had a symptomatic labral tear on magnetic resonance angiography (MRA) were designated for hip arthroscopy. The inclusion criteria for this study were adult patients age 18 or older who underwent arthroscopic labral repair with capsular autograft labral reconstruction and completion of a minimum 2-year follow-up. Intraoperatively, these patients were found to have a labrum with hypoplastic tissue (width < 5 mm), complex tearing, or frank degeneration of native tissue. Patients with lateral center edge angle (LCEA) ≤ 20° were excluded from analysis. Using the patients’ clinical visit notes with detailed history and physical exam findings, demographic and descriptive data were collected, including age, sex, laterality, body mass index (BMI), and Tönnis grade to evaluate osteoarthritis. Patients completed patient-reported outcome measures and postoperatively at 3 months, 6 months, 12 months, and annually thereafter. Results: A total of 72 hips (69 patients) met inclusion criteria. No patients were excluded. The cohort consisted of 37 (51.4%) male and 35 (48.6%) female patients. The minimum follow-up was 24 months, with an average follow-up of 30.3 ± 13.2 months (range, 24-60). The mean patient age was 44.0 ± 10.4 years (range 21-64), with mean body mass index of 26.3 ± 4.3. The cohort consisted of 6 (8.3%) Tönnis grade 0, 48 (66.7%) Tönnis grade 1, and 18 (25.0%) Tönnis grade 2. Two (2.8%) progressed to total hip arthroplasty. Intraoperatively, 5 (6.9%) patients were classified as Outerbridge I, 14 (19.4%) Outerbridge II, 45 (62.5%) Outerbridge III, and 8 (11.1%) Outerbridge IV. Seventy-two (100.0%) patients had a confirmed labral tear, 34 (47.2%) isolated pincer lesion, 4 (5.6%) isolated CAM lesion, and 27 (37.5%) had both a pincer and CAM lesion. The mean of differences between preoperative and 24-month postoperative follow-up PROMs was 22.5 for mHHS, 17.4 for HOS-ADL, 32.7 for HOS-Sport, 22.9 for NAHS, 33.9 for iHOT-33. (Figure 1) The mean of differences between preoperative and final post-operative follow-up PROMs was 22.1 for mHHS, 17.6 for HOS-ADL, 33.2 for HOS-Sport, 23.3 for NAHS, and 34.2 for iHOT-33. (Table 1) Patient age and presence of femoroacetabular impingement were independently predictive of higher postoperative PROM improvements at final follow-up, whereas Tönnis grade was not. (Table 2) The proportion of patients to achieve the minimally clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) thresholds were also calculated. (Table 3) Conclusions: In this study of 72 hips undergoing arthroscopic labral repair with capsular autograft labral reconstruction, we found excellent outcomes that exceeded the MCID thresholds in the majority of patients at an average 30.3 months follow-up. When compared to capsular reconstruction from autografts and allografts, this technique offers the potential advantages of minimized donor-site morbidity and fewer complications, respectively. [Table: see text][Table: see text][Table: see text]

Acetabular Labral Tear Dimensions and Number of Suture Anchors Used to Repair in Patients with Femoroacetabular Impingement Syndrome

2021 ◽  
Author(s):  
Guillaume D. Dumont ◽  
Matthew J. Pacana ◽  
Adam J. Money ◽  
Thomas J. Ergen ◽  
Allen J. Barnes ◽  
...  
Keyword(s):  
Femoroacetabular Impingement ◽  
Impingement Syndrome ◽  
Labral Tear ◽  
Labral Repair ◽  
Suture Anchors ◽  
Labral Tears ◽  
Femoroacetabular Impingement Syndrome ◽  
The Mean ◽  
Tear Size ◽  
Anterior Extent

AbstractFemoroacetabular impingement syndrome (FAIS) is commonly associated with acetabular labral tears. Correction of impingement morphology and suture anchor repair of labral tears have demonstrated successful early and midterm patient-reported outcomes. The purpose of this study was to evaluate the posterior and anterior extent and size of labral tears in patients with FAIS undergoing arthroscopic labral repair, and to evaluate the number of suture anchors required to repair these tears. The design of this study was retrospective case series (Level 4). A single surgeon's operative database was retrospectively reviewed to identify patients undergoing primary arthroscopic hip labral repair between November 2014 and September 2019. Patient-specific factors and radiographic measurements were recorded. Arthroscopic findings including labral tear posterior and anterior extents, and the number of suture anchors utilized for the repair were recorded. Linear regression was performed to identify factors associated with labral tear size. The number of suture anchors used relative to labral tear size was calculated. Three-hundred and thirteen patients were included in the study. The mean posterior and anterior extent for labral tears were 11:22 ± 52 and 2:20 ± 34 minutes, respectively. Mean tear size was 2 hours, 58 minutes ± 45 minutes. The mean number of suture anchors utilized for labral repair was 3.1 ± 0.7. The mean number of anchors per hour of labral tear was 1.1 ± 0.3. Increased age, lateral center edge angle, and α angle were associated with larger labral tears. Our study found that acetabular labral tears associated with FAIS are, on average, 3 hours in size and centered in the anterosuperior quadrant of the acetabulum. Arthroscopic labral repair required 1.1 anchors per hour of tear size, resulting in a mean of 3.1 anchors per repair. Level of Evidence IV

Recurrent Instability after Arthroscopic Glenoid Labral Repair with a Minimum of Three Points of Fixation: Do the Number of Anchors or Fixation Points Correlate to Outcomes?

2021 ◽  
Author(s):  
Sean Mc Millan ◽  
Brian Fliegel ◽  
Michael Stark ◽  
Elizabeth Ford ◽  
Manuel Pontes ◽  
...  
Keyword(s):  
Shoulder Instability ◽  
Statistical Significance ◽  
Labral Repair ◽  
Secondary Outcome ◽  
Consecutive Series ◽  
Recurrent Instability ◽  
Significant Difference ◽  
Fixation Points ◽  
Definition Of ◽  
Shoulder Score

Introduction: The goal of this study was to evaluate the recurrence rate of instability following arthroscopic Bankart repairs in regard to the number and types of fixation utilized. A Bankart lesion is a tear in the anteroinferior capsulolabral complex within the shoulder, occurring in association with an anterior shoulder dislocation. These injuries can result in glenoid bone loss, decreased range of motion, and recurrent shoulder instability. Successful repair of these lesions has been reported in the literature with repair constructs that have three points of fixation. However, the definition of “one point of fixation” is yet to be fully elucidated. Materials and Methods: A consecutive series of arthroscopically repaired Bankart lesions were evaluated pertaining to the points of fixation required to achieve shoulder stability. This included the number, position, and types of anchors used. Patients consented to complete a series of surveys at a minimum of two years postoperatively. The primary outcome was to determine recurrent instability via the UCLA Shoulder Score, the ROWE Shoulder Instability Score, and the Oxford Shoulder Score. A secondary outcome included pain on a Visual Analog Scale (VAS). Results: There were 116 patients reviewed, 46 patients achieved three points of fixation in their surgical repair via two anchors and 70 patients achieved a similar fixation with three or more anchors. There was no significant difference in the mean age, gender, or body mass index (BMI). Patients receiving two anchors demonstrated recurrent instability 8.7% of the time (4 of 46 patients). Patients who received three or more anchors demonstrated recurrent instability 8.6% of the time (6 of 70 patients). Overall, there was no statistical significance between the number/types of anchors used. Between the two cohorts, there was no statistically significant difference found between VAS, ROWE, UCLA, and Oxford Scores. There was a significant difference in pain reported on the VAS scale with an average VAS score of 0.43 versus 2.5 in those without and with recurrent instability respectively. Conclusion: Contention still exists surrounding the exact definition of “a point of fixation” in arthroscopic Bankart repairs. Three-point constructs can be created through a variety of combinations including anchors and sutures, ultimately achieving the goal of a stable shoulder.

scholarly journals Does the innate relative size of the humeral head and glenoid affect the risk of anterior shoulder instability?

2018 ◽  
Vol 11 (6) ◽  
pp. 424-429
Author(s):  
NW Willigenburg ◽  
RA Bouma ◽  
VAB Scholtes ◽  
VPM van der Hulst ◽  
DFP van Deurzen ◽  
...  
Keyword(s):  
Shoulder Instability ◽  
Humeral Head ◽  
Relative Size ◽  
Ct Scans ◽  
Anterior Shoulder Instability ◽  
Multivariate Logistic Regression ◽  
Recurrent Instability ◽  
Bony Lesions ◽  
Joint Contact ◽  
And Gender

Background Bony lesions after shoulder dislocation reduce the joint contact area and increase the risk of recurrent instability. It is unknown whether the innate relative sizes of the humeral head and glenoid may predispose patients to shoulder instability. This study evaluated whether anterior shoulder instability is associated with a larger innate humeral head/glenoid ratio (IHGR). Methods We evaluated CT scans of 40 shoulders with anterior shoulder instability and 48 controls. We measured axial humeral head diameter and glenoid diameter following native contours, discarding any bony lesions, and calculated IHGR by dividing both diameters. Multivariate logistic regression determined whether the IHGR, corrected for age and gender as potential confounders, was associated with anterior shoulder instability. Results Mean IHGR was 1.48 ± 0.23 in the group with anterior shoulder instability and 1.42 ± 0.20 in the group without anterior shoulder instability. Measurements for axial humeral head and axial glenoid diameters demonstrated excellent intra-rater reliability (ICC range: 0.94–0.95). IHGR was not significantly associated with anterior shoulder instability (OR = 1.105, 95%CI = 0.118–10.339, p = 0.930). Discussion The innate ratio of humeral head and glenoid diameters was not significantly associated with anterior shoulder instability in this retrospective sample of 88 shoulder CT scans.

Recurrence After Arthroscopic Labral Repair for Traumatic Anterior Instability in Adolescent Rugby and Contact Athletes

2018 ◽  
Vol 46 (12) ◽  
pp. 2969-2974 ◽  
Author(s):  
Emma Torrance ◽  
Ciaran J. Clarke ◽  
Puneet Monga ◽  
Lennard Funk ◽  
Michael J. Walton
Keyword(s):  
Recurrence Rate ◽  
Shoulder Instability ◽  
Case Series ◽  
Labral Repair ◽  
Shoulder Injuries ◽  
Adolescent Athletes ◽  
Recurrence Rates ◽  
Level Of Evidence ◽  
Bony Bankart ◽  
The Mean

Background: Traumatic glenohumeral dislocation of the shoulder is one of the most common shoulder injuries, especially among adolescent athletes. The treatment of instability for young athletes continues to be controversial owing to high recurrence rates. Purpose: To investigate the recurrence rate of shoulder instability after arthroscopic capsulolabral repair for adolescent contact and collision athletes. Study Design: Case series; Level of evidence, 4. Methods: Sixty-seven patients aged <18 years underwent an arthroscopic labral repair over a 5-year period. The mean ± SD age of the cohort was 16.3 ± 0.9 years (range, 14-17 years) and consisted of 1 female and 66 males. All patients were contact athletes, with 62 of 67 playing rugby. Demographic, clinical, and intraoperative data for all patients with shoulder instability were recorded in our database. Recurrence rates were recorded and relative risks calculated. Results: At a follow-up of 33 ± 20 months, 34 of 67 patients had recurrent instability for an overall recurrence rate of 51% among adolescent contact athletes after arthroscopic labral repair surgery. The mean time to recurrence was 68.1 ± 45.3 weeks. All recurrences occurred as a result of a further sporting injury. Relative risk analysis demonstrated that athletes aged <16 years had 2.2 (95% CI, 1.2-2.1) times the risk of developing a further instability episode as compared with athletes aged ≥16 years at the time of index surgery ( P = .0002). The recurrence rate among adolescent athletes after bony Bankart repairs was 57.9% versus 47.9% for soft tissue labral repairs ( P = .4698). The incidence of Hill-Sachs lesions ( P = .0002) and bony Bankart lesions ( P = .009) among adolescent athletes was significantly higher than among adult controls ( P = .002). The presence of bone loss did not lead to a significant increase in recurrence rate over and above the effect of age. Conclusion: Adolescent contact athletes undergoing arthroscopic labral repair have an overall recurrence rate of 51%. Rugby players who undergo primary arthroscopic shoulder stabilization aged <16 years have 2.2 times the risk of developing a further instability episode when compared with athletes aged ≥16 years at the time of index surgery, with a recurrence rate of 93%.

Clinical Outcomes of Physiotherapy for Patients with Acetabular Labral Tears: An Analysis According to Severity of Injury

2020 ◽  
Author(s):  
Makoto Kawai ◽  
Kenji Tateda ◽  
Yuma Ikeda ◽  
Ryosuke Motomura ◽  
Ima Kosukegawa ◽  
...  
Keyword(s):  
Treatment Strategies ◽  
Labral Tear ◽  
Stage Iii ◽  
Labral Repair ◽  
Short Term ◽  
Post Intervention ◽  
Term Outcome ◽  
Labral Tears ◽  
Acetabular Labral Tear ◽  
Severity Of Injury

Abstract Background: Arthroscopic labral repair is an effective treatment for femoroacetabular impingement (FAI) and acetabular labral injury. However, the effectiveness of physiotherapy treatment is controversial. Previous studies that analyzed the outcome of physiotherapy for patients with FAI or acetabular labral tears did not consider damaged tissues or the severity of the acetabular labral tear. This study aimed to evaluate (1) the short-term outcome of physiotherapy in patients with acetabular labral tears confirmed by magnetic resonance imaging (MRI) and (2) the effectiveness of physiotherapy according to the severity of the labral tear.Methods: Thirty-five patients who underwent physiotherapy for symptomatic acetabular labral tears from August 2013 to July 2018 were enrolled. We evaluated the severity of the acetabular labral tears, which were classified based on the Czerny classification system using 3-T MRI. Clinical findings of microinstability and extra-articular pathologies of the hip joint were also examined. Outcome scores were evaluated using the International Hip Outcome Tool 12 (iHOT12) at pre- and post-intervention.Results: The mean iHOT12 score significantly improved from 44.0 to 73.5 in 4.7 months. The post-intervention iHOT12 scores were significantly higher than the pre-intervention scores at stages I (pre 51.0, post 74.4; P=0.004) and II (pre 44.8, post 81.2; P<0.001). However, there were no significant differences between the pre-intervention and post-intervention iHOT12 scores at stage III (pre 36.6, post 60.8; P=0.061). Furthermore, 7 patients (20.0%) had positive microinstability tests, and 22 (62.9%) had findings of extra-articular pathologies. Of 35 patients, 8 (22.9%) underwent surgical treatment after failure of conservative management, of whom 4 had Czerny stage III.Conclusions: Physiotherapy significantly improved the iHOT12 score of patients with acetabular labral tears in the short-term period. In patients with severe acetabular labral tear, improvement of clinical score by physiotherapy may be poor. Identifying the severity of acetabular labral tears can be useful in determining treatment strategies.

Sign in / Sign up

Export Citation Format

Share Document