Inconsistencies in Controlling for Risk Factors for Recurrent Shoulder Instability After Primary Arthroscopic Bankart Repair: A Systematic Review

2021 ◽  
pp. 036354652110387
Author(s):  
Nicholas A. Trasolini ◽  
Navya Dandu ◽  
Eric N. Azua ◽  
Grant E. Garrigues ◽  
Nikhil N. Verma ◽  
...  
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
Bone Loss ◽  
Full Text ◽  
Severity Index ◽  
Index Score ◽  
Glenoid Bone Loss ◽  
Bankart Repair ◽  
Advanced Imaging ◽  
Severity Index Score

Background: Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging. Purpose: The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score. Results: After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis. Conclusion: Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.

scholarly journals The Instability Severity Index Score Revisited: Evaluation of 217 Consecutive Cases of Recurrent Anterior Shoulder Instability

2019 ◽  
Vol 7 (7_suppl5) ◽  
pp. 2325967119S0026
Author(s):  
Matthew T. Provencher ◽  
George Sanchez ◽  
Andrew S. Bernhardson ◽  
Liam A. Peebles ◽  
Daniel B. Haber ◽  
...  
Keyword(s):  
Bone Loss ◽  
Severity Index ◽  
Index Score ◽  
Glenoid Bone Loss ◽  
Anterior Shoulder Instability ◽  
Arthroscopic Stabilization ◽  
Recurrent Instability ◽  
Severity Index Score ◽  
Recurrent Anterior Shoulder Instability

Objectives: The instability severity index score (ISIS) was designed to predict the risk of recurrence after arthroscopic instability shoulder surgery and to better predict those who would benefit from an open or bone transfer operation. Although this score has been widely disseminated to predict recurrence, there are certain areas in which preoperative assessment is limited, especially in radiographic workup. The objective of this study was to examine the validity of ISIS based on its existing variables, as well as to evaluate additional imaging and patient history variables pertinent to the potential redevelopment of a new score to assess risk of recurrent anterior instability following an arthroscopic Bankart repair. Methods: All consecutive patients were prospectively enrolled with recurrent anterior shoulder instability who subsequently underwent an arthroscopic stabilization with minimum 24 months follow-up. Exclusion criteria included, prior surgery on the shoulder, posterior or multidirectional instability, or a rotator cuff tear. All instability severity index score variables were recorded (age <20, degree and sport type, hyperlaxity, Hill Sachs on AP xray, glenoid loss of contour on AP xray), as well as additional variables: 1. Position of arm at dislocation; 2. Number of instability events; 3. Total time of instability; 4. Glenoid bone loss percent; 5. Amount of attritional glenoid bone loss; 6. Hill Sachs measures (H/W/D and volume), and outcomes (recurrent instability) and scores (WOSI, ASES and SANE). Regression analysis was utilized to determine preoperative variables that predicted outcomes and failures. Results: There were 217 consecutive patients (209 male-96.5%, 8 female-3.5%) who met criteria and were all treated with a primary arthroscopic shoulder stabilization during a 3.5-year period (2007-2011), with mean follow-up of 42 (range, 26-58 mos). The mean age at first instability event was 23.9 (range, 16-48), with 55% right shoulder affected, 60% dominant shoulder. Outcomes were improved from mean scores preoperative (WOSI=1050/2100, ASES=61.0, SANE=52.5) to postoperative (WOSI=305/2100, ASES=93.5, SANE=95.5), and 11.5% (25/217) had evidence or recurrent instability or subluxation. A total of 51/217 were 20 years or under, hyperlaxity in 5, Hill Sachs on internal rotation XR in 77, glenoid contour on AP XR in 41, with an overall mean ISIS score of 3.6. Factors associated with failure were glenoid bone loss greater than 14.5%(p<0.001), total time of instability symptoms >11.5 months(p<0.03), Hill Sachs volume > 1.3 cm3 with H>1.5 cm, W>1.0 cm and D>5 mm(p<0.01), contact sport (p<0.01) and age 20 or under (p<0.01). There was no correlation in outcomes with Hill Sachs on IR or glenoid contour on XR (p>0.45), sports participation, and Instability Severity Score (mean=3.4 success, vs 3.9 failure, p>0.44). Conclusion: At nearly four years of follow-up, there was an 11.5% failure rate of scope stabilization surgery. However, there was no correlation between treatment outcome and the ISIS measure given a mean score of 3.4 with little difference identified in those that failed. However, several important parameters previously unidentified were detected including, glenoid bone loss >14.5%, Hill Sachs volume >1.3 cm3, and time length of instability symptoms. Therefore, the ISIS measure may need to be redesigned in order to incorporate variables that more accurately portray the actual risk of failure following arthroscopic stabilization.

Long-term, Prospective, Multicenter Study of Isolated Bankart Repair for a Patient Selection Method Based on the Instability Severity Index Score

2019 ◽  
Vol 47 (5) ◽  
pp. 1057-1061 ◽  
Author(s):  
Hervé Thomazeau ◽  
Tristan Langlais ◽  
Alexandre Hardy ◽  
Jonathan Curado ◽  
Olivier Herisson ◽  
...  
Keyword(s):  
Recurrence Rate ◽  
Severity Index ◽  
Index Score ◽  
Bankart Repair ◽  
Prospective Multicenter Study ◽  
Severity Index Score ◽  
Bony Lesions ◽  
Long Term Recurrence Rate

Background: An isolated arthroscopic Bankart repair carries a high mid- and long-term risk of recurring instability. Preoperative patient selection based on the Instability Severity Index Score should improve outcomes. Purpose: To report the overall long-term recurrence rate for isolated Bankart repair, investigate the predictive factors for recurrence, analyze time to recurrence, and determine a quantitative cutoff point for recurrence in terms of Instability Severity Index Score. Study Design: Cohort study; Level of evidence, 2. Methods: This was a prospective multicenter study. Inclusion criteria were recurring anterior instability and an Instability Severity Index Score of 4 or less. Of the 125 patients included, 20 patients had a score of 0, 31 patients scored 1, 29 patients scored 2, 34 patients scored 3, and 11 patients scored 4. All centers used the same arthroscopic technique and rehabilitation protocol. Follow-up data were collected at 3, 6, 12, and 24 months and 3 and 9 years. The primary endpoint was recurrence of instability (total or partial dislocation). The statistical analysis was performed by use of the software package SAS 9.4. Results: We initially identified 328 patients, of whom 125 patients were prospectively included. The main reason for excluding the 202 patients was the presence of bony lesions, which carry 2 points each in the Instability Severity Index Score (humeral head notch and/or glenoid lesion visible on standard radiographs). Of the 125 eligible patients, 73% were athletes and 22.5% competitors; 16% were lost at the last follow-up. At the endpoint, 23% had experienced a recurrence after a mean interval of 35 months (range, 5.5-103 months). No statistical differences were found between patients with and without bony lesions in the overall group of 125 patients or in the subgroup with an Instability Severity Index Score of 3 or 4 points ( P = .4). According to univariate analysis, the only predictive factor for recurrence was age less than 20 years at the time of surgery, with a 42% rate of recurrence in this group ( P = .03). Multivariate analysis showed that the Instability Severity Index Score was the only predictive factor with a quantitative cutoff point (namely, a score of ≤2 points) that was statistically associated with a decreased long term recurrence rate ( P = .02). The recurrence rate was 10% for a preoperative Instability Severity Index Score of 2 or less compared with 35.6% for a score of 3 or 4. The survival curves demonstrated no new dislocations after year 4 for patients with an Instability Severity Index Score of up to 2 points. Conclusion: In a preselected population, mainly without bony lesions, the Instability Severity Index Score cutoff value that provides an acceptable recurrence rate at 9 years after isolated Bankart repair is 2 out of 10.

scholarly journals When to Abandon the Arthroscopic Bankart Repair: A Systematic Review

2020 ◽  
Vol 12 (5) ◽  
pp. 425-430
Author(s):  
Benjamin J. Levy ◽  
Nathan L. Grimm ◽  
Robert A. Arciero
Keyword(s):  
Systematic Review ◽  
Bone Loss ◽  
Study Design ◽  
Humeral Head ◽  
Measurement Techniques ◽  
Glenoid Bone Loss ◽  
Bankart Repair ◽  
Glenohumeral Instability ◽  
Level Of Evidence ◽  
Arthroscopic Bankart Repair

Context: Bone loss is a major factor in determining surgical choice in patients with anterior glenohumeral instability. Although bone loss has been described, there is no consensus on glenoid, humeral head, and bipolar bone loss limits for which arthroscopic-only management with Bankart repair can be performed. Objective: To provide guidelines for selecting a more complex repair or reconstruction (in lieu of arthroscopic-only Bankart repair) in the setting of glenohumeral instability based on available literature. Data Sources: An electronic search of the literature for the period from 2000 to 2019 was performed using PubMed (MEDLINE). Study Selection: Studies were included if they quantified bone loss (humeral head or glenoid) in the setting of anterior instability treated with arthroscopic Bankart repair. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: Study design, level of evidence, patient demographics, follow-up, recurrence rates, and measures of bone loss (glenoid, humeral head, bipolar). Results: A total of 14 studies met the inclusion criteria. Of these, 10 measured glenoid bone loss, 5 measured humeral head bone loss, and 2 measured “tracking” without explicit measurement of humeral head bone loss. Measurement techniques for glenoid and humeral head bone loss varied widely. Recommendations for maximum glenoid bone loss for arthroscopic repair were largely <15% of glenoid width in recent studies. Recommendations regarding humeral head loss were more variable (many authors providing only qualitative descriptions) with increasing attention on glenohumeral tracking. Conclusion: It is essential that a standardized method of glenoid and humeral head bone loss measurements be performed preoperatively to assess which patients will have successful stabilization after arthroscopic Bankart repair. Glenoid bone loss should be <15%, and humeral head lesions should be “on track” if an arthroscopic-only Bankart is planned. If there is greater bone loss, adjunct or open procedures should be performed.

scholarly journals Instability Severity Index Score Does Not Predict the Risk of Shoulder Dislocation after a First Episode Treated Conservatively

2021 ◽  
Vol 18 (22) ◽  
pp. 12026
Author(s):  
Umile Giuseppe Longo ◽  
Rocco Papalia ◽  
Gianluca Ciapini ◽  
Sergio De Salvatore ◽  
Carlo Casciaro ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Rotator Cuff ◽  
Shoulder Dislocation ◽  
Severity Index ◽  
Index Score ◽  
Anterior Dislocation ◽  
First Episode ◽  
Rotator Cuff Injury ◽  
Severity Index Score

The first purpose of this study was to verify the association between Instability Severity Index Score (ISIS) and Recurrent Shoulder Dislocation (RSD) after a first episode treated conservatively. The second aim is to identify the risk factors associated with RSD after a primary acute shoulder anterior dislocation treated conservatively. A total of 111 patients with first traumatic anterior shoulder dislocation treated at a single trauma centre between January 2014 and March 2016 were enrolled. The main predictive variables of risk factors and the ISIS score were calculated. Among the 85 patients included, 26 cases of RSD were observed (30.6%). Considering the whole population, no significant association between ISIS and RSD were reported. Regarding other risk factors, high-risk working activities and rotator cuff injury had a significantly higher RSD risk. Sex, dominant limb, familiar history, hyperlaxity, contact or overhead sports, competitive sport, post-reduction physiokinesitherapy, return to sports activity time, Hill-Sachs lesion, bony Bankart lesion and great tuberosity fracture did not seem to influence the risk of RSD. No correlation between ISIS score and RSD in patients treated conservatively after a first episode of shoulder dislocation were reported. The only risk factors with a significant association to RSD were high-risk working activities and rotator cuff injury.

scholarly journals The Nonoperative Instability Severity Index Score (NISIS): A Simple Tool to Guide Operative Versus Nonoperative Treatment of the Unstable Shoulder

2020 ◽  
Vol 12 (6) ◽  
pp. 598-602
Author(s):  
John M. Tokish ◽  
Charles A. Thigpen ◽  
Michael J. Kissenberth ◽  
Stefan J. Tolan ◽  
Keith T. Lonergan ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Bone Loss ◽  
Shoulder Instability ◽  
Return To Sport ◽  
Severity Index ◽  
Anterior Shoulder Instability ◽  
High Risk Patients ◽  
Severity Index Score ◽  
Risk Patients

Background: The management of the adolescent athlete after initial shoulder instability remains controversial. Hypothesis: Individual risk factors in athletes with shoulder instability who are managed nonoperatively can be integrated into a scoring system that can predict successful return to sport. Study Design: Retrospective cohort study. Level of Evidence: Level 4. Methods: A total of 57 scholastic athletes with primary anterior shoulder instability who were managed nonoperatively were reviewed. Success was defined as a return to index sport at the same level and playing at least 1 subsequent season without missed time as a result of the shoulder. Patient-specific risk factors were individually evaluated, and odds ratios were calculated. A 10-point Nonoperative Injury Severity Index Score (NISIS) incorporated the risk factors for failure. This score was then retrospectively applied with regression analysis and a chi-square analysis to determine the overall optimal score that predicted failure of nonoperative management. Results: In total, 6 risk factors for failure were included in the NISIS: age (>15 years), bone loss, type of instability, type of sport (contact vs noncontact), male sex, and arm dominance. Overall, 79% of patients treated nonoperatively were able to successfully return to sport. Nearly all (97%) low-risk patients (NISIS <7) successfully returned to sport, while only 59% of high-risk patients returned to sport, a relative risk of 12.2 ( P = 0.001). High-risk patients with unipolar bone loss successfully returned (100%), but 67% of high-risk patients with bipolar bone loss failed. Conclusion: The NISIS is a simple and effective clinical tool to determine successful nonoperative management following anterior shoulder instability and may be helpful in guiding decision making when presented with the unstable shoulder in the scholastic athlete.

scholarly journals Age, participation in competitive sports, bony lesions, ALPSA lesions, > 1 preoperative dislocations, surgical delay and ISIS score > 3 are risk factors for recurrence following arthroscopic Bankart repair: a systematic review and meta-analysis of 4584 shoulders

2021 ◽  
Author(s):  
Lukas P. E. Verweij ◽  
Sanne H. van Spanning ◽  
Adriano Grillo ◽  
Gino M. M. J. Kerkhoffs ◽  
Simone Priester-Vink ◽  
...  
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
Bone Loss ◽  
Bankart Repair ◽  
Competitive Sports ◽  
Recurrent Instability ◽  
Surgical Delay ◽  
Arthroscopic Bankart Repair ◽  
Risk Factors For Recurrence ◽  
Meta Analyses

Abstract Purpose Determining the risk of recurrent instability following an arthroscopic Bankart repair can be challenging, as numerous risk factors have been identified that might predispose recurrent instability. However, an overview with quantitative analysis of all available risk factors is lacking. Therefore, the aim of this systematic review is to identify risk factors that are associated with recurrence following an arthroscopic Bankart repair. Methods Relevant studies were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, CINAHL/Ebsco, and Web of Science/Clarivate Analytics from inception up to November 12th 2020. Studies evaluating risk factors for recurrence following an arthroscopic Bankart repair with a minimal follow-up of 2 years were included. Results Twenty-nine studies met the inclusion criteria and comprised a total of 4582 shoulders (4578 patients). Meta-analyses were feasible for 22 risk factors and demonstrated that age ≤ 20 years (RR = 2.02; P < 0.00001), age ≤ 30 years (RR = 2.62; P = 0.005), participation in competitive sports (RR = 2.40; P = 0.02), Hill-Sachs lesion (RR = 1.77; P = 0.0005), off-track Hill-Sachs lesion (RR = 3.24; P = 0.002), glenoid bone loss (RR = 2.38; P = 0.0001), ALPSA lesion (RR = 1.90; P = 0.03), > 1 preoperative dislocations (RR = 2.02; P = 0.03), > 6 months surgical delay (RR = 2.86; P < 0.0001), ISIS > 3 (RR = 3.28; P = 0.0007) and ISIS > 6 (RR = 4.88; P < 0.00001) were risk factors for recurrence. Male gender, an affected dominant arm, hyperlaxity, participation in contact and/or overhead sports, glenoid fracture, SLAP lesion with/without repair, rotator cuff tear, > 5 preoperative dislocations and using ≤ 2 anchors could not be confirmed as risk factors. In addition, no difference was observed between the age groups ≤ 20 and 21–30 years. Conclusion Meta-analyses demonstrated that age ≤ 20 years, age ≤ 30 years, participation in competitive sports, Hill-Sachs lesion, off-track Hill-Sachs lesion, glenoid bone loss, ALPSA lesion, > 1 preoperative dislocations, > 6 months surgical delay from first-time dislocation to surgery, ISIS > 3 and ISIS > 6 were risk factors for recurrence following an arthroscopic Bankart repair. These factors can assist clinicians in giving a proper advice regarding treatment. Level of evidence Level IV.

Risk Factors for Recurrence After Arthroscopic Instability Repair—The Importance of Glenoid Bone Loss >15%, Patient Age, and Duration of Symptoms: A Matched Cohort Analysis

2020 ◽  
Vol 48 (12) ◽  
pp. 3036-3041
Author(s):  
Travis J. Dekker ◽  
Liam A. Peebles ◽  
Andrew S. Bernhardson ◽  
Samuel I. Rosenberg ◽  
Colin P. Murphy ◽  
...  
Keyword(s):  
Risk Factors ◽  
Bone Loss ◽  
Cohort Analysis ◽  
Glenoid Bone Loss ◽  
Bankart Repair ◽  
Recurrence Rates ◽  
Recurrent Instability ◽  
Duration Of Symptoms ◽  
Arthroscopic Bankart Repair ◽  
The Mean

Background: Glenoid bone loss (GBL) has been implicated as a risk factor for failure of arthroscopic anterior glenohumeral instability repair. Although certain amounts of GBL are associated with higher recurrence rates, there are limited studies on successes versus failures in these cohorts. Purpose: To compare the outcomes of arthroscopic Bankart repair in patients with and without GBL to determine a threshold percentage of GBL that predicts success. Study Design: Cohort study; Level of evidence, 2. Methods: All consecutive patients who underwent arthroscopic Bankart repair for anterior shoulder instability between 2004 and 2013 were prospectively enrolled. Patients with ≤25% GBL were included. Patients with no GBL were grouped and compared with those having 5% to 25% GBL. Outcomes included Single Assessment Numerical Evaluation, Western Ontario Shoulder Index, and American Shoulder and Elbow Surgeons scores, with evidence of recurrent instability. Patients with and without GBL were statistically compared with respect to outcomes and recurrence rates. Results: Of 434 eligible patients, the cases of 405 (45 female, 360 male; mean age, 27.5 years [range, 18-47 years]) were followed for a mean 61 months (range, 48-96 months). There were 189 (46.6%) with no GBL and 216 (53.3%) with GBL; the mean GBL of the latter cohort was 15% (range, 5%-25%). The mean duration of instability symptoms was 7.9 months (range, 1-21 months) and was significantly longer in the GBL group ( P < .05). The mean recurrence rate was 14.8%, which was significantly greater in patients presenting with GBL versus those with none (48/216 [22.2%] vs 12/189 [6.3%]; P < .01). Within the GBL group, GBL ≥15%, duration of symptoms >5 months, and younger age (<20 years) were independent risk factors for failure ( P < .01). Patients with any GBL had >4-times greater odds of recurrence after arthroscopic stabilization (odds ratio, 4.21; 95% CI, 2.16-8.21). Moreover, patients presenting for arthroscopic Bankart repair with GBL ≥15% had nearly 3-times greater odds of recurrent instability. Conclusion: GBL ≥15% in an active patient population portends to increased odds of recurrent instability events and inferior clinical outcomes after arthroscopic Bankart repair. Furthermore, nonmodifiable risk factors, such as age (<20 years) and duration of symptoms before presentation (>5 months), significantly affect risk of recurrence and should be key factors when counseling patients on risk of failure and determining the ideal procedure for the individual patient.

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