Pathology and clinical outcomes after arthroscopic stabilization in shoulders with traumatic anterior instability older than 40 years: Comparison between shoulders with the first dislocation before or after 40 years (241)

Objectives: Traumatic anterior shoulder instability is common in young population but sometimes seen in middle-aged and elderly patients. The higher incidence of rotator cuff tears has been reported in middle-aged and elderly patients with anterior shoulder instability than young population. We, however, had an impression through clinical experiences that the pathology, including the incidence of rotator cuff tears, might be different by age at the first dislocation. There have been few articles that reported the pathology of shoulders with anterior shoulder instability in older population. The purpose of this study was to investigate pathology and clinical outcomes in patients who underwent arthroscopic stabilization at 40 years or older and to compare them between shoulders with the first dislocation before or after 40 years. Methods: The inclusion criteria of this study were as follows: 1) shoulders that underwent arthroscopic stabilization between October 2005 and September 2017, 2) traumatic anterior shoulder instability, and 3) 40 year old or older. The exclusion criterion was < 2-year follow-up. Glenoid morphology was evaluated with preoperative 3-dimensional computed tomography, and the size of glenoid bone defect was measured. Intraoperative findings, including rotator cuff tear, Bankart lesion, and humeral avulsion of the glenohumeral ligament (HAGL) lesion, and surgical procedures were investigated with surgical records. Range of motion was assessed preoperatively and at the final follow-up. Postoperative re-dislocation was also investigated. The subjects were divided into two groups according to the age at the first dislocation: Group 1, < 40 years; Group 2, 40 years or older. The findings and outcomes were compared between the two groups. The unpaired t-test was used to compare continuous data between the groups, and the paired t-test was used for pre- and postoperative comparison of continuous data. The chi-square test was used for categorical variables. The level of significance was set at p < 0.05. Results: Between October 2005 and September 2017, 198 shoulders (198 patients) underwent arthroscopic shoulder stabilization for traumatic anterior shoulder instability at 40 years or older. Fifty-six shoulders were excluded due to < 2-year follow-up, and 142 shoulders (142 patients) were included in this study. They consisted of 69 males and 73 females with a mean age of 51 (range, 40-78) years. The mean follow-up was 4 (range, 2-12) years. Group 1 included 105 shoulders (52 males and 53 females] with a mean age of 48 (range, 40-77) years. Group 2 included 37 shoulders (17 male and 20 females) with a mean age of 59 (range, 40-78) years. Group 1 had a longer time from the first dislocation to surgery (P<.001) and larger number of dislocation (P<.001) than Group 2 (Table 1). Bony Bankart lesion was more frequently seen in Group 2 than Group 1 (P=.02), and bone defect was greater in Group 1 than Group 2 (P=.02). The incidence of Bankart lesion or HAGL lesion was not significantly different between the groups. There were 2 full-thickness (1 small and 1 medium) and 16 joint-side partial-thickness rotator cuff tears in Group 1, while 16 full-thickness (4 small, 4 medium, 5 large, and 3 massive) and 8 joint-side partial-thickness tears were found in Group 2. The difference in the incidence of rotator cuff tears was significant between the groups (P<.001). Arthroscopic Bankart repair (ABR) with or without augmentation was performed in 103 shoulders (98 %) in Group 1 and in 35 shoulders (95%) in Group 2 (Table 2). There were 2 isolated HAGL repairs (2 %) in Group 1 and 2 isolated rotator cuff repairs (6 %) in Group 2. Two shoulders (6%) in Group 2 experienced re-dislocation. Forward flexion showed significant improvement from 159 (range, 100-180) to 170 (range, 140-180) degrees in Group 1 and from 148 (range, 40-180) to 163 (range, 70-180) degrees in Group 2 (P<.001 for each). Postoperative forward flexion showed no significant difference between the groups. External rotation showed no postoperative changes in both groups, while Group 1 had significantly better pre- and postoperative external rotation than Group 2. Conclusions: This study demonstrated that the incidence of rotator cuff tears was much higher in shoulders with the first dislocation after 40 years compared to shoulders with the first dislocation before 40 years. Shoulders with the first dislocation before 40 years had larger glenoid bone loss, while 51% of shoulders with the first dislocation after 40 years retained bony fragments. The longer time from the initial injury to surgery might be associated with the larger glenoid bone loss and absorption of bone fragments. Both groups showed satisfactory outcomes with the low rate of complications.

Arthroscopic Bankart Repair Using a Lasso-Loop Stitch

Anterior inferior shoulder dislocation is a common injury. After primary traumatic shoulder dislocation and conservative treatment, the risk of re-dislocation is very high in patients younger than 35 years. With age, the risk of re-dislocation after traumatic shoulder dislocation and conservative treatment decreases. Surgical treatment via either open or arthroscopic stabilization minimizes the risk of re-dislocation. Today, anterior shoulder stabilization by arthroscopic refixation of the labroligamentous complex with suture anchors is a standard procedure, if there is no severe chronic bony defect at the glenoid site. Lafosse et al. described the so-called „Lasso-loop stitch“. This technique allows for positioning of the knot away from the joint and at the same time it establishes a labral bump that stabilizes the humeral head against (sub)luxation. The surgical principle and aim consist of refixation of the anterior labrum-capsule-ligament complex to the glenoid with positioning of the knot at distance to the joint as well as bulging up the labrum. This stabilizes the shoulder joint and therefore avoids further dislocations and associated pathologies. The aim of this work is to give an illustrated instruction of the surgical technique of arthroscopic Bankart repair using the lasso-loop stitch.

Failure Rates After Revision Arthroscopic Stabilization for Recurrent Anterior Shoulder Instability Based on Anterior Capsulolabral Complex Conditions

Background: A labral retear is an important contributing factor to surgical failure after arthroscopic soft tissue stabilization for recurrent anterior shoulder instability. However, surgeons frequently encounter poor tissue conditions in the anterior capsule, such as capsular tears, during revision surgery. Purpose: To analyze the clinical outcomes and failure rates of revision arthroscopic stabilization after failed Bankart repair based on the tissue conditions of the anterior capsule and the labrum. Outcomes were compared for revision after failed Bankart repair because of a labral retear versus a healed labrum but with capsular tears. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 55 patients who underwent revision arthroscopic stabilization after failed Bankart repair were included. Revision surgery was indicated if patients had a history of recurrent instability with positive apprehension test results, regardless of magnetic resonance imaging (MRI) findings of a labral retear. Patients were allocated into 2 groups based on arthroscopic findings at the time of revision surgery: group 1 consisted of patients who had a healed labrum with definite anterior capsular tears, and group 2 comprised patients who had labral retears without capsular tears. Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons score, Rowe score, and surgical failure rate. Results: Overall, 10 patients were included in group 1, and 45 patients were included in group 2. No capsular tears were detected on preoperative MRI or magnetic resonance arthrography scans in either group, whereas all patients in group 2 had evidence of anterior labral retears on imaging scans. After revision surgery, 9 patients (16.4%) showed surgical failure by 25.6 months postoperatively. Patients in group 1 had a significantly higher surgical failure rate than did those in group 2 (4 patients [40.0%] vs 5 patients [11.1%], respectively; P = .04). The incidence of capsular tears was significantly higher in patients with surgical failure versus those without surgical failure (44.4% vs 13.0%, respectively; P = .04). Conclusion: A capsular tear of the anterior capsulolabral complex was an important indicator for surgical failure after revision arthroscopic stabilization. If patients demonstrate symptomatic instability after arthroscopic soft tissue stabilization without evidence of labral retears on imaging scans, an anterior capsular tear should be considered as a possible factor for recurrence.

The role of Hill-Sachs localization on the failure of arthroscopic shoulder stabilization. The results of a prospective cohort study

Objectives: Recurrent glenohumeral instability is frequently associated with glenoid and humeral bone loss. It is predictive of capsulolabral repair failure. However, the best way to quantify these shortcomings remains controversial. The aim of our study is to determine the best predictor of recurrent instability after arthroscopic shoulder stabilization. Methods: Over the past 10 years, all the patients recruited for shoulder stabilization surgery in 4 academic centers have been included in the prospective cohort called "LUXE". The ISIS score is used to stratify patients for surgery (Bankart, Bankart + Remplissage, Latarjet). Only patients with a preoperative CT scan with 3D reconstruction and clinical follow-up ≥1 year were included. Of a total of 262 patients included in the “LUXE” cohort, 103 met the inclusion criteria. The majority of patients were male (79%) with an average age of 28 years. The median number of dislocations before stabilization surgery was six. Bone deficits were measured on the 3D reconstructions using the Glenoid Clock and Ratio, the Humeral Clock and Ratio and the Glenoid Track methods and the angle of engagement of the Hill-Sachs lesion in the axial plane. Results: Seventy patients had arthroscopic stabilization and 33 a Latarjet procedure. The ISIS scores for the two groups were 2.7 and 4.8 (p<0.001) respectively. The average glenoid bone loss was 9+/-10% (0-37%), humeral bone loss was 15+/-6% (0-36%) and the angle of engagement of the Hill-Sachs lesion was 71+/-30° in external rotation. Fifty-three patients (51%) had an off-track lesion. Eighteen patients had recurrent instability after arthroscopic stabilization (23%) versus only 2 patients (6%) for Latarjets (OR= 4.6, p=0.034). Preoperative bone loss was not related to failure after a Latarjet procedure. The risk factors identified after arthroscopic stabilization were a lower engaging Hill-Sachs angle in external rotation (65° vs. 72°; p=0.05), less humeral bone loss (humeral clock of 42° vs. 58°; p=0.034) and an extended follow-up time (p=0.006). Glenoid bone loss, or the combined measurement (glenoid track) was not predictive of failure. Conclusion: Despite a lower ISIS score, arthroscopic management with Bankart +/- Remplissage is correlated with a significantly higher recurrence rate compared to the Latarjet procedure. Failure was related to humeral bone loss and to the morphology/orientation of the Hill-Sachs lesion rather than the volume of bone loss.

Arthroscopic Anatomic Glenoid Reconstruction Using Distal Tibial Allograft for Recurrent Anterior Shoulder Instability: Clinical and Radiographic Outcomes

Background: The all-arthroscopic anatomic glenoid reconstruction technique using a distal tibial allograft avoids damage to the subscapularis muscle and allows repair of the capsulolabral tissue. Purpose: To analyze the clinicoradiologic outcomes of patients who underwent this procedure to treat anterior shoulder instability with glenoid bone loss with a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Over 6 years, 73 patients (52 male and 21 female; mean age, 28.8 years) under the care of the same surgeon underwent arthroscopic stabilization with capsulolabral Bankart repair and bony allograft augmentation of the glenoid for recurrent shoulder instability with significant bone loss. Pre- and postoperative patient-reported functional assessment was performed using 2 questionnaires, the Western Ontario Shoulder Instability Index (WOSI) and the Disabilities of the Arm, Shoulder and Hand, and radiological assessment was performed using radiographs and computed tomography scans obtained preoperatively and approximately 1 year later (mean ± SD, 0.9 ± 1.1 years). Results: The mean follow-up was 4.7 ± 1.1 years. The mean pre- and postoperative WOSI scores were 71.1 ± 17.5 and 25.6 ± 21.9, respectively ( P < .001). There were no recurrences of dislocation, although 1 patient had symptoms of subluxation; however, 5 patients had hardware complications that required screw removal. There were no cases of nerve injury. Postoperative computed tomography scans were available for 66 patients. Seven patients were lost to follow-up. The graft union rate was 100%. Overall, graft resorption was <50% in 86% of patients (57/66). Eighteen patients (27%) had no resorption (grade 0), 39 (59%) had <50% (grades 1 and 2), and 9 (14%) had ≥50% (grade 3); however, none had symptoms of instability. The mean alpha angle of the screw between the screw shaft axis and the native glenoid axis was 18.3°± 5.7°. Graft positioning was flush with the glenoid in 61 of 66 patients (92.4%), and vertical positioning was excellent in 64 of 66 patients (97.0%) (3- to 5-o’clock position). Conclusion: Arthroscopic stabilization using distal tibial allograft augmentation resulted in excellent clinicoradiologic outcomes at a 2-year follow-up. This procedure has the advantages of being an anatomic reconstruction that addresses bony and soft tissue instability. However, long-term follow-up studies are necessary for better assessment of outcomes.