Search

Background: There is uncertainty with regard to the optimal revision procedure after failed labral repair for anterior shoulder instability. An overview of outcomes of these procedures with quantitative analysis is not available in literature. The aim of this review is (1) to compare recurrence rates after revision labral repair (RLR) and revision bony reconstruction (RBR), both following failed labral repair. In addition, (2) recurrence rates after RBR following failed labral repair and primary bony reconstruction (PBR) are compared to determine if a previous failed labral repair influences the outcomes of the bony reconstruction. Methods: Randomized controlled trials and cohort studies with a minimum follow-up of 2 years and reporting recurrence rates of (1) RBR following failed labral repair and PBR and/or (2) RLR following failed labral repair and RBR following failed labral repair were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics. Results: Thirteen studies met the inclusion criteria and comprised 1319 shoulders. Meta-analyses showed that RBR has a significantly higher recurrence rate than PBR (risk ratio [RR] 0.51, P < .008) but found no significant difference in the recurrence rates for RLR and RBR (RR 1.40, P < .49). Also, no significant differences were found between PBR and RBR in return to sport (RR 1.07, P < .41), revision surgery (RR 0.8, P < .44), and complications (RR 0.84, P < .53). Lastly, no significant differences between RLR and RBR for revision surgery (RR 3.33, P < .19) were found. Conclusion: The findings of this meta-analyses show that (1) RBR does not demonstrate a significant difference in recurrence rates compared with RLR and that (2) RBR has a significantly higher recurrence rate than PBR.

To biomechanically compare the dynamic double-sling with single-sling augmentation using the conjoined tendon (CT) with 20% of an anteroinferior glenoid bone defect under the high loads in shoulders.With the shoulder in 60° of glenohumeral abduction and 60° of external rotation, the 12 shoulders stability was tested sequentially in 5 conditions: intact, 20% glenoid bone loss, Bankart repair, single-sling augmentation with the CT, and double-sling augmentation with both the CT and long head of the biceps tendon (LHBT). The anteroinferior humeral head (HH) translation force of 20N, 30N, 40N, 50N, or 60N was applied to determine the shoulder stability in each condition.The total HH translation over 8.77 mm represented the anteroinferior shoulder instability (95% confidence interval of bone defect: 7.76-8.77 mm). A significant increase in anteroinferior HH translation was demonstrated after the creation of 20% glenoid bone defect under the 20N translational force (10.52 ± 0.71 mm). Structural failure after the Bankart repair and the single-sling augmentation under the 30N (9.84 ± 1.25 mm) and 40N (9.59 ± 0.66 mm) translational forces, respectively, were observed. The double-sling augmentation effectively prevented the anteroinferior HH translation under the translational force of less than 40N, and only half of the augmentation structure (8.25 ± 1.66 mm) had failed under the 50N translational forces.In the absence of any Hill-Sachs lesion and when tested at 60° abduction and external rotation in shoulders with 20% glenoid bone defects, at time-zero, the double-sling augmentation strategy could effectively prevent anteroinferior translation when compared with the Bankart repair or the single-sling augmentation technique under all magnitudes of the translational force in biomechanical simulation. Nevertheless, none of the constructs restored the HH translation to the normal intact state.Double-sling augmentation technique may represent a reliable option for preventing anteroinferior translation.

The Watson Instability Program (WIP1) is current best evidence for conservative management of atraumatic shoulder instability, but it is unknown if this program can be effectively delivered via tele-consultation. The purpose of this longitudinal pre-post intervention study was to determine the effects of the WIP1 on patient-reported outcome measures, scapular position, shoulder strength, and handstand stability in student circus performers with atraumatic shoulder instability when delivered via tele-consultation.Student circus performers aged between 15 and 35 years from the National Institute of Circus Arts were recruited. A 12-week shoulder exercise program was delivered via tele-consultation during the Melbourne, Australia COVID-19 (coronavirus disease 2019) lockdown. The primary outcome measures were the Western Ontario Shoulder Instability Index score and the Melbourne Instability Shoulder Scale score. Secondary outcomes measures included the Orebro Musculoskeletal Pain Questionnaire, the Tampa Scale for Kinesiophobia, and physical assessment measures including strength via handheld dynamometry, scapular position using an inclinometer, and handstand stability via center-of-pressure fluctuation. Patient-reported outcomes were collected at baseline and 6-week, 12-week, 6-month, and 9-month time points, and physical outcomes were measured at baseline and 9-month time points. A repeated-measures mixed model (with effect sizes [ESs] and 95% confidence intervals [CIs]) was used to analyze patient-reported outcomes, handstand data, strength, and scapular measures. Significance was set at P.05.Twenty-three student circus arts performers completed the study. Significant improvements were found in both Western Ontario Shoulder Instability Index scores (effect size [ES], 0.79 [95% CI, 0.31-1.33] at 6 weeks; ES, 1.08 [95% CI, 0.55-1.6] at 12 weeks; ES, 1.17 [95% CI, 0.62-1.78] at 6 months; and ES, 1.31 [95% CI, 0.74-1.95] at 9 months; P.001) and Melbourne Instability Shoulder Scale scores (ES, 0.70 [95% CI, 0.22-1.22] at 6 weeks; ES, 0.83 [95% CI, 0.34-1.37] at 3 months; ES, 0.98 [95% CI, 0.46-1.54] at 6 months; and ES, 0.98 [95% CI, 0.43-1.50] at 9 months; P.001), as well as Orebro Musculoskeletal Pain Questionnaire scores at all follow-up time points. The Tampa Scale for Kinesiophobia scores reached significance at 6 weeks and 12 weeks. Following rehabilitation, we found statistically significant increases in shoulder strength in all positions tested and increased scapular upward rotation measured at end-of-range abduction, as well as during loaded external rotation. The affected arm showed greater instability than the unaffected arm with a significant intervention effect on the affected arm showing a greater consistent anterior-posterior movement pattern.In a group of circus performers with atraumatic shoulder instability, treatment with the WIP1 via telehealth resulted in clinically and statistically significant improvements in shoulder symptoms and function.

Purpose To evaluate the rate and duration of return to work in patients undergoing Latarjet for failed soft-tissue stabilization or glenoid bone loss. Methods Consecutive patients undergoing Latarjet from 2005 to 2015 at our institution were retrospectively reviewed at a minimum of 2 years postoperatively. Patients completed a standardized and validated work questionnaire, Western Ontario Shoulder Instability Index Survey, and a satisfaction survey. Results Of 89 eligible patients who had Latarjet, 67 patients (75.3%) responded to the questionnaire, of whom 51 patients (76.1%) were employed within 3 years before surgery (mean age: 29.9 ± 11.8 years; mean follow-up: 54.6 ± 11.9 months) and had an average glenoid bone loss of 14.5 ± 6.1%. Fifty patients (98.0%) returned to work by 2.7 ± 3.0 months postoperatively; 45 patients (88.2%) patients returned to the same level of occupational intensity. Those who held sedentary, light, moderate, or heavy intensity occupations returned to their previous occupation at a rate of 100.0%, 93.3%, 90.0%, and 66.7% (P = .2) at a duration of 1.2 ± 1.6 months, 1.8 ± 1.9 months, 3.1 ± 3.5 months, and 6.5 ± 4.1 months (P = .001), respectively. The average postoperative Western Ontario Shoulder Instability Index score was 70.9 ± 34.2. Fifty patients (98.0%) noted at least “a little improvement” in their quality of life following surgery, with 35 patients (68.6%) noting great improvement. Furthermore, 49 patients (96.1%) reported being satisfied with their procedure, with 25 patients (49.0%) reporting being very satisfied. Four patients (7.8%) returned to the operating room, with 1 patient (2.0%) requiring arthroscopic shoulder stabilization. Conclusions Approximately 98% of patients who underwent Latarjet returned to work by 2.7 ± 3.0 months postoperatively. Patients with greater-intensity occupations had a longer duration of absence before returning to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations. Level of Evidence IV, case series.

Bony stabilization procedures are a reliable solution for recurrent shoulder instability, but have a steep learning curve due to technical difficulties. Meticulous capsular closure is critical, and can be augmented with suture anchor constructs. Additionally, while fracture or fragmentation of the coracoid graft is a relatively uncommon, it is devastating. Here, we describe the use of additional circumferential suture fixation to Improve compression across the graft/glenoid interface, and help mitigate the risk of fracture bony augmentation procedures

Augmentation of the anterior glenoid with bone graft is an established treatment for recurrent anterior instability due to critical glenoid bone loss. Both open and arthroscopic techniques have been described. Fixation with metal screws through an open approach is the most common technique, but the risk of metal screw–related complications remains a concern. A variety of arthroscopic techniques using suspensory fixation or suture anchors have been described in the literature. However, they all require a posterior incision to insert a targeting device or to manage sutures. We describe a technique for arthroscopic bone grafting of the anterior glenoid via a purely anterior approach with 2 linked knotless suture anchors, thereby avoiding posterior suture management and glenoid metalwork complications., Technique Video Video 1 Stepwise illustration of graft augmentation for glenoid bone loss using all-suture anchor fixation technique.

Purpose: The purpose of this study is to evaluate the patient-reported outcomes of open Latarjet (OL) compared to arthroscopic Latarjet (AL) for anterior shoulder instability. Methods: A retrospective review of patients who underwent either OL or AL for anterior shoulder instability between 2011 and 2019 was performed. Recurrent instability, visual analog scale (VAS) score, Shoulder Instability-Return to Sport after Injury (SIRSI), Subjective Shoulder Value (SSV), Western Ontario Shoulder Instability (WOSI) score, patient satisfaction, willingness to undergo surgery again, and return to work/sport (RTW/RTS) were evaluated. A P value of < .05 was considered to be statistically significant. Results: Our study included 102 patients in total; 72 patients treated with OL, and 30 treated with AL. There were no demographic differences between the two groups (P > .05 for all). At final follow up (mean of 51.3 months), there was no difference between those that underwent OL or AL in the reported WOSI, VAS, VAS during sports, SSV, and SIRSI scores, nor in patient satisfaction, or whether they would undergo surgery again (P > .05). Overall, there was no significant difference in the total rate of RTP (65% vs 60.9%; P = .74), or timing of RTP (8.1 months vs 7 months; P = .35). Additionally, there was no significant difference in the total rate of RTW (93.5% vs 95.5%; P = .75). Overall, 3 patients in the OL group and 2 patients in the AL group had recurrent instability events (6.9% vs 6.7%; P = .96), with no significant difference in the rate of recurrent dislocation (4.2% vs 3.3%; P = .84). Conclusion: In patients with anterior shoulder instability, both the OL and AL are reliable treatment options, with a low rate of recurrent instability, and similar patient-reported outcomes.

Background There is still a disagreement on the postoperative rehabilitation concerning position of immobilization of the shoulder after arthroscopic anterior shoulder stabilization and its influence on the clinical outcome. The aim of this study was to evaluate the clinical results and the recurrence rate after arthroscopic anteroinferior shoulder stabilization and postoperative immobilization in internal rotation vs. external rotation. Methods Twenty-five patients (22 male and 3 female, mean age 28.5 years) were included in this prospective nonrandomized cohort study. In group I (11 male, 2 female, mean age 28 years), the postoperative functional immobilization was carried out in internal rotation of 60°, and in group II (11 male, 1 female, mean age 30 years), 15° of external rotation of the arm for 4 weeks in both groups. The clinical follow-up was performed at 2, 4, and 6 weeks as well as at 3, 6, and 12 months postoperatively including assessment of range of motion and functional shoulder scores (Subjective Shoulder Value, Constant score, Rowe score, Walch Duplay score, Melbourne Instability Shoulder Score). Furthermore, shoulder instability was evaluated using the apprehension, relocation, and surprise tests. Mid-term follow-up data were additionally assessed after a minimum of 4 years. Results Twenty patients (19 male and 1 female) with an average age of 28 years were followed up for 62 (53-72) months after arthroscopic stabilization. The comparison of both groups showed almost equal results regarding the range of motion without any significant differences (P > .05). The evaluation of the shoulder function scores also showed no significant differences with an average Subjective Shoulder Value of 95% vs. 91%, Constant score of 89 vs. 88 points, Rowe score of 96 vs. 94 points, Walch Duplay score of 86 vs. 89 points, Melbourne Instability Shoulder Score of 96 points, and Western Ontario Shoulder Instability Index of 88% vs. 84% (P > .05). There was no recurrent dislocation in both groups. Conclusion The type of immobilization after arthroscopic shoulder stabilization does not influence the clinical results after a mid- to long-term follow-up.

Rugby has the highest incidence of traumatic injuries of any sport, and glenohumeral injuries result in the lengthy delay in return to play. The purpose of this study is to survey surgeons from the American Shoulder and Elbow Surgeons (ASES), and the British Elbow and Shoulder Society (BESS) to evaluate the current state of management of anterior glenohumeral instability, and compare the differences in practices.A survey of surgeons from ASES and BESS was conducted. Treatment options were proposed in a variety of clinical scenarios of glenohumeral instability. The time of immobilization post-operatively, return to play, and attitudes on current contact regulations. Results were compared using the chi-square test or t-test.Ninety-seven surgeons responded to the survey. There was a significant difference in treatment between ASES and BESS surgeons in the setting of primary dislocation (p 0.05), but not recurrent dislocation (p 0.05). The period of immobilization following injury and surgery was different between both treating groups. There was a significant difference in return to play between ASES and BESS surgeons with arthroscopic stabilization and open Bankart repair (p 0.05), but not following conservative treatment or the Latarjet procedure (p 0.05).There remains wide variance on the management of glenohumeral instability in rugby union players among surgeons. While immobilization times post-operatively were similar, the BESS surgeons were more confident in allowing earlier return to play. There is also a significant concern that contact levels should be regulated to protect player safety.Level 4 (case series).

Extensive glenoid labral tears, whether the result of repetitive instability or first-time dislocation, compromise the mechanical stability of the glenohumeral joint due to disruption of the anterior, inferior, posterior, and/or superior portions of the labrum. These lesions often result in recurrent multiplanar instability and pain that is nonresponsive to conservative management and difficult to diagnose due to variability in clinical presentation and advanced imaging findings. Arthroscopic repair techniques to address symptomatic shoulder instability have showed positive patient-reported outcomes, low failure rates, and high return-to-sport rates. The evolution of knotless suture anchors offers a fixation method that has proven to be functionally equivalent to knotted suture anchors while avoiding the risks of knotted anchors (knot loosening, knot migration, articular abrasion) and allowing easier placement and decreased operative time. The purpose of this technique is to describe our preferred method to treat a 270° labral tear through arthroscopic knotless anchor repair and demonstrate the expanded application of this technique for extensive glenoid labral pathology., Technique Video Video 1 For the treatment of a 270° labral tear in this left shoulder, the patient is placed in the lateral decubitus position and the standard diagnostic arthroscopy is performed using a posterior portal, anterior superior portal, and mid glenoid portal. Initial evaluation includes confirmation of the labral tear extending from 2 o’clock anteriorly to 11 o’clock posteriorly. Then attention is turned to the glenoid rim and torn labrum in preparation for repair. An arthroscopic shaver is used to debride the damaged labral tissue and create a bleeding surface on the glenoid rim to allow for better suture fixation and facilitate healing of the repaired labrum. A curved elevator is used to lyse capsulolabral adhesions and mobilize the labrum to allow for it to fall at the level of the glenoid articular surface. Suture repair is then performed using a ReelPass SutureLasso (Arthrex) to pass the repair suture through the capsule and grasp a several-millimeter (approximately 2-3 mm) portion of the labrum to integrate it into the repair. To address the anterior portion of the 270° labral tear, three 2.9 mm knotless PEEK PushLock Anchors (Arthrex) are fixed 5-7 mm apart from the 6 o’clock to 4 o’clock position. An accessory 7 o’clock portal is established for better accessibility to the posterior portion of the labral tear. A 3 mm knotless SutureTak Anchor (Arthrex) is placed at the 7 o’clock position followed by three additional 2.9 mm knotless PushLock Anchors 2-3 mm apart to the 11 o’clock position. A total of seven anchors are required to fully complete the capsulolabral repair and provide restoration of the labrum contour anterior, inferiorly, and posteriorly. Inspection with an arthroscopic probe is performed to check the integrity of the repair. The portal sites are then closed with no. 3-0 Monocryl suture, Dermabond, and Steri-Strips. A sterile dressing is placed, and then the shoulder is placed into a padded abduction sling.

Background Many of the complications related to bone block augmentation for recurrent shoulder instability are related to metal screw fixation. Alternative fixation techniques using suspensory fixation have been described with good results, although they require an additional posterior incision to manage the button. It was postulated that the use of an all-suture anchor would remove the requirement for a posterior incision, whilst providing equivalent union rates. Thus, the aim of this study was to evaluate the radiological outcome of a technique using all-suture anchor fixation of iliac crest autograft. Methods Eleven patients (mean age 28 years, 10 males, 1 female) underwent open anterior shoulder stabilization using an autologous iliac crest bone graft that was fixed with all-suture anchors and supplemented by 2-hole tibial plate. Union of the graft was evaluated 6 months postoperatively using computed tomography. Results There were no intraoperative complications and none of the participants needed further surgery. All patients reported a stable shoulder at 6 months follow-up. The grafts united in 10 out of the 11 patients. Conclusion An all-suture anchor construct is a viable alternative to metal screw fixation for iliac crest bone grafting in shoulder instability with critical bone loss, and unlike suspensory techniques does not require a second posterior incision.

Shoulder instability in hypermobile Ehlers-Danlos syndrome can result in lifelong pain and functional disability. Treatment in this population is complicated by the severe degree of instability as well as the underlying abnormalities of the joint connective tissue. Appropriate care for these patients requires a thorough understanding of the natural history of their disease, knowledge of the available treatment options, and certain special considerations. This article reviews the pathoanatomy, recognition, and management of shoulder instability in the patient with hypermobile Ehlers-Danlos syndrome.

The purpose of this study was to compare the outcomes of open Latarjet (OL) in competitive athletes with primary shoulder instability versus those with recurrent instability versus those undergoing OL for failed prior instability surgery.A retrospective review of patients who underwent OL with a minimum of 24-month follow-up was performed. Additionally, these were pair-matched in a 1:2:1 ratio for age, gender, sport, level of preoperative play, and follow-up length for primary instability, recurrent instability and failed prior instability surgery. Return to sport, the level of return and the timing of return were assessed. Additionally, recurrence, Visual Analogue Scale for pain (VAS), Subjective Shoulder Value (SSV), Rowe score, Shoulder Instability-Return to Sport after Injury (SIRSI) score, satisfaction, and whether they would undergo the same surgery again were compared.After pair-matching, a total of 200 patients were included, with a mean age of 22.7 years and a mean follow-up of 38.8 months. Overall, there was no significant difference in any of the clinical outcome scores (VAS, Rowe, SIRSI, SSV) used for the 3 groups (P0.05 for all). However, there was a significantly lower rate of return to play for those undergoing OL because of failed prior instability surgery (88% vs 91% vs 64%, P0.0001) and for return at the same or a higher level (66% vs 78% vs 56%, P = 0.02). There was no significant difference in the rate of recurrent instability among the 3 groups (6% vs 5% vs 6%, P = 0.95).OL results in excellent clinical outcomes and low recurrence rates for those with primary shoulder instability, those with recurrent instability and those undergoing OL for failed prior instability surgery. However, in those undergoing OL for failed prior stabilization surgery, there was a lower rate of return to play.Level III: Retrospective Comparative Study.

The arthroscopic Bankart repair is a safe and reliable procedure for the treatment of recurrent shoulder instability for the well-indicated patient. Many repair techniques have been described to restore both labral height and width and recreate a dynamic concavity–compression effect. The modified Mason–Allen knot was first described for rotator cuff tear repair and consists of a horizontal mattress knot with a simple vertical stitch on the same anchor. The purpose of this work is to present the use of the modified Masen–Allen knot for the repair of the capsular labral complex during an arthroscopic Bankart procedure., Technique Video Video 1 In a complex capsulolabral lesion faced in recurrent anterior shoulder instability, the modified Mason–Allen stitch is useful to better restore both the height and width of the capsulolabral complex to recreate a dynamic concavity–compression effect. First, a modified Mason–Allen knot is performed on an all-suture double-loaded anchor positioned at the 5-o’clock position. It is composed of the association of a horizontal mattress knot with a passing of a superior and an inferior thread separated by 5 mm. An overlapping simple vertical stitch is passed over the mattress knot with the tread passed in the middle of the both anteriorly passed threads. The horizontal mattress knot and the simple vertical stitch can then be tied. The same procedure is repeated at the 3- or 4-o’clock position. If needed, a simple stitch can be used to treat the concomitant anterior extent of the lesion or a posterior capsulolabral lesion.

Background The investigation of Hill-Sachs and bony Bankart lesions continues to evolve. Patients with large bone lesions can present with a positive apprehension test even at ranges below 45° of abduction and external rotation of the shoulder. Modern concepts, such as glenoid track and quantification of glenoid bone loss, have been increasingly applied to shoulder instability. The objective of this study was to assess the correlation of the glenoid track and glenoid bone loss on the apprehension test conducted at 0°, 45°, and 90° of shoulder abduction. Methods Ninety-four shoulders of 90 patients with anterior glenohumeral instability were retrospectively assessed. The apprehension test was performed at 0°, 45°, and 90° of shoulder abduction. Computed tomography, magnetic resonance imaging, or magnetic resonance arthrogram scans were performed to calculate the glenoid track and glenoid bone loss. A descriptive analysis, an association analysis, and a logistic regression analysis were used in this study. Logistic regression analysis was used to assess the influence of glenoid track and glenoid bone loss when the apprehension test was positive in lower degrees of abduction. Results A positive apprehension test at 0°, 45°, and 90° of abduction revealed significant association with off-track lesions, glenoid bone losses greater than 13.5%, and bipolar bone lesions. Shoulders classified as off-track were 36.4 times more likely to test positive at 0°, 45°, and 90° than on-track shoulders. The logistic regression analysis revealed that the positive apprehension test at 0°, 45°, and 90° of abduction seems to be more influenced by off-track lesions than by glenoid bone loss greater than the 13.5% threshold. Conclusion Shoulders with a positive apprehension test at 0°, 45°, and 90° are significantly associated with off-track lesions, bipolar bone lesions, and glenoid bone losses greater than 13.5%.

Purpose To identify factors predictive of a large labral tear at the time of shoulder instability surgery. Methods As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. Results After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). Conclusions Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. Level of Evidence I, prognostic study.

Purpose To determine the definitions for recurrence used in the literature, assess the consensus in using these definitions, and determine the impact of these definitions on recurrence rates. Methods A literature search was performed in PubMed and EMBASE including studies from 2000 to 2020 reporting on recurrence rates after anterior arthroscopic shoulder instability surgery. Dislocation, apprehension, subluxation and recurrence rates were compared. Results Ninety-one studies were included. In 68% of the eligible studies, recurrence rates are not well defined. Thirty (33%) studies did not report on dislocations, 45 (49%) did not report on subluxations, and 58 (64%) did not report on apprehension. Seventeen different definitions for recurrence of instability, 4 definitions of dislocations, and 8 definitions of subluxation were used. Conclusion Recurrence rates are poorly specified and likely underreported in the literature, hampering comparison with results of other studies. This highlights the need for a consensus on definition of recurrence across shoulder instability studies. We recommend not using the definition recurrence of instability anymore. We endorse defining dislocations as a radiographically confirmed dislocation or a dislocation that is manually reduced, subluxations as the feeling of a dislocation that can be (spontaneously) reduced without the need for a radiographically confirmed dislocation, and a positive apprehension sign as fear of imminent dislocation when placing the arm in abduction and external rotation during physical examination. Reporting on the events resulting in a dislocation or subluxation aids in making an estimation of the severity of instability. Level of Evidence Level IV, systematic review.

Background: Shoulder microinstability is often overlooked, which can be problematic, especially in overhead athletes. The slipping phenomenon is defined as posterior or lateral sliding of the humeral head in an elevated arm. When the shoulder is close to the end range of stability, the infraspinatus is highly activated and keeps the shoulder in the glenoid cavity. This study aimed to examine the characteristic physical function and infraspinatus activity during the pitching motion in baseball pitchers with shoulder instability. Methods: Twenty-one male baseball pitchers participated and were divided into 2 groups based on radiograph findings at zero position: slipped (group S) and nonslipped (group N) groups. Physical function using Hara test and infraspinatus muscle activity during pitching were evaluated. Results: The infraspinatus muscle activity during the acceleration phase was significantly greater in group S (59.5 ± 33.0%MVC) than in group N (33.0 ± 16.9%MVC) (P

Background Management of failed anterior stabilization is difficult. There are two main options for revision either a revision labral repair which has published high failure rates because of poor quality capsulolabral tissues or a bone block/Latarjet procedure with associated morbidity and complication rates. On this background, the senior author (D.T.) has developed a new procedure to treat this difficult to manage clinical scenario. Aim The aim of this study was to evaluate the 2-year results of an arthroscopic conjoint tendon transfer procedure. The procedure has previously been developed to provide a potential solution for active patients with a failed labral repair, subcritical glenoid bone loss, and an on-track Hill-Sachs lesion. Methods Consecutive patients who fulfilled the inclusion criteria were prospectively recruited. Inclusion criteria were active patients with recurrent shoulder instability owing to failed labral repair, less than 10% anterior glenoid bone loss, and an on-track Hill Sachs lesion. Patients were fully consented and offered a choice of revision with an arthroscopic labral repair, a Latarjet procedure or the arthroscopic conjoint tendon transfer procedure. Preoperative and postoperative Western Ontario Shoulder Instability Index and Oxford Instability Score were collected. Results Eight patients met the inclusion criteria and opted for the conjoint tendon transfer procedure. Mean age was 35 with a male:female ratio of 7:1. No patients had hyperlaxity clinically. At median follow-up of 31 months (range 24-41), there was a significant improvement in both the median Western Ontario Shoulder Instability Index (53.7 to 13.4, P = .0003) and Oxford Instability Score (27 to 44.5, P = .0017) scores. No patient had a further dislocation, and all were able to resume contact and noncontact sports. Conclusion Our results at a minimum of 2-year follow-up demonstrate that the arthroscopic transfer of the conjoint tendon confers clinical stability in patients with a failed primary labral repair who have minimal bone loss.

BACKGROUND Several functional outcome scores have been proposed for the evaluation of shoulder instability. Most are multiple-item questionnaires, which can be time-consuming and difficult for patients to understand, as well as leading to lack of compliance. The Single Assessment Numeric Evaluation (SANE) score is a single question that has recently gained widespread acceptance based on its simplicity and correlation with more complex scoring systems. The purpose of this study was to assess the correlation of a new modified version of the SANE score, the SANE-instability score, with the Rowe score after treatment for shoulder instability. MATERIALS AND METHODS We prospectively evaluated a consecutive series of 253 patients (268 shoulders) treated surgically or nonoperatively for shoulder instability between November 2017 and November 2019, for whom the Rowe and SANE-instability scores were collected before treatment and/or after treatment. The SANE-instability score was assessed with the following question: "What is the overall percent value of your shoulder if a completely stable shoulder represents 100%?" Correlations were tested using the Pearson coefficient (r) and interpreted as very high (r = 0.90-1.00), high (r = 0.70-0.89), moderate (r = 0.50-0.69), low (r = 0.30-0.49), or negligible (r = 0.00-0.29). Subgroup analyses were also performed to observe correlation variations according to follow-up length (before treatment and at 6, 12, 26, 52, and 104 weeks after treatment), patient age (

Among the many different procedures available in the treatment of shoulder instability, the Trillat procedure remains indicated in case of recurrent shoulder instability in elderly patient with an irreparable cuff tear or in case of hyperlaxity. Despite the constantly increasing number of arthroscopic assisted techniques, the open procedure remains a simple, reliable and fast surgical procedure with a shorter learning curve than the arthroscopic techniques. It consists in a partial osteotomy of the anterior cortical of the coracoid process which is then tilted and fixed with a screw into the anterior part of the scapula downwards and medially to obtain a re-centering effect due to the conjoint tendon on the humeral head when rotational movement are applied. This article aims to present a stepwise approach for the open surgical technique., Technique Video Video 1 A step-by-step approach of the realization of an open Trillat procedure for recurrent anterior shoulder instability with a patient in the supine position. Patient is with the arm freely accessible to be able to apply rotational movement during the procedure. The skin incision is centered on the apex of the coracoid process. After a classical deltopectoral approach, a release of the coracoacromial ligament and pectoralis minor tendon is made. A careful osteotomy of the superior cortical is performed with an osteotome, with caution not to break the inferior cortical. The coracoid process is then carefully positioned medially and downward before drilling both the coracoid process and anterior scapular neck with a 3.2-mm drill bit with the arm positioned in internal rotation. A cancellous screw is then tightened without any compression upward the superior border of subscapularis muscle with the arm still maintained in internal rotation. The sling effect of the conjoint tendon on the humeral head can be controlled at the end of the procedure while rotational movements are applied on the upper limb of the patient.

Introduction: Significant glenoid bone loss contributes to recurrent anterior shoulder instability. Reconstruction using an iliac crest bone graft provides an anatomic restoration of the glenohumeral arc. We present a case series of an all-arthroscopic glenoid bone reconstruction using iliac crest bone graft (ICBG) with a double cannulated screw fixation technique. Materials and methods: This is a retrospective study from 2012 to 2017. Patient selection was based on Instability Severity Index Score (ISIS) of greater than 3 points and the presence of glenoid bone defect of more than 20% surface area. The ICBG was harvested from the ipsilateral hip and delivered arthroscopically to the deficient glenoid. The bone graft was then fixed with two cannulated screws. All patients were evaluated at 0, 6, 12 and 24 months for range of motion, isometric strength, pain score, and functional outcome scores: Constant-Murley Score (CMSO), Oxford Shoulder Score (OSS), and UCLA Shoulder Score. Results: 7 patients (6 males, 1 female) with the mean age of 40.2 years and mean glenoid bone loss of 41.8% were included. At 24 months, the mean active flexion improved from 119 to 143° (p = 0.128) and active abduction improved from 112 to 138° (p = 0.063). Isometric strength increased from 14.7 to 17.6lbs (p = 0.345). All functional scores showed significant improvement (p

The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability.A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures.Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48%10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure.The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

Background: Latarjet has become a common treatment option for patients with shoulder instability in the setting of bone loss. The coracoid is commonly secured with screws Methods: All patients who underwent Latarjet with suture-button fixation with minimum 1-year follow-up were eligible for inclusion. Preoperative demographic and clinical outcome data including American Shoulder and Elbow Surgeons (ASES), Single Assessment Numerical Evaluation (SANE), and Visual Analog Scale (VAS) were recorded and compared with postoperative scores. Radiographs were reviewed for signs of nonunion. Complications were recorded. Results: Overall 21 patients (76% male, average age: 30.4 ± 11.3 years) underwent Latarjet with suture-button fixation. Significant improvements at 1 year were seen in ASES (P < 0.001), SANE (P < 0.001), and VAS (P = 0.011) scores compared with preoperative scores. Of the 21 patients who had reached 1-year follow-up, 17 (81%) reached 2-year follow-up. For the 17 patients who reached 2-year follow-up, there were significant improvements in ASES (P = 0.001), SANE (P = 0.001), and VAS (P = 0.005) scores from preoperative values. When isolating the 17 patients with 2-year follow-up, there were no significant differences between their 1-year and 2-year ASES (P = 0.73), SANE (P = 0.17), and VAS (P = 0.37) scores. Overall, 3 patients (14%) sustained a complication (one redislocation, one with coracoid migration and a fibrous union, and one superior labral tear requiring biceps tenodesis and superior labral repair). Conclusion: Suture-button fixation of the coracoid during the Latarjet provides encouraging clinical and radiographic outcomes at 1 and 2 years.

Background The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability. Methods Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient’s home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery. Results Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%. Conclusion We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.

Background Glenohumeral instability is a common condition of the shoulder. Glenoid bone loss and humeral head bone loss are well recognized as risk factors for recurrent instability. There are few studies in the literature that examine the role of coracoacromial arch anatomy in the pathogenesis of glenohumeral instability. Previous reports found an association between posterior acromial coverage (PAC) and posterior instability. We hypothesize that coracoacromial arch anatomy is related to anterior shoulder instability. Methods In this retrospective cohort study, 50 patients with unidirectional anterior shoulder instability were matched to a control group of 50 glenohumeral arthritis patients without any history of shoulder instability. Radiographic measurements of the coracoacromial arch anatomy were made: shoulder arch angle, scapular Y angle, anterior coracoid tilt (ACT), posterior acromial tilt, anterior acromial coverage angle, PAC angle, coracoid height, posterior acromial height, and critical shoulder angle were determined using standard lateral scapular and anteroposterior radiographs. Results Logistic regression analyses found a significant association between the presence of anterior instability and flatter coracoacromial arch angles (mean, 124.1°) vs. the arthritis control group (mean, 120.6°) (odds ratios [OR] = 1.113; 95% confidence interval [CI] = 1.039-1.191; P = .002). There was a significant association between anterior instability and ACT (OR = 1.144; 95% CI = 1.053-1.243; P = .001), whereas a negative association was found between anterior instability and PAC (OR = 0.909; 95% CI = 0.853-0.969; P = .004) and posterior acromial tilt (OR = 0.878; 95% CI = 0.773-0.998; P = .046). Lower critical shoulder angle values were associated with the arthritis group (28.2° vs. 33.9°) (OR = 1.555; 95% CI = 1.202-2.012; P = .001). Conclusions Shoulder coracoacromial arch morphology may play a role in the stability of the shoulder joint and development of recurrent anterior instability. Shoulders with a decreased shoulder arch angle, a less contained and flatter coracoacromial arch and larger ACT, were associated with anterior instability. This study identifies the shoulder coracoacromial arch angle and anterior coracoid tile angles as risk factors for anterior shoulder instability. Our findings suggest that measuring these angles may help orthopedic surgeons understand the risk of anterior instability and analyze risk factors to improve clinical decision making.

Background The shoulder is a commonly injured area in hockey, yet information is lacking on the prevalence and effect of shoulder instability. Our study investigates the incidence of shoulder dislocation events in the National Hockey League (NHL) and the effects on return-to-play (RTP) and player performance. We hypothesize that NHL players would have high RTP rates without significant changes in performance after injury. Methods NHL players who suffered in-season shoulder instability events between 2003-2004 and 2017-2018 seasons were identified. Demographic characteristics, incidence of injury, recurrences, RTP, and statistical performance data were collected. Postinjury performance was compared with experience-matched, era-matched, position-matched, and age-matched controls. A mixed generalized linear regression model was used to compare postinjury performance as a function of operative and nonoperative treatment. Results A total of 57 players experienced 67 shoulder instability events with 98.5% of players returning to play after an average of 26.3 ± 20.8 regular season games missed. Surgery was performed in 47.8% of players with no recurrent injuries postoperatively. Nonoperatively managed players experienced a decrease in points per game (P = .034) compared with surgically treated patients. Recurrence occurred in 14.3% of conservatively managed players, with 33.3% experiencing a season-ending injury. Players with recurrent injuries missed significantly more career games compared with those treated initially with surgery (P = .00324). Conclusion Professional hockey players experience high rates of RTP with acceptable performance outcomes after shoulder instability events; however, recurrent injuries led to significantly more career games missed when treated nonoperatively at the time of injury.

Introduction: Fragment-type glenoid bone loss is known to remodel after arthroscopic Bankart repair. To our knowledge, no studies have been reported about the morphologic changes of the erosion-type bone loss. Aim: To determine the morphologic changes of erosion-type glenoid bone loss after arthroscopic Bankart repair. Methods: Twenty-eight patients (mean age: 31 years) with traumatic anterior glenohumeral instability with an erosion-type glenoid bone loss

The purpose of this study was to evaluate short-term outcomes including medical complications, overnight admission, and 30-day readmission with regard to patient age at the time of shoulder instability surgery.Patients undergoing surgery for glenohumeral instability were collected from the National Surgical Quality Improvement Program between the years of 2005 and 2016. These patients were separated into cohorts of younger than 25 years, 25-34 years, and older than 34 years. Medical complications, hospital admission, and 30-day readmission were compared using multivariate analysis.Of the 5449 patients included, there were 2035 (37.0%) patients younger than 25 years, 1815 (33.0%) between 25 and 34 years, and 1649 (30.0%) 35 and older. Overall, 81.7% of patients underwent an arthroscopic Bankart repair, 12.6% of patients underwent an open Bankart repair, and 5.7% of patients underwent a Latarjet-Bristow procedure. The risk of 30-day readmission increased with age, ranging from 0.24% for25 years old to 0.92% for 35 years and older (P = .040). Operative duration greater than 60 minutes (odds ratio [OR] 1.76; P = .001), duration greater than 90 minutes (OR 3.58; P.001), and American Society of Anesthesiologists class III and IV (OR 1.80; P = .001) were associated with increased risk of overnight hospital stay. Compared with arthroscopic Bankart repair, the Latarjet-Bristow procedure was associated with increased total complications (OR 3.30; P = .021), overnight hospital stay (OR 4.64; P.001), and 30-day readmission (OR 3.39; P = .013).This study demonstrates that even in the relatively young and healthy shoulder instability patient cohort, patients older than 25 years are almost 4 times more likely to experience a complication. Additionally, Latarjet-Bristow procedures are 3-4 times more likely to experience a complication or readmission than other shoulder instability procedures.

Aim: Positioning and fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, can be challenging. We present the results of a series of patients who underwent a revision bone block procedure secured with double suture buttons using a drill guide system, the position of which was calculated from a preoperative computed tomography (CT) scan. Materials and methods: We undertook a revision bone block stabilization of the shoulder, using a guided double suture-button fixation, in 10 patients with significant retained glenoid metalwork from previous procedures. A preoperative CT scan was used to determine a position for the guide to allow a safe drill trajectory that would avoid any retained metalwork. A coracoid transfer was undertaken in 4 patients and an Eden-Hybinette in 6. Patients were assessed preoperatively and at final follow-up clinically and using the Oxford Shoulder Instability Score and the Subjective Shoulder Value score. Bone block position and healing was assessed by a CT scan at 6 months. The median follow-up was 36 months (range, 24-47 months). Results: There were 3 female and 7 male patients with a median age of 24.5 years (17-49 years). At final follow-up, the mean Oxford Shoulder Instability Score had decreased from 25.9 (range, 21-35) to 5.8 (range, 3-14) (P < .005). The mean Subjective Shoulder Value score had risen from 87.1 (range, 10-60) to 80 (range, 60-90) (P < .05). All of the patients considered their shoulder to be stable apart from 1 patient. There had been no redislocations. The bone block positioned in the glenoid lower quadrant had healed for all of the patients on CT at 6 months. Conclusion: Guided suture-button fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, provides a satisfactory outcome in terms of shoulder stability, graft position, and healing.

Introduction Recurrent multidirectional shoulder instability after failed capsular repair/plication, is a challenging treatment problem. The long head of the biceps has been identified as a structure that may be utilized as a checkrein to stop abnormal anterior and inferior translation of the humeral head. The purpose of this study is to analyse the outcomes of biceps suspensionplasty (BS) in the treatment of recurrent shoulder instability. Methods A retrospective review identified patients with recurrent multidirectional instability that underwent BS as part of a revision shoulder stabilization procedure. Clinical records were reviewed for demographics, pain, complications, recurrent instability, reoperations, and range of motion. Patients were also administered ASES/SST/SANE/Rowe and Oxford instability questionnaire at minimum of 2-year clinical follow-up. Results Five patients (7 shoulders) were included with a mean follow-up of 3.2 years (2–7 years). Patients had an average of 1.6 prior procedures (1–3). Average patient age was 24.2 years (18.7–32.4 years) and all were female. Four shoulders were treated open while 3 were treated arthroscopically with a capsular shift and biceps suspension. Four shoulders also underwent capsular reconstruction with allograft. At final follow-up three shoulders had recurrent inferior subluxation, although all patients considered their shoulders to be much better (4) or somewhat better (3) and none have undergone repeat surgery. Conclusion In our series of patients, we found BS may be useful as an adjunct to a revision capsular shift or reconstruction. While 42.8% of patients experienced recurrent subluxations, this high-risk population demonstrated encouraging subjective results and avoiding joint arthrodesis in the short-term.

Objective Two glenoid bone loss calculations are compared across a range of anatomic glenoid sizes. Methods 20 cadaveric paired glenoid diameters were measured to create glenoid models with bone loss calculated in 1 mm linear increments up to 50% bone loss comparing the linear measurement percentage (LMP) to the circle line method (CLM) gold standard. Results The LMP overestimates glenoid bone loss at every potential 1 mm increment across each glenoid model until bone loss reaches 50%. Conclusion The widely-used LMP method overestimates bone loss compared to a gold standard potentially misguiding surgeons towards bony reconstruction in shoulder instability during preoperative planning.

Background The minimal clinically important difference (MCID) is used when interpreting the importance of outcome data. However, a consensus regarding the MCID for commonly used patient-reported outcomes in shoulder surgery has not been established. The purpose of this systematic review was to evaluate the available literature on shoulder MCID to improve clinical interpretation of shoulder outcome data. Methods A systematic review of the literature was conducted to identify studies reporting anchor-based MCID values for the patient-reported outcomes recommended by the American Shoulder and Elbow Surgeons (ASES): Veterans Rand 12 score, ASES score, Single Assessment Numeric Evaluation (SANE) score, Western Ontario Rotator Cuff (WORC) score, Western Ontario Osteoarthritis Score (WOOS), Western Ontario Shoulder Instability Index (WOSI), Pennsylvania Shoulder Score, and Oxford Shoulder Score (OSS). Results A total of 14 articles reporting anchor-based MCID values were included in the final analysis. No studies reporting the Western Ontario Osteoarthritis Score (WOOS) were identified. The ASES score (6 studies), OSS (4 studies), and WORC score (2 studies) were the only instruments investigated in more than 1 study. The average reported MCID values for the ASES, OSS, and WORC scores were 15.5 (15% total difference), 275.7 (13% total difference), and 6 (13% total difference), respectively. The vast majority of studies failed to report information necessary to validate the credibility of these MCID values. Discussion and conclusion The current utility of the MCID for patient-report shoulder outcome instruments is limited by poor study methodology, inadequate reporting, and a lack of data. Further research is needed to more clearly define the MCID values for commonly used patient-reported outcomes in shoulder surgery.

Arthroscopic Latarjet is a relatively new, but viable option for the treatment of anterior shoulder instability. Arthroscopic Latarjet has the advantage of faster recovery, reduced stiffness, identification of additional shoulder pathology, and improved cosmesis when compared with open Latarjet. By the majority of clinical and radiographic parameters, arthroscopic Latarjet produces equivalent outcomes compared with open Latarjet. A relatively substantial learning curve for arthroscopic Latarjet exists at about 25 cases; however, multiple studies have demonstrated comparable outcomes and surgical time after the learning curve.

Objectives To examine whether patients, diagnosed with the hypermobility type of the Ehlers-Danlos syndrome (hEDS) or Hypermobility Spectrum Disorder (HSD), with multidirectional shoulder instability (MDI) have increased humeral head translations compared to healthy controls and to describe the direction of the humeral translations during five exercises. Design Observational study. Setting Ghent University Hospital. Participants Twenty-seven female patients (aged mean (SD) 35 (13) years) with hEDS/HSD and MDI and 20 female healthy controls (aged 34 (11) years) participated in this study. Interventions The acromiohumeral (AHD) and humeralglenoid distance (HGD) were measured using ultrasound during five isometric exercises: shoulder external rotation, shoulder extension, shoulder flexion, elbow extension and holding a 2 kg dumbbell. Main outcome measures Ultrasound measures of the AHD and HGD. Results During isometric shoulder extension, elbow extension and dumbbell loading, patients had a significantly larger change in AHD compared to controls. In patients, the AHD was significantly smaller during isometric shoulder flexion, extension and elbow extension compared to the AHD measured in rest. By contrast, the AHD was significantly larger during isometric external rotation and dumbbell loading compared to the AHD measured in rest. Regarding the HGD, no significant differences between patients and controls were observed. However, significantly smaller HGD values were found in patients during isometric shoulder flexion compared to the HGD in rest. Conclusions Isometric external rotation and holding a 2 kg dumbbell caused an inferior translation in patients with hEDS/HSD and MDI, whereas isometric shoulder flexion and shoulder/elbow extension respectively led to an anterior-superior and superior translation.

Since its first description over 30 years ago arthroscopic stabilisation has evolved. With improvements in knowledge, surgical techniques and materials technology, arthroscopic bankart repair has become the most widely used method for treating patients with symptomatic anterior shoulder instability. These procedures are typically performed in a younger, high demand patient population after a primary dislocation or to treat recurrent instability. A thorough clinical evaluation is required in the clinic setting not only to fully understand the injury pattern but also consider patient expectations prior to embarking on surgery. Diagnostic imaging will aid the clinician in determining the soft tissue pathology as well as assessing bone loss, which facilitates surgical decision-making. Selected patients may benefit from adjunctive procedures such as a remplissage for an "engaging" Hill-sachs lesion. This review will focus on the indications, pre-operative considerations, surgical techniques and outcomes of arthroscopic stabilisation.

MR imaging of the postoperative shoulder after instability surgery is challenging. The radiologist must be familiar with surgical procedures, altered anatomy, and expected postoperative findings for correct interpretation of normal findings versus a true pathology. Artifacts from metallic hardware or abrasions further complicate MR image interpretation, but are reduced with metal artifact reduction techniques. This article focuses on capsulolabral surgery, bone block transfers, and humeral bone loss procedures in patients with shoulder instability and their postoperative imaging evaluation. Surgical procedures and common complications are explained, and normal and pathologic postoperative imaging findings are presented.

Recurrent multidirectional shoulder instability is a common clinical presentation in certain demographics and sporting groups. One such demographic is patients with connective tissue disorders (CTD) such as Ehlers-Danlos syndrome (EDS), in whom shoulder pathologies are exacerbated owing to ligamentous laxity. Features of this laxity can present as both anterior and posterior shoulder instability, which are problematic sources of shoulder pain. Many patients with these injuries require surgical anterior and/or posterior glenohumeral reconstruction. Surgical reconstruction for posterior capsular defects can be challenging and has higher failure rates compared with anterior capsular reconstruction methods. Management can be especially difficult for patients with CTDs, and there is a requirement for the development of novel surgical techniques. Human acellular dermal allografts have been found to be particularly useful for patients with CTDs compared with other methods that use the patient’s own tissue for the repair. This note and surgical video describe an all-arthroscopic technique for a combined anterior capsule augmentation and posterior glenohumeral capsular reconstruction, using a human acellular dermal allograft for EDS patients with multidirectional instability.

The glenohumeral joint is prone to instability. Patients with instability should have a physical examination. Imaging studies can provide additional information. Classification schemes that into account soft tissue pathology, neuromuscular control, bone loss, and activity level. An arthroscopic Bankart repair is the mainstay for unidirectional instability. Bone block procedures are indicated for patients with bone loss or a failed attempt at stabilization surgery. The arthroscopic Latarjet is a promising option for these patients. For patients with multidirectional instability, prolonged rehabilitation is indicated, followed by capsular plication or inferior capsular shift if instability is unresponsive to physical therapy.

Background Shoulder instability is extremely common, with various outcome scores used to assess its progression after treatment. This review was performed to identify the scores most commonly used and to evaluate them according to the 4 core domains of shoulder trials (according to the Core Outcome Measures in Effectiveness Trials [COMET] initiative) and their respective psychometric qualities. Methods A systematic review of the literature of 3 databases (MEDLINE, Embase, PubMed) was undertaken. Studies were identified using eligibility criteria and critically appraised by 2 authors. Data were extracted using an a priori template. Outcome scores were identified and assessed regarding COMET domain inclusion and their psychometric properties. Results The most frequently used scores were the Rowe (58%), Constant (33%), Western Ontario Shoulder Instability Index (WOSI; 24%), and American Shoulder and Elbow Surgeons (23%) scores. The majority of outcome scores assessed pain and all assessed physical functioning. Quality of life and a global assessment of treatment success were rarely incorporated. No single outcome score considered all core COMET domains. The WOSI was the most acceptable measure of those assessed with respect to its validity, reliability, and responsiveness. Conclusions The WOSI incorporated 3 of the 4 core domains for shoulder trials (pain, physical functioning, and health-related quality of life). It had the most psychometric testing of the identified scores, confirming its reliability, validity, and responsiveness in the setting of shoulder instability. We recommend its use in this setting; however, it should be supplemented with additional outcome scores, such as the University of California–Los Angeles score, to cover all of the core COMET domains.

Purpose Compare intraarticular pressure of the glenohumeral joint in patients with and without shoulder instability after a volume-limited arthrogram. Materials and methods Patients aged 18–45 years with shoulder instability or pain were included. After injecting 10 cc of contrast-mixture, intraarticular pressure was recorded using an arterial-line pressure-transducer connected to a portable monitor. Results 14/16 (86%) patients were included – 7/14 (50%) had instability. Post-injection pressure measurement averaged 59.9 ± 44.0 mmHg (range 15–181). Instability patients averaged 60.8 ± 37.6 (range 15–117) versus 41.9 ± 14.0 mmHg (range 30–64) for non-instability (p > 0.1). Conclusion Glenohumeral pressure measurements are variable when utilizing standardized volume-limited arthrograms.

Subscapularis function after arthroscopic Bankart repair has been widely studied. However, data regarding subscapularis performance after arthroscopic Latarjet procedures are lacking. This study aimed to evaluate subscapularis clinical and radiologic performance after arthroscopic Latarjet procedures.We included 40 patients who underwent arthroscopic Latarjet procedure with a minimum 2-year follow-up. Clinical evaluation included Western Ontario Shoulder Instability Index and Rowe scores, specific subscapularis isokinetic study, and lift-off tests. Contralateral measurements were used for comparison. Computed tomographic evaluation included graft consolidation, muscle dimensions, and degree of fatty atrophy, calculated as the mean muscle attenuation (MMA).There was a decrease of 8.3% of maximum internal rotation peak torque in the operated arm (P = .02). However, there was no significant difference in the agonist-antagonist ratio: 76.9% in the operated arm and 76% in the contralateral (P = .82). Lift-off strength test demonstrated a decrease in the first year but not at final follow-up (P = .38). There was a significant decrease in lift-off distance of 23% compared to the contralateral side (P.001). Subscapularis MMA was diminished when compared to the infraspinatus/teres minor (P.001) at the expense of its upper part (P = .03). Hyperlaxity and number of dislocation episodes were correlated to a lower MMA (P = .046 and P = .005).Arthroscopic Latarjet procedures provide satisfactory clinical results. There seems to be a diminished subscapularis MMA depending on its superior half. Hyperlaxity and number of previous dislocations were correlated to a lower MMA. Although there was a decrease in the maximum internal rotation peak torque, we did not find any difference in the agonist-antagonist ratio or in the final lift-off strength between sides.

Hypothesis: We hypothesized that players in the National Basketball Association (NBA) who sustained a shoulder destabilizing injury could return to play (RTP) successfully at a high rate regardless of treatment type. Methods We used publicly available data to identify and evaluate 50 players who sustained an in-season shoulder instability event (subluxation/dislocation) while playing in the NBA. Demographic variables, return to NBA gameplay, incidence of surgery, time to RTP, recurrent instability events, and player efficiency rating (PER) were collected. Overall RTP was determined, and players were compared by type of injury and mode of treatment. Results All players (50/50) returned to game play after sustaining a shoulder instability event. In those treated nonoperatively, athletes who sustained shoulder subluxations returned after an average of 3.6 weeks, compared with 7.6 weeks in those who sustained a shoulder dislocation (P = .037). Players who underwent operative management returned after an average of 19 weeks. Athletes treated operatively were found to have a longer time interval between a recurrent instability event (70 weeks vs. 28.5 weeks, P = .001). Conclusion We found 100% rate of RTP after a shoulder instability event in an NBA athlete. Players who experience shoulder dislocations were found to miss more time before RTP and were more likely to undergo surgical intervention compared with those who experienced a subluxation. Surgical repair maintained a longer interval between recurrent instability. Future investigations should aim to evaluate outcomes based on surgical procedures and identify possible risk factors predictive of recurrent instability or failure to RTP.

Pathologic activation pattern of muscles can cause shoulder instability. We propose to call this pathology functional shoulder instability (FSI). The purpose of this prospective study was to provide an in-detail description of the characteristics of FSI.In the year 2017, a total of 36 consecutive cases of FSI presenting to our outpatient clinic were prospectively collected. Diagnostic investigation included a pathology-specific questionnaire, standardized clinical scores, clinical examination, psychological evaluation, video and dynamic fluoroscopy documentation of the instability mechanism, as well as magnetic resonance imaging (MRI). In a final reviewing process, the material from all collected cases was evaluated and, according to the observed pattern, different subtypes of FSI were determined and compared.Based on the pathomechanism, positional FSI (78%) was distinguished from nonpositional FSI (22%). Controllable positional FSI was observed in 6% of all cases and noncontrollable positional FSI in 72%, whereas controllable and noncontrollable nonpositional FSI were each detected in 11% of the cases. The different subtypes of FSI showed significant differences in all clinical scores (Western Ontario Shoulder Instability Index: P = .002, Rowe Score: P = .001, Subjective Shoulder Value: P = .001) and regarding functional impairment (shoulder stability: P.001, daily activities: P = .001, sports activities: P.001). Seventy-eight percent had posterior, 17% anterior, and 6% multidirectional instability. Although several patients showed constitutional glenoid shape alterations or soft tissue hyperlaxity, only few patients with acquired minor structural defects were observed.FSI can be classified into 4 subtypes based on pathomechanism and volitional control. Depending on the subtype, patients show different degrees of functional impairment. The majority of patients suffer from unidirectional posterior FSI.

Recurrent shoulder instability complicated by capsular insufficiency due to underlying soft-tissue disorders or multiple prior failed surgical procedures poses a challenging surgical problem. Traditional capsulolabral soft-tissue reconstruction techniques are less effective in this setting, and bony procedures sacrifice normal anatomic relations. The described arthroscopic technique aims to prevent instability while maintaining range of motion through creation of a soft-tissue allograft “sling” augmenting the posterior glenohumeral capsule.

In railroad, unfavorable ballast performances (e.g., ballast fouling, loss of lateral confinement) can lead to deterioration of upper structures such as the rail and tie. Therefore, accurate and timely monitoring of ballast condition is critical for rail safety operation and effective maintenance. In this paper, a series of ballast box tests were conducted to investigate the ballast particle movement pattern inside railway ballast under different ballast, loading, moisture, and shoulder confinement conditions. Eight wireless embedded devices – “SmartRocks” – were used in the laboratory tests in three different locations to study different ballast movement patterns under different conditions. A statistical Autoregressive (AR) model with X-bar control chart method was used to identify changes in particle movement patterns under different conditions. The results show that 1) the ballast particle movements are much more sensitive to moisture content for the fouled ballast than for the clean ballast; and 2) the AR model is capable of identifying ballast fouling and shoulder instability. In addition, a threshold value of 20% for the percentage of outliers of ballast particle movement patterns is suggested for the test conditions considered in this study. This study represents a preliminary step towards developing a reliable ballast condition identification index and further field studies are needed.

Isolated soft tissue stabilization procedures for treatment of recurrent shoulder instability are often not appropriate when the patient demonstrates bone loss of greater than 15% and in situations where there is recurrent instability after multiple attempts at arthroscopic stabilization. Current techniques for glenoid reconstruction include autografts with coracoid transfers, both Latarjet and Bristow techniques, autografts from the iliac crest, and allografts. Recent focus is on the use of distal tibial allografts for glenoid reconstruction. Distal tibial allografts provide a nearly identical radius of curvature to the glenoid with the addition of a thick cartilaginous surface that helps to restore the natural arc of the glenoid, ultimately leading to improved contact pressures by increasing the contact area. Additionally, these grafts are readily available and offer exceptional bone strength for fixation with a screw. This article discusses the surgical technique of distal tibial allograft augmentation for recurrent shoulder instability as well as the pre- and postoperative management of these patients.

The Latarjet procedure remains the most favored technique in dealing with patients with recurrent shoulder instability, instability secondary to bony Bankart lesions, off-track lesions, bipolar lesions and in patients with Humeral avulsion of glenohumeral ligament (HAGL lesions). Traditionally this procedure has been performed as an open procedure; however, the Arthroscopic Latarjet procedure has been described with similar outcomes to that of open technique. This article describes our preferred technique for the Arthroscopic Latarjet procedure.