Search

Background: The use of isolated soft tissue repair versus bone block stabilization for the treatment of recurrent anterior shoulder instability in adolescents has no scientific evidence., Purpose: To compare the clinical outcomes of adolescent patients who underwent isolated arthroscopic Bankart (iB) repair with those who underwent the arthroscopic Bristow-Latarjet procedure in addition to Bankart (BLB) repair., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 60 shoulders in adolescents (aged 13-18 years) were reviewed with a minimum 2 years' follow-up: iB repair (n = 36) and arthroscopic Bankart repair with an additional Bristow-Latarjet procedure (BLB; n = 24). The characteristics of the patients in each group in terms of age at the first instability episode, age at surgery, hyperlaxity, participation in at-risk sports, and Instability Severity Index Score were comparable. The mean follow-up was longer in the iB group (7.7 vs 4.1 years, respectively), whereas the rates of patients engaged in competition and those with glenoid lesions were higher in the BLB group. The primary outcome measures were failure, defined as the recurrence of instability (clinical dislocation or subluxation), and return to sports. The mean follow-up was 6.2 years (range, 2-16 years)., Results: At the last follow-up, the rate of recurrence was significantly higher in the iB group, with 22% (8/36) failures, than in the BLB group, with 8% (2/24) instability recurrences ( P < .05). The rate of return to sports at the same level was significantly higher after the BLB repair than after iB repair (79% vs 47%, respectively; P < .001). No statistical difference was found in patient-reported outcome scores between treatment groups ( P > .05). Although failures occurred early after the BLB repair, 88% of failures after iB repair occurred after 2 years. On multivariate analysis, adolescents in the iB group with >3 episodes of preoperative dislocation and shoulder hyperlaxity (external rotation >90°) had a 60% recurrence rate ( P < .005)., Conclusion: Adolescent patients undergoing the BLB repair had a lower rate of recurrent instability and higher rates of return to sports and competition than those undergoing iB repair. Patients with shoulder hyperlaxity (external rotation >90°) and >3 dislocations had an unacceptable failure rate of 60% after iB repair., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.B. has received consulting fees from Smith & Nephew and support to develop the specific instruments and implants used to perform the discussed procedure. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Purpose: To validate the subjective shoulder value for sport (SSV-Sport) by measuring its correlation with existing patient-reported outcome measures (PROMs) and defining its psychometric properties., Methods: Between May 2021 and May 2022, we established 2 patient groups. Group 1 included those (1) aged 18 years or older, who were (2) consulting for the first time for any shoulder condition, (3) regularly participated in sports, and were capable of accessing a questionnaire independently. There were asked to rate their SSV and SSV-Sport at admission and 2 weeks later; they also were asked to answer a questionnaire including other PROMS. Group 2 comprised patients who had (1) undergone shoulder stabilization surgery and had (2) a minimum follow-up period of 6 months., Results: For the shoulder disability patients (group 1, n = 62), there was a strong and significant correlation between SSV-Sport and other PROMs: Quick Disabilities of the Arm, Shoulder and Hand Sport (r = 0.84), Walch-Duplay (r = 0.65), Rowe (r = 0.74), Western Ontario Shoulder Instability (r = 0.78), and SSV (r = 0.75) (P = .0001). The SSV-Sport was reliable at baseline and 2 weeks after (0.91, 95% confidence interval 0.85-0.94), and was responsive to change (P < .001). For the anterior instability patients (group 2, n = 83), SSV was on average 50 points greater than SSV-Sport (29.2 vs 79.4, P < .001) for preoperative values. In both groups, the values of SSV were constantly and significantly higher than the values of SSV-Sport (81.9 ± 21.3 vs 54.8 ± 30.9; P < .001)., Conclusions: The SSV-Sport is an easily administered, reliable, responsive, and valid measure of shoulder function in athletes that is highly correlated with other PROMs. SSV-Sport is better adapted than SSV to quantify pre- and postoperative shoulder deficiency in athletes., Level of Evidence: Level III, cohort study (diagnosis)., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Functional posterior shoulder instability (FPSI) (type B1) is a severe type of instability, mainly in teenagers and young adults, that leads to loss of function, pain, and stigmatization among peers. An experimental nonsurgical treatment protocol based on neuromuscular electrical stimulation (NMES) showed very promising early results in the treatment of FPSI. The hypothesis of this study was that NMES-enhanced physical therapy leads to better outcomes than physical therapy alone as the current gold standard of treatment in patients with FPSI., Methods: In this multicenter randomized controlled trial, patients with FPSI were randomly allocated in a 1:1 ratio to either 6 weeks of physical therapy or 6 weeks of physical therapy with simultaneous motion-triggered NMES. Baseline scores as well as outcome scores at 6 weeks, 3 months, 6 months, and 12 months after the intervention were obtained. The predefined primary outcome of this trial was the Western Ontario Shoulder Instability Index (WOSI) at the 3-month time point., Results: Forty-nine patients were randomized and eligible for the trial. The group that received physical therapy with simultaneous motion-triggered NMES showed a significantly better main outcome measurement in terms of the 3-month WOSI score (64% [SD = 16%] vs 51% [SD = 24%]). Two-thirds of the patients from the physical therapist group crossed over to the group that received physical therapy with simultaneous motion-triggered NMES due to dissatisfaction after the 3-month follow-up and showed a significant increase in their WOSI score from 49% [SD = 8%] to 67% [SD = 24%]. The frequency of instability episodes showed a significant improvement in the group that received physical therapy with simultaneous motion-triggered NMES at the 3-month follow-up and beyond, while in the physical therapist group, no significant difference was observed., Conclusion: The current study shows that NMES-enhanced physical therapy led to statistically significant and clinically relevant improvement in outcomes in the treatment of FPSI compared to conventional physical therapy alone-from which even patients with prior unsatisfactory results after conventional physical therapy can benefit., Impact: Based on the results of this study, NMES-enhanced physical therapy is an effective new treatment option for FPSI, a severe type of shoulder instability. NMES-enhanced physical therapy should be preferred over conventional physical therapy for the treatment of patients with FPSI., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association.)

Purpose: The purpose of this study is to report the outcomes of the all-arthroscopic Trillat procedure, combined with capsular plication, for the treatment of recurrent anterior instability in young athletes with shoulder hyperlaxity (external rotation >90°)., Methods: We performed a retrospective evaluation of patients with recurrent anterior instability and shoulder hyperlaxity who underwent an arthroscopic Trillat between 2009 and 2019. Patients with concomitant rotator cuff lesions or voluntary or multidirectional instability were excluded. The osteotomized coracoid was fixed above the subscapularis with a cannulated screw or a suture button; a capsular plication was systematically associated. We followed patients with x-rays, computed tomography scans, and Subjective Shoulder Value, visual analog scale, Walch, Constant, and Rowe scores. Mean follow-up was 56 months (24-145)., Results: Twenty-eight consecutive patients (30 shoulders) with a mean age of 25 years were identified, and all met criteria. The main finding under arthroscopy was a "loose shoulder" with anteroinferior capsular redundancy and no or few (10%) labrum tears, glenoid erosion (13%), or Hill-Sachs lesions (10%). At last follow-up, 90% of the shoulders (27/30) were stable, and 79% (19/24) of the patients practicing sports returned to their preinjury activity level. The Walch-Duplay and Rowe scores improved from 54 (38-68) to 81 (4-100) and 55 (30-71) to 84 (45-100), respectively, P < .001., Conclusions: The arthroscopic Trillat is an effective procedure for the treatment of recurrent anterior instability in young athletes with shoulder hyperlaxity but no substantial humeral or glenoid bone loss, allowing return to overhead/contact sports., Level of Evidence: Level IV, retrospective study., (Copyright © 2022. Published by Elsevier Inc.)

Background: There is growing interest in using suture buttons for coracoid fixation to avoid the complications associated with screws during the Latarjet procedure. However, achieving bone block healing is critical for successful shoulder stabilization and return to sport. The purpose of this study was to assess and compare the healing rates and positioning of the coracoid bone block fixed with cortical suture buttons that were either manually tensioned (using a knot pusher) or mechanically tensioned (using a tensioning device) during arthroscopic Latarjet procedures., Methods: This prospective, nonrandomized, comparative study enrolled 69 consecutive patients (mean age, 27 years) who underwent an arthroscopic guided Latarjet procedure with suture-button fixation. Hand tensioning was performed in the first 34 shoulders, whereas the next 35 shoulders underwent mechanical tensioning. Twelve patients (17%) had a history of failed Bankart stabilization. The characteristics of the patients in each group in terms of age, sex, type of sport, bone loss, number of previous failed surgical procedures, smoking, and length of follow-up were comparable. Intraoperatively, the tensioning device was set at 100 N successively 3 times until complete immobilization of the bone block was confirmed, as assessed with a probe. The primary outcome measure was coracoid bone block union and position on computed tomography scan images at 6 months' follow-up. Secondary outcome measures included functional outcome scores, shoulder stability, return to sports, and complications at last follow-up., Results: Overall, the rate of bone block healing was 74% (25 of 34 patients) in the hand-tensioning group and 94% (33 of 35 patients) in the mechanical tensioning group (P = .043). Smoking was an independent risk factor associated with nonunion (P < .001) in each group. Patient age, size of the preoperative glenoid bone defect (<20% or >20%), and a history of surgery were not found to have any influence. The tensioning modality did not affect the bone block position, which was subequatorial in 92% of the cases and flush with the glenoid rim in 92%. At a mean of 34 months of follow-up (range, 24-62 months), 96% of the patients (65 of 69) had a stable shoulder and 87% returned to sports. At final follow-up, no significant difference in clinical scores was noted between the groups; no neurologic or hardware complications were observed., Conclusion: Mechanical tensioning achieves significantly higher healing rates than hand tensioning during the arthroscopic Latarjet procedure with suture-button fixation. The use of a suture-tensioning device is a key step to the suture-button fixation technique during arthroscopic Latarjet procedures. By making the suture-button construct rigid, the tensioning device transforms the initially flexible suture into a "rigid fixation", similar to a bolt (or a rivet)., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: While 2 screws are traditionally used for coracoid bone block fixation, no gold standard technique has yet been established when using cortical buttons., Purpose: To compare anatomic and clinical outcomes of the arthroscopic Latarjet procedure using either 2 or 4 buttons for coracoid bone block fixation., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 23 patients with 4-button fixation (group 4B) were matched for age at surgery, sex, and follow-up to 46 patients who had 2-button fixation (group 2B). All patients underwent guided arthroscopic Latarjet (using coracoid and glenoid guides), and a tensioning device was used to rigidify the suture button construct and get intraoperative bone block compression. The primary outcome was assessment of bone block positioning and healing using computed tomography scans performed at 2 weeks and at least 6 months after surgery. The mean ± standard deviation follow-up was 49 ± 7 months (range, 24-64 months)., Results: The bone block healing rate was similar in both groups: 91% in group 4B versus 95.5% in group 2B. The transferred coracoid was flush to the glenoid surface in 21 patients (91%) in group 4B and 44 patients (96%) in group 2B ( P = .6); it was under the equator in 22 patients (96%) in group 4B and 44 patients (96%) in group 2B ( P ≥ .99). There was no secondary bone block displacement; the rate of bone block resorption was similar between the groups: 28% in group 4B and 23% in group 2B ( P = .71). Patient-reported outcomes, return to sports, and satisfaction were also similar between the groups. The operating time was significantly longer in group 4B (95 vs 75 minutes; P = .009)., Conclusion: A 4-button fixation technique did not demonstrate any anatomic or clinical advantages when compared with a 2-button fixation technique, while making the procedure more complex and lengthening the operating time by 20 minutes. A 2-button fixation is simple, safe, and sufficient to solidly fix the transferred coracoid bone block. The use of drill guides allows accurate graft placement, while the use of a tensioning device to rigidify the suture button construct provides high rates of bone block healing with both techniques (>90%).

Background: Recurrence of anterior instability after arthroscopic Bankart prevents return to sports and remains a surgical challenge. We aim to assess clinical and radiologic outcomes after coracoid bone-block performed either open or under arthroscopy, for the management of failed arthroscopic Bankart PATIENTS AND METHODS: Fifty-nine consecutive patients with anterior instability recurrence after arthroscopic Bankart were revised with a Bristow or Latarjet procedure performed either open (25 cases) or under arthroscopy (34 cases). Patients were reviewed for clinical and radiologic examination at a minimum 2-year follow-up. Glenohumeral bony lesions were evaluated preoperatively with computed tomographic scans. Postoperative bone-block position, union, and postinstability arthritis were also evaluated., Results: The mean follow-up was 89 months (24-193). The epidemiologic analysis showed that patients with failed arthroscopic Bankart were young (age <23 years), 58 (98%) were practicing sports, with contact/forced overhead sports (53%), often in competition (53%), had hyperlaxity (71%), and for the most part of them glenohumeral bone loss (88%). Their mean preoperative Instability Severity Index Score was 5.4 ± 2.2 points. After revision with Bristow-Latarjet procedure, 53 patients (91%) returned to sports, 37 (70%) to their previous sports activity, and 17 (46%) to their previous level. No patient suffered recurrent dislocation. Four patients (7%) had recurrent subluxations, all after open procedure; 8 patients (14.5%) had persistent anterior apprehension. A large and deep Hill-Sachs lesion was a risk factor for persistent anterior apprehension (P = .002) and lower level when returned to sports (P = .04). Ninety-two percent of bone-blocks were positioned flush with the glenoid anterior rim, with 84% of bone union. At last follow-up, 5% of patients had severe postinstability osteoarthritis (Samilson 4)., Conclusion: The Bristow-Latarjet, performed either open or under arthroscopy, is an efficient procedure to restore shoulder stability and allow returning to sports in patients with failed arthroscopic Bankart and glenoid bone loss. Patients with a large and deep Hill-Sachs lesion had more persistent anterior apprehension and a lower sports level., (Copyright © 2021. Published by Elsevier Inc.)

Purpose: To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss., Methods: A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus., Results: After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out., Conclusions: The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed., Level of Evidence: Level V, consensus statement., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Aims: We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable., Methods: Consecutive patients who had an operation for recurrent posterior instability before the age of 18 years were studied retrospectively. All patients had failed conservative treatment for at least six months prior to surgery; and no patients had psychiatric disorders. Two groups were identified and compared: voluntary posterior instability starting in childhood which became uncontrollable and involuntary (group VBI); and involuntary posterior instability (group I). Patients were reviewed and assessed at least two years after surgery by two examiners., Results: In all 38 patients (40 shoulders) were included: group I (20 shoulders), with involuntary posterior instability (onset at 14 years of age (SD 2.3), and group VBI (20 shoulders), with initially voluntary posterior instability (onset at 9 years of age (SD 2.6) later becoming involuntary (16 years of age (SD 3.5). Mean age at surgery was 20 years (SD 4.6 years; 12 to 35). A posterior bone block was performed in 18 patients and a posterior capsular shift in 22. The mean follow-up was 7.7 years (2 to 18). Recurrence of posterior instability was seen in nine patients, 30% in group VBI (6/20 shoulders) and 15% in group I (3/20 shoulders) (p > 0.050). At final follow-up, the shoulder's of two patients in each group had been revised. No differences between either group were found for functional outcomes, return to sport, subjective, and radiological results., Conclusion: Although achieving stability in patients with so-called voluntary instability, which evolves into an involuntary condition, is difficult, shoulder stabilization may be undertaken with similar outcomes to those patients treated surgically for involuntary instability. Cite this article: Bone Joint J 2020;102-B(12):1760-1766.

Purpose: To report the results of a guided arthroscopic Eden-Hybbinette procedure, using suture button for iliac crest bone graft fixation, in a series of patients with a prior failed Latarjet and persistent glenoid bone loss., Methods: Seven consecutive patients (5 males, 2 females, mean age: 30.7 years [range, 17-47 years]) with recurrent anterior dislocations and glenoid deficiency greater than 20% underwent the all-arthroscopic revision procedure. The iliac crest bone graft and suture-button device (Bone-Link) were shuttled through the rotator interval. Specific drill guides were used and a suture tensioning device allowed bone graft compression. Previous broken screw shafts (3 patients) were left in situ. Graft placement and healing was assessed postoperatively with computed tomography imaging., Results: No neurologic injury or hardware problems occurred, and no patient required further surgery. On computed tomography scan, optimal positioning (flush and under the equator) and healing of the bone graft was observed in all patients. At a mean follow-up of 21 months (range, 12-39 months), all but one patient were satisfied and had a stable shoulder; 5 returned to sports. The Constant score increased from 32 to 81 points, and the subjective shoulder value from 31% to 87% (P < .001). The Walch-Duplay and Rowe scores averaged 85.7 (range, 65-100) points and 86.4 (range, 70-100) points, respectively., Conclusion: Recurrence of anterior shoulder instability after a failed Latarjet procedure can be successfully treated by an all-arthroscopic Eden-Hybbinette procedure. Suture-button fixation is reliable and permits optimal positioning and predictable healing of the new bone graft; in addition, it is an appropriate fixation option in the setting of retained broken hardware., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze the functional results after unipolar or bipolar arthroscopic soft tissue stabilization in the treatment of recurrent anterior instability after a coracoid bone block procedure., Methods: We studied a retrospective series of 41 patients (33 male, 8 female) with recurrent anterior shoulder instability after Bristow (n = 7) or Latarjet (n = 34) coracoid bone block treated with unipolar (isolated Bankart, n = 22) or bipolar (Bankart + Hill-Sachs remplissage, n = 19) arthroscopic stabilization., Results: The mean follow-up was 72 (25-208) months. Severe glenoid erosion (>25%) was found in 17 patients, and a medium or deep Hill-Sachs lesion (Calandra 2 and 3) was found in 24 patients. A radiographic control was available in 28 patients at final follow-up. Five patients (12%) presented a recurrence of instability (4 subluxations, 1 dislocation). Two patients required revision surgery, 1 in each group. At final follow-up, persistent anterior apprehension was more frequent in patients presenting with severe glenoid bone loss (P = .04) and in patients with medium or deep Hill-Sachs lesions who were treated with unipolar stabilization (P = .04). Return to sports was achieved in 81% of cases. Visual analog scale was 1.3 ± 2, subjective shoulder value was 83% ± 18%, Rowe score was 78 ± 24, and Walch-Duplay score was 76 ± 28. No patients developed severe glenohumeral arthritis (Samilson 4)., Conclusions: Arthroscopic soft tissue stabilization provides good functional results after failed coracoid bone block with an acceptable rate of recurrence and a return to sports in most cases. Patients with significant Hill-Sachs lesions showed better results when treated with combined Bankart repair and Hill-Sachs remplissage. Severe glenoid bone loss was associated with poorer functional results., Level of Evidence: Level IV, case series., (Copyright © 2019. Published by Elsevier Inc.)

Purpose: Osteoarthritis may be observed after surgery for instability and in the natural history of pathology. The primary objective was to analyze the late clinical and radiographic results of reverse shoulder arthroplasties (RSA) for patients who had instability arthropathy., Methods: This is a retrospective cohort of 25 patients with a mean follow-up of 6.6 years. Patients had a history of instability surgery (80%) or multiple closed reductions. All were clinically evaluated with the constant score (CS), and radiologically (true AP view and Y view)., Results: No significant differences in pre- and post-operative function, radiologic status, and complication rate between the patients treated with a prior bone block procedure for the anterior instability and those treated by a capsular plication or non-operatively. A 36-mm sphere was implanted in 67%. Bone grafting of the glenoid was needed in 71%. No intra-operative complication has been reported. Clinically, the active anterior elevation increased from 70° to 140° (p < 0.01) and external rotation from 9° to 21° (p = 0.02). The adjusted CS increased from 38 to 98 (p < 0.01). Two early post-operative complications were collected: one spine fracture and one superficial infection. No early or late dislocation or neurologic complication was observed. At the latest follow-up, there were 38.10% of glenoid spurs, and 55% of scapular notch., Conclusions: The overall complication rate in this specific group is relatively low. Patients' satisfaction rate is high and clearly higher than those reported with anatomic TSA for this indication. Clinical results are comparable to other studies describing results of RSA.

Purpose: To evaluate mid-term clinical outcomes, complications, bone-block healing, and positioning using suture-button fixation for an arthroscopic Latarjet procedure., Methods: Patients with traumatic recurrent anterior instability and glenoid bone loss underwent guided arthroscopic Latarjet with suture-button fixation. We included patients with anterior shoulder instability, glenoid bone loss >20%, and radiographic and clinical follow-up minimum of 24 months. Patients with glenoid bone loss <20% or those that refused computed tomography imaging were excluded. Bone-block fixation was accomplished with 2 cortical buttons connected with a looped suture (4 strands). The looped suture was tied posteriorly with a sliding-locking knot. After transfer of the bone block on the anterior neck of the scapula, compression (100 N) was obtained with the help of a tensioning device. Clinical assessment was performed at 2 weeks, 3 months, 6 months, and then yearly with computed tomography completed at 2 weeks and 6 months to confirm bony union., Results: A consecutive series of 136 patients underwent arthroscopic Latarjet with 121 patients (89%; mean age 27 years) available at final follow-up (mean follow-up, 26 months; range, 24-47 months). No neurologic complications or hardware failures were observed; no patients had secondary surgery for implant removal. The transferred coracoid process healed to the scapular neck in 95% of the cases (115/121). The bone block did not heal in 4 patients; it was fractured in 1 and lysed in another. Smoking was a risk factor associated with nonunion (P < .001). The coracoid graft was positioned flush to the glenoid face in 95% (115/121) and below the equator in 92.5% (112/121). At final follow-up, 93% had returned to sports, whereas 4 patients (3%) had a recurrence of shoulder instability. The subjective shoulder value for sports was 94 ± 3.7%. Mean Rowe and Walch-Duplay scores were 90 (range, 40-100) and 91 (range, 55-100), respectively., Conclusions: Suture-button fixation is an alternative to screw fixation for the Latarjet procedure, obtaining predictable healing with excellent graft positioning, and avoiding hardware-related complications. There was no need for hardware removal after suture-button fixation. The systematic identification of the axillary and musculocutaneous nerves reduced risk of neurologic injury. A low instability recurrence rate and excellent return to pre-injury activity level was found. Suture-button fixation is simple, safe, and may be used for both open and arthroscopic Latarjet procedure., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2019. Published by Elsevier Inc.)

Purpose: To analyze graft and fixation (screw and EndoButton) positioning after the arthroscopic Latarjet technique with 2-dimensional computed tomography (CT) and to compare it with the open technique., Methods: We performed a retrospective multicenter study (March 2013 to June 2014). The inclusion criteria included patients with recurrent anterior instability treated with the Latarjet procedure. The exclusion criterion was the absence of a postoperative CT scan. The positions of the hardware, the positions of the grafts in the axial and sagittal planes, and the dispersion of values (variability) were compared., Results: The study included 208 patients (79 treated with open technique, 87 treated with arthroscopic Latarjet technique with screw fixation [arthro-screw], and 42 treated with arthroscopic Latarjet technique with EndoButton fixation [arthro-EndoButton]). The angulation of the screws was different in the open group versus the arthro-screw group (superior, 10.3° ± 0.7° vs 16.9° ± 1.0° [P < .001]; inferior, 10.3° ± 0.8° vs 15.7° ± 0.9° [P < .0001]). The angulation of the EndoButtons was 5.7° ± 0.5°; this was different from that of open inferior screws (P = .003). In the axial plane (level of equator), the arthroscopic techniques resulted in lateral positions (arthro-screw, 1.5 ± 0.3 mm lateral [P < .001]; arthro-EndoButton, 0 ± 0.3 mm lateral [P < .0001]) versus the open technique (0.9 ± 0.2 mm medial). At the level of 25% of the glenoid height, the arthroscopic techniques resulted in lateral positions (arthro-screw, 0.3 ± 0.3 mm lateral [P < .001]); (arthro-EndoButton, 0.7 ± 0.3 mm lateral [P < .0001]) versus the open technique (1.0 ± 0.2 mm medial). Higher variability was observed in the arthro-screw group. In the sagittal plane, the arthro-screw technique resulted in higher positions (55% ± 3% of graft below equator) and the arthro-EndoButton technique resulted in lower positions (82% ± 3%, P < .0001) versus the open technique (71% ± 2%). Variability was not different., Conclusions: This study shows that the position of the fixation devices and position of the bone graft with the arthroscopic techniques are statistically significantly different from those with the open technique with 2-dimensional CT assessment. In the sagittal plane, the arthro-screw technique provides the highest positions, and the arthro-EndoButton technique, the lowest. Overall, the mean position of the bone block with the open Latarjet technique in the axial plane is slightly medial to the joint line, as recommended. Conversely, with the arthroscopic techniques, the bone grafts are more lateral with a slight overhang. The main differences are observed in the dispersion of the values (more extreme positions) with the arthro-screw technique, given the acknowledged limitations. Despite the statistical significance, the clinical significance of these differences is yet unknown., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Most of the complications of the Latarjet procedure are related to the bone block positioning and use of screws. The purpose of this study was to evaluate if an arthroscopic Latarjet guiding system improves accuracy of bone block positioning and if suture button fixation could be an alternative to screw fixation in allowing bone block healing and avoiding complications., Materials and Methods: Seventy-six patients (mean age, 27 years) underwent an arthroscopic Latarjet procedure with a guided surgical approach and suture button fixation. Bone graft union and positioning accuracy were assessed by postoperative computed tomography imaging. Clinical examinations were performed at each visit., Results: At a mean of 14 months (range, 6-24 months) postoperatively, 75 of 76 patients had a stable shoulder. No neurologic complications were observed; no patients have required further surgery. The coracoid graft was positioned strictly tangential to the glenoid surface in 96% of the cases and below the equator in 93%. The coracoid graft healed in 69 patients (91%)., Conclusions: A guided surgical approach optimizes graft positioning accuracy. Suture button fixation can be an alternative to screw fixation, obtaining an excellent rate of bone union. Neurologic and hardware complications, classically reported with screw fixation, have not been observed with this guided technique and novel fixation method., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Arthroscopic Bankart repair alone cannot restore shoulder stability in patients with glenoid bone loss involving more than 20% of the glenoid surface. Coracoid transposition to prevent recurrent shoulder dislocation according to Bristow-Latarjet is an efficient but controversial procedure., Questions/purposes: We determined whether an arthroscopic Bristow-Latarjet procedure with concomitant Bankart repair (1) restored shoulder stability in this selected subgroup of patients, (2) without decreasing mobility, and (3) allowed patients to return to sports at preinjury level. We also evaluated (4) bone block positioning, healing, and arthritis and (5) risk factors for nonunion and coracoid screw pullout., Methods: Between July 2007 and August 2010, 79 patients with recurrent anterior instability and bone loss of more than 20% of the glenoid underwent arthroscopic Bristow-Latarjet-Bankart repair; nine patients (11%) were either lost before 2-year followup or had incomplete data, leaving 70 patients available at a mean of 35 months. Postoperative radiographs and CT scans were evaluated for bone block positioning, healing, and arthritis. Any postoperative dislocation or any subjective complaint of occasional to frequent subluxation was considered a failure. Physical examination included ROM in both shoulders to enable comparison and instability signs (apprehension and relocation tests). Rowe and Walch-Duplay scores were obtained at each review. Patients were asked whether they were able to return to sports at the same level and practice forced overhead sports. Potential risk factors for nonhealing were assessed., Results: At latest followup, 69 of 70 (98%) patients had a stable shoulder, external rotation with arm at the side was 9° less than the nonoperated side, and 58 (83%) returned to sports at preinjury level. On latest radiographs, 64 (91%) had no osteoarthritis, and bone block positioning was accurate, with 63 (90%) being below the equator and 65 (93%) flush to the glenoid surface. The coracoid graft healed in 51 (73%), it failed to unite in 14 (20%), and graft osteolysis was seen in five (7%). Bone block nonunion/migration did not compromise shoulder stability but was associated with persistent apprehension and less return to sports. Use of screws that were too short or overangulated, smoking, and age higher than 35 years were risk factors for nonunion., Conclusions: The arthroscopic Bristow-Latarjet procedure combined with Bankart repair for anterior instability with severe glenoid bone loss restored shoulder stability, maintained ROM, allowed return to sports at preinjury level, and had a low likelihood of arthritis. Adequate healing of the transferred coracoid process to the glenoid neck is an important factor for avoiding persistent anterior apprehension., Level of Evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background: Arthroscopic Bankart repair and open Latarjet bone block procedure are widely considered mainstays for surgical treatment of recurrent anterior shoulder instability. The choice between these procedures depends mainly on surgeon preference or training rather than published evidence., Questions/purposes: We compared patients with recurrent posttraumatic anterior shoulder instability treated with arthroscopic Bankart or open Latarjet procedure in terms of (1) frequency and timing of recurrent instability, (2) risk factors for recurrent instability, and (3) patient-reported outcomes., Methods: In this retrospective comparative study, we paired 93 patients undergoing open Latarjet procedures with 93 patients undergoing arthroscopic Bankart repairs over the same period for posttraumatic anterior shoulder instability by one of four surgeons at the same center. Both groups were comparable except that patients in the Latarjet group had more glenoid lesions and more instability episodes preoperatively. Minimum followup was 4 years (mean, 6 years; range, 4-10 years). Patients were assessed with a questionnaire, including stability, Rowe score, and return to sports. Recurrent instability was defined as at least one episode of recurrent dislocation or subluxation. Return to sports was evaluated using a 0% to 100% scale that patients completed after recovery from surgery. Various risk factors for recurrent instability were also analyzed., Results: At latest followup, 10% (nine of 93) in the Latarjet group and 22% (20 of 93) in the Bankart group demonstrated recurrent instability (p = 0.026; odds ratio, 0.39; 95% CI, 0.17-0.91). Ten recurrences in the Bankart group (50%) occurred after 2 years, compared to only one (11%) in the Latarjet group. Reoperation rate was 6% and 7% in the Bankart and Latarjet groups, respectively. In both groups, patients younger than 20 years had higher recurrence risk (p = 0.019). In the Bankart group, independent factors predictive for recurrence were practice of competitive sports and shoulder hyperlaxity (ie, passive external rotation > 85° in the contralateral uninjured shoulder). Although return to sports was not different between groups, the mean Rowe score was higher in the Latarjet group (78 versus 68, p = 0.018)., Conclusions: Patients who had the open Latarjet procedure had less recurrent instability and better Rowe scores over a mean 6-year followup. We now perform isolated arthroscopic Bankart repair for carefully selected patients, including patients with an Instability Severity Index Score of 3 or less., Level of Evidence: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Purpose: To determine the optimal position and orientation of the coracoid bone graft for the Latarjet procedure for recurrent instability in patients with recurrent anterior instability and high degrees of glenoid bone loss., Methods: A systematic review of the literature including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2012), and Medline (1980-2012) was conducted. The following search teams were used: glenoid bone graft, coracoid transfer, glenoid rim fracture, osseous glenoid defect, and Latarjet. Studies deemed appropriate for inclusion were then analyzed. Study data collected included level of evidence, patient demographic characteristics, preoperative variables, intraoperative findings, technique details, and postoperative recovery and complications where available., Results: The original search provided a total of 344 studies. A total of 334 studies were subsequently excluded because they were on an irrelevant topic, used an arthroscopic technique, or were not published in English or because they were review articles, leaving 10 studies eligible for inclusion. Given the different methods used in each of the studies included in the review, descriptive analysis was performed. The duration of follow-up ranged from 6 months to 14.3 years postoperatively. With the exception of 2 studies, all authors reported on recurrent shoulder instability after Latarjet reconstruction; the rate of recurrent anterior shoulder instability ranged from 0% to 8%. Overall patient satisfaction was listed in 4 studies, each of which reported good to excellent satisfaction rates of more than 90% at final follow-up., Conclusions: As noted in this review, the current literature on Latarjet outcomes consists mostly of retrospective Level IV case series. Although promising outcomes with regard to a low rate of recurrent instability have been seen with these reports, it should be noted that subtle variations in surgical technique, among other factors, may drastically impact the likelihood of glenohumeral degenerative changes arising in these patients., Level of Evidence: Level IV, systematic review of Level IV studies., (Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

In its natural state, the shoulder is unbalanced in both the vertical and horizontal planes because the deltoid is stronger than the rotator cuff muscles and the internal rotator muscles are stronger than the external rotator muscles. With aging, this muscle imbalance can become worse, leading to tendon wear, irreversible fatty infiltration of the rotator cuff muscles, and upward migration of the humeral head. Most shoulders with tendon wear are functional and asymptomatic. A traumatic event (such as a fall onto the upper limb) can lead to rotator cuff tearing and a shoulder that becomes symptomatic and nonfunctional. Symptomatic massive irreparable rotator cuff tears present in one of four recognizable patterns depending on the muscular imbalance that occurs and the symptoms that are present: painful loss of active elevation, with conserved muscle balance; isolated loss of active elevation, with loss of vertical muscle balance; isolated loss of external rotation, with loss of horizontal muscle balance; and combined loss of elevation and external rotation, with loss of vertical and horizontal muscle balance. Assessing the plane of shoulder muscle imbalance is a key feature in the decision-making process. Classifying and understanding these tears allows surgeons to select the correct treatment (conservative measures, arthroscopic techniques, reverse shoulder arthroplasty, or tendon transfers) to restore shoulder balance and function.

Background: There is limited knowledge regarding revision of reverse shoulder arthroplasty (RSA). This study assesses reasons for failure in RSA and evaluates the outcomes of revision RSA., Materials and Methods: Between 1997 and 2009, 37 patients with RSA had revision surgery. Clinical and radiologic examinations performed preoperatively and at 3 months, at 6 months, and then annually postoperatively were analyzed retrospectively. Patients were reviewed with a minimum 2-year follow-up., Results: The most common causes for RSA revision were prosthetic instability (48%); humeral loosening, derotation, or fracture (21%); and infection (19%). Only 2 patients (3%) had to be reoperated on for glenoid loosening. More than 1 re-intervention was performed in 11 patients (30%) because of recurrence of the same complication or appearance of a new complication. Underestimation of humeral shortening and excessive medialization were common causes of recurrent prosthetic instability. Proximal humeral bone loss was found to be a cause for humeral loosening or derotation. Previous surgery was found as a potential cause of low-grade infection. At a mean follow-up of 34 months, 32 patients (86%) had retained the RSA whereas 2 patients (6%) had undergone conversion to humeral hemiarthroplasty and 3 (8%) to a resection arthroplasty. The mean Constant score in patients who retained the RSA increased from 19 points before revision to 47 points at last follow-up (P < .001)., Conclusions: Even if revision may lead to several procedures in the same patient, preservation or replacement of the RSA is largely possible, allowing for a functional shoulder. Full-length scaled radiographs of both humeri are recommended to properly assess humeral shortening and excessive medialization before revision., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: Neer modified the Bankart procedure by combining a superoinferior capsular shift with the labral reattachment. The theoretical advantages of the modification were that such a procedure would restore the patient's anatomy and also treat the repeated capsular stretching encountered in anteroinferior instability without limiting external rotation and, thereby reducing the risk of arthritis., Questions/purposes: We therefore determined: (1) the rate of recurrent instability after this modification, (2) patient function, and (3) the incidence and stage of glenohumeral osteoarthritis at greater than 2 years followup in patients with traumatic anteroinferior instability., Methods: We retrospectively reviewed all 64 patients (average age, 27 years) who had the modified Bankart procedure for recurrent dislocations (n = 39) or subluxation (n = 25) from 1991 to 1997. The labrum was reattached with suture anchors and a superoinferior capsular shift was added. We determined the rate of recurrent instability, Rowe and Walch-Duplay scores and shoulder ROM, and the presence of glenohumeral osteoarthritis (modified Samilson and Prieto classification). The minimum followup was 24 months (median, 40 months; range, 24-120 months)., Results: Recurrent instability occurred in seven of the 64 patients (11%) at an average of 25 months postoperatively (range, 7 days to 6 years); in six patients the recurrence was associated with trauma; five of the six patients underwent reoperation with a Latarjet procedure. Eight additional patients (13%) presented with persistent shoulder apprehension or discomfort. The average Rowe score was 83% (range, 20-100%) and average Walch-Duplay score 83% (range, 15-100%). However, only 36 of 64 (56%) patients could return to the same sport at the same level. The loss of external rotation was 13° compared with the contralateral side. Glenohumeral osteoarthritis incidence increased from 4% preoperatively to 17% postoperatively., Conclusions: The open Bankart procedure modified by Neer provided high function scores but a relatively low rate of return to sport and high rate of recurrent instability. Our rate of recurrent instability, similar to that obtained with arthroscopic Bankart procedures, has prompted us to abandon the open procedure.

Introduction: Our purpose was to evaluate if, in case of aseptic glenoid loosening and failure in anatomical total shoulder arthroplasty (TSA), revision by a reverse shoulder arthroplasty (RSA) is a reliable therapeutic option., Methods: Retrospective multicenter cohort study of 37 consecutive anatomical TSA revised by RSA for aseptic glenoid loosening or failure. The decision to implant a RSA was related to the presence of associated complications: rotator cuff tears (n = 24), subscapularis insufficiency (n = 29), prosthetic instability (n = 13), and glenoid bone deficiency (n = 37). The patients were reviewed clinically and radiographically at a mean follow-up of 47 months (range, 24-104)., Results: Eighty-six percent of the patients were satisfied or very satisfied. The average Constant score increased from 24 to 55 pts (P < .0001) and active anterior elevation from 68° to 121° (P < .0001). Twenty-two of the 29 (76%) associated bone grafts were incorporated in the glenoid. Eight patients (21%) needed a subsequent reoperation because of recurrent or new complications: glenoid loosening (n = 3), prosthetic anterior instability (n = 3), and humeral subsidence (n = 2); the reverse prosthesis had to be converted to a hemiarthroplasty in 1 patient and removed in another., Conclusion: Revision with a RSA is a reliable therapeutic option which provides the double benefit of glenoid bone stock reconstruction by fixing the bone graft with the help of the baseplate and screws and of solving the problem of soft tissue insufficiency and prosthetic instability. However, surgeons should be aware that the rate of postoperative complications and subsequent reoperations is high, and that the surgical technique is demanding., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: The aim of this study was to radiographically analyze the long-term glenoid migration patterns following total shoulder arthroplasty to better understand the factors responsible for loosening., Methods: Complete radiographic follow-up of more than five years was available for 518 total shoulder arthroplasties performed for primary glenohumeral osteoarthritis with use of an anatomically designed prosthesis with a cemented, all-polyethylene, keeled glenoid component. Radiographs were assessed for humeral head subluxation, periprosthetic radiolucent lines, and shifting of the position of the glenoid component. The type of migration of the glenoid was defined according to the direction of tilt, or as subsidence in the case of medial migration., Results: Definite radiographic evidence of glenoid loosening was observed in 166 shoulders (32%) and was characterized by radiolucency of ≥2 mm over the entire bone-cement interface in thirty shoulders and by a migration of the glenoid component (shift or subsidence) in 136 shoulders. Three predominant patterns of migration of the glenoid component were observed: superior tilting in fifty-two shoulders (10%), subsidence in forty-one shoulders (7.9%), and posterior tilting in thirty-three shoulders (6.4%). Superior tilting of the glenoid was associated with three risk factors: low positioning of the glenoid component, superior tilt of the glenoid component on the immediate postoperative coronal plane radiographs, and superior subluxation of the humeral head (p < 0.05 for all). Subsidence of the glenoid component was associated with the use of reaming to optimize the seating and positioning of the glenoid component (p < 0.001). Posterior tilting of the glenoid component was associated with preoperative posterior subluxation (i.e., a Walch type-B glenoid) and with excessive reaming (p < 0.01 for both)., Conclusions: The three patterns of migration observed in this study underscore the potential importance of the supporting bone beneath the glenoid component. In some shoulders, use of a keel or pegs to provide fixation of a polyethylene component in the absence of good support from subchondral bone may not be sufficient to resist compressive and eccentric forces, resulting in loosening. Preserving subchondral bone may be important for long-term longevity of the glenoid component.

Hypothesis: The etiology of shoulder pain in the overhead athlete is often difficult to determine. This study hypothesized that (1) instability can present in a purely painful form, without any apparent history of instability, but with anatomic lesions indicative of instability, termed unstable painful shoulder (UPS), and that (2) arthroscopic shoulder stabilization is effective., Materials and Methods: The study evaluated 20 patients (mean age, 22 ± 8 years) at a mean of 38 months postoperatively (range, 24-69 months). Inclusion criteria were painful shoulder with lesions indicative of instability on imaging or at surgery, minimum 2-year follow-up. Exclusion criteria were recognized instability, other associated pathologies, and previous shoulder surgery., Results: Patients were young, hyperlax athletes who complained of deep, anterior shoulder pain and denied any instability. Pain was reproduced with the arm in an anterior apprehension position and relieved by a relocation test; however, no actual apprehension was experienced. Patients often had glenohumeral laxity and hyperlaxity. Lesions indicative of instability confirmed that at least 1 unapparent shoulder subluxation occurred. The Rowe, Walch-Duplay, and University of California, Los Angeles scores improved significantly (P < .05); 19 patients (95%) were satisfied, and 15 (75%) returned to their previous level of sports., Discussion: The diagnosis of UPS is often missed but is important to consider in the young hyperlax athlete. Soft tissue and/or bony lesions consistent with instability are necessary to confirm the diagnosis. Arthroscopy certainly deserves a significant place in this form of anteroinferior instability because it allows both the assessment of lesions (ie, diagnosis) and a satisfactory functional result and return to sport., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

The all-arthroscopic technique that the authors propose combines a Bristow-Latarjet procedure with a Bankart repair. This combined procedure provides a triple blocking of the shoulder (the so-called 2B3 procedure): (1) the labral repair recreates the anterior bumper and protects the humeral head from direct contact with the coracoid bone graft (Bumper effect); (2) the transferred coracoid bone block compensates for anterior glenoid bone loss (Bony effect); and (3) the transferred conjoined tendon creates a dynamic sling that reinforces the weak anteroinferior capsule by lowering the inferior part of the subscapularis when the arm is abducted and externally rotated (Belt or sling effect). The procedure combines the theoretic advantages of the Bristow-Latarjet procedure and the arthroscopic Bankart repair, eliminating the potential disadvantages of each. The extra-articular positioning of the bone block together with the labral repair and capsule retensioning allows the surgeon to perform a nearly anatomic shoulder repair. This novel procedure allows the surgeon to extend the indications of arthroscopic shoulder reconstruction to the subset of patients with recurrent anteroinferior shoulder instability with glenoid bone loss and capsular deficiency. It is an attractive surgical option to treat patients with a previous failed capsulolabral repair for which the surgical solutions are limited., (Copyright 2010 Elsevier Inc. All rights reserved.)

The treatment of traumatic anterior glenohumeral instability has evolved considerably in recent years. The results of arthroscopic repair have considerably improved, and, for many surgeons, arthroscopic techniques have supplanted traditional open techniques. Although a scoring system and other assessment tools can be useful, the choice of a surgical treatment for glenohumeral stabilization requires a careful assimilation of the patient's expectations and the surgeon's experience as well as an understanding of the relevant individual pathoanatomy. Pathoanatomy, nonsurgical and surgical treatment of shoulder instability, bone loss, unsuccessful stabilization treatment, and review of recent literature are important factors.

Purpose: The purpose of this study was to evaluate the results of revision arthroscopic stabilization after failed open anterior shoulder stabilization., Methods: We studied a retrospective series of 22 consecutive patients with recurrent anterior shoulder instability after open surgical stabilization (12 Latarjet procedures, 4 Eden-Hybinette procedures, 3 open Bankart repairs, and 3 capsular shifts). Failure was associated with a traumatic episode in 12 patients, capsular laxity with persistent Bankart lesions in all patients, and a bone block complication in 13 patients. Labral reattachment and capsuloligamentous retensioning with suture anchors were performed in all cases. An additional rotator interval closure was performed in 4 cases and an inferior capsular application in 12. Bone block screws were removed during arthroscopy in 8 patients because of malpositioning or mobility. Nineteen patients were evaluated at a mean follow-up of 43 months., Results: All patients returned to their previous occupations, including 6 cases of work-related injury. Of the patients, 1 (5%) had recurrent subluxation and 2 (11%) had persistent apprehension. The subjective shoulder value was 83% +/- 23%. A good or excellent result was found in 85% of patients according to the Walch-Duplay score and 13 patients (67%) according to the Rowe score. Shoulder pain was found in 6 patients (32%) (4 with light pain and 2 with moderate pain). Of the 5 patients with osteoarthritis before surgery, 3 progressed by 1 stage., Conclusions: Arthroscopic revision of failed open anterior shoulder stabilization provides satisfactory results in a selected patient population. Some persistent pain and osteoarthritis progression remain concerns. The main advantages of the arthroscopic approach are the avoidance of anterior dissection in front of the subscapularis, which places the axillary nerve at risk, and the ability to address the various soft-tissue pathologies encountered., Level of Evidence: Level IV, therapeutic case series.

Purpose: We report the results of a new technique consisting of a combined arthroscopic Bankart repair associated with a transfer of the coraco-biceps tendon to reinforce the deficient anterior capsule by lowering the subscapularis., Methods: The procedure combines 2 parts: an arthroscopic Bankart repair, which recreates the glenoid concavity and retensions the inferior glenohumeral ligament (i.e., "the belt," or intra-articular ligamentoplasty), and an arthroscopic transfer of the conjoined tendon with a coracoid fragment, to reinforce the stretched or torn inferior glenohumeral ligament (i.e., "the suspenders," or extra-articular ligamentoplasty). The coracoid fragment is exteriorized, shaped, and calibrated, and a tenodesis of the coraco-biceps tendon is performed above the subscapularis tendon by fixing the coracoid fragment with a bioabsorbable interference screw in a glenoid socket in the scapular neck. Thirty-six patients were available for clinical and radiographic review with a minimum 1-year follow-up., Results: Of the patients, 28 (78%) were very satisfied, 5 (14%) were satisfied, and 3 (8%) were disappointed. In comparison to the contralateral shoulder, postoperative mobility revealed no loss of active anterior elevation, a mean deficit of 9 degrees in external rotation with the arm at the side, a mean deficit of 15 degrees in external rotation in abduction, and no loss of internal rotation. The mean Walch-Duplay score was 87 points. Failures occurred in 3 patients (8%) who presented with recurrent instability., Conclusions: This new intra- and extra-articular combined technique constitutes an alternative in the treatment of anterior shoulder instability in patients with deficient or stretched anterior capsule. It combines the theoretic advantages of the Bristow bone-block procedure and the arthroscopic Bankart repair while eliminating the potential disadvantages of each., Level of Evidence: Level IV, therapeutic case series.

Background: The higher failure rates reported with arthroscopic stabilization of traumatic, recurrent anterior shoulder instability compared with open stabilization remain a concern. The purpose of this study was to evaluate the outcomes of arthroscopic Bankart repairs with the use of suture anchors and to identify risk factors related to postoperative recurrence of shoulder instability., Methods: Ninety-one consecutive patients underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. The mean age (and standard deviation) at the time of surgery was 26.4 +/- 5.4 years. Seventy-one patients were male. Seventy-nine patients were involved in sports (forty, in high-risk sports). Capsulolabral reattachment and capsule retensioning was performed with use of absorbable suture anchors (mean, 4.3 anchors; range, two to seven anchors). All patients were prospectively followed, and, at the time of the last review, the patients were examined and assessed functionally by independent observers., Results: At a mean follow-up of thirty-six months, fourteen patients (15.3%) experienced recurrent instability: six sustained a frank dislocation and eight reported a subluxation. The mean delay to recurrence was 17.6 months. The risk of postoperative recurrence was significantly related to the presence of a bone defect, either on the glenoid side (a glenoid compression-fracture; p = 0.01) or on the humeral side (a large Hill-Sachs lesion; p = 0.05). By contrast, a glenoid separation-fracture was not associated with postoperative recurrent dislocation or subluxation. Recurrence of instability was significantly higher in patients with inferior shoulder hyperlaxity (p = 0.03) and/or anterior shoulder hyperlaxity (p = 0.01). On multivariate analysis, the presence of glenoid bone loss and inferior hyperlaxity led to a 75% recurrence rate (p < 0.001). Lastly, the number of suture-anchors was critical: patients who had three anchors or fewer were at higher risk for recurrent instability (p = 0.03)., Conclusions: In the treatment of traumatic recurrent anterior shoulder instability, patients with bone loss or with shoulder hyperlaxity are at risk for recurrent instability after arthroscopic Bankart repair. At least four anchor points should be used to obtain secure shoulder stabilization.

We describe a new technique to allow easy placement of anterior sutures and to improve the proximal capsular shift in arthroscopic anterior stabilization of the shoulder, which we call the temporary outside traction suture (TOTS). Two standard portals are used: posterior and anterosuperior. Using a curved suture hook, both the capsule and the labrum are perforated at approximately the 5-o'clock position, and a monofilament suture is passed through the tissues. The suture is first retrieved through the anterior canula and then placed outside the canula. After labrum detachment and glenoid preparation, 1 or 2 further inferior sutures can be placed before the first suture is retrieved inside the canula and used. The technique of the TOTS has many advantages. (1) It allows easy placement of the first suture before the anterior capsule and labrum have been released. This makes this step much more difficult due to the lack of tension in the anterior tissues and anterior subluxation of the humeral head. (2) It allows the surgeon to choose, with accuracy, the amount of capsule taken, according to the severity of the capsular lesions and the degree of capsular laxity. It can also allow anatomic recreation of the anterior band of the inferior glenohumeral ligament (IGHL). (3) By placing tension on the suture, it avoids damaging the anterior capsule and labrum with the shaver and burr while preparing the scapula neck and can aid with haemostasis. (4) Tension on the suture also allows one to easily place 1 or 2 further sutures in a lower position. (5) It avoids entangling the sutures in the canula. (6) It allows one to perform a capsular shift of approximately 10 to 15 mm when the traction suture is retrieved and implanted with an anchor in the 3- or even 2-o'clock position.