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Shoulder glenohumeral joint dislocations and subluxations are a relatively common injury among athletic populations. Evaluating the patient both on the field initially and through early recovery helps to determine the best treatment strategies and predict the natural history of each unique injury., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The indications for bone block augmentation of the glenoid following recurrent anterior shoulder instability are expanding. Arthroscopic anatomic glenoid reconstruction (AAGR) is an evolving technique with similar clinical results to the Latarjet procedure and other open bone block procedures. Multiple types of bone grafts and fixation techniques have been described, with varying results on bony integration, resorption, articular congruity, and recurrence rates. This review focuses on biomechanics, patient workup, indications, current evidence, and the authors' preferred surgical technique for AAGR., Competing Interests: Disclosure There are no commercial or financial conflicts of interest to disclose. There are no funding sources for any of the authors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

In the evaluation of shoulder instability, recognition of relevant pathology on imaging is critical to planning a surgical treatment that minimizes the risk for recurrent instability. The purpose of this review is to (1) discuss the use of radiography, computed tomography, and MRI in evaluating shoulder instability and (2) demonstrate how various imaging modalities are useful in identifying critical pathologies in the shoulder that are relevant for treatment., Competing Interests: Disclosure The authors report no relevant disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Overhead athletes with anterior, posterior, and multidirectional shoulder instability present with a wide range of symptoms, especially considering the injury mechanism and affected supportive structures. As such, the management of shoulder instability is widely variable and relies on rehabilitation, operative management, and sport-specific considerations, such as positional and seasonal demands on the athlete. Biomechanical analysis may further aid in the recovery process or serve as a predictive tool to identify an increased risk for injury., Competing Interests: Disclosure The authors have no relevant disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Anterior glenohumeral instability is one of the most common injuries suffered from sport. Despite padding and conditioning, the shoulder joint remains particularly vulnerable to injury, especially in the setting of contact. The overall rate of anterior instability is reported to be 0.12 injuries per 1000 athlete exposures, although this is increased up to 0.40 to 0.51 in the contact athlete. Successful treatment requires consideration of restoring stability while minimizing loss of glenohumeral motion. Common treatment strategies involve addressing the pathology that results from anterior shoulder dislocation including labral detachment as well as bony defects to the humeral head and glenoid., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The rationale for the Latarjet procedure was described as the "triple blocking" effect. Satisfactory surgical outcomes have been reported after surgery. However, it has been reported that the "triple blocking" effect increases joint stability, but it does not fully restore it. Moreover, the procedure is nonanatomic and concerns remain regarding the effects. The study of scapulohumeral rhythm, which is a clinical parameter used for the functional evaluation of shoulder kinematics, can offer new perspectives on the rationale for the procedure. This study aimed to compare the shoulder kinematics of patients after the Latarjet procedure to the shoulders of a healthy population using magnetic and inertial measurement units with a motion analysis system., Methods: A retrospective study with prospective data collection was conducted on 28 patients who underwent the open Latarjet procedure for recurrent shoulder instability. At a minimum 12-month follow-up, each patient was evaluated by assessing the range of motion, the Rowe score, and the Constant-Murley score. Patients were examined using the ShowMotion 3D kinematic tracking system (NCS Lab, Modena, Italy), which uses wireless wearable noninvasive magnetic and inertial measurement units sensors to assess the three-dimensional kinematics of the shoulder. For each plane of elevation (ie, flexion and abduction), the scapulohumeral rhythm was described by three scapulothoracic rotations (ie, protraction-retraction, mediolateral rotation and posterior-anterior tilting) as a function of humeral anteflexion or humeral abduction., Results: The mean time from first shoulder dislocation to surgery was 6.6 ± 3 years (range, 1-12 years). No intraoperative complications occurred, and computed tomography (CT) performed 3 months after surgery showed graft union in all patients. After a mean follow-up time of 32.4 ± 20 months (range, 12-96), the mean Constant-Murley score and Rowe scores were 94.5 ± 4.8 (range, 84-100) and 96.7 ± 3.5 (range, 90-100), respectively. All patients showed no signs of glenohumeral arthritis on X-ray examination. Scapular posterior tilt and scapular internal rotation were significantly greater in the patient group than in the healthy population for the flexion-extension and abduction-adduction movements along the whole shoulder range of motion (all P < .05); no differences were found in upward/downward scapular rotation., Conclusion: A greater scapular posterior tilt and scapular internal rotation were observed after the Latarjet procedure. The modified position of the scapula was maintained during the entire range of motion, suggesting a shoulder-stabilizing kinematic effect in addition to the bony, sling and bumper effects., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Online patient education materials (OPEMs) exist to inform patient medical decisions, yet the average adult in the United States reads at an eighth-grade level and 50% of Medicaid patients read at or below a fifth-grade level. To appropriately meet US health literacy needs, the American Medical Association and National Institutes of Health recommend that patient education materials not exceed a sixth-grade level. The purpose of this study was to assess and compare the readability of English and Spanish online patient education materials pertaining to shoulder instability surgery., Methods: Google searches of the terms "shoulder instability surgery" and "cirugía de inestabilidad de hombro'' were conducted to include 25 eligible online patient education materials OPEMs per language. English OPEM readability was calculated using Flesch-Kincaid Grade Level, Flesch Reading Ease, Flesch Reading Ease Grade Level, Gunning-Fog Index, Coleman-Liau Index, and Simple Measure of Gobbledygook. Spanish OPEM readability was assessed using Fernandez-Huerta Index (FHI) (the Spanish equivalent of Flesch Reading Ease), FHI Grade Level, Gutiérrez de Polini's Fórmula de comprensibilidad, and INFLESZ., Results: Readability index analysis revealed that the mean Flesch Reading Ease of English online patient education materials was significantly lower than the mean FHI of Spanish online patient education materials. English materials were also found to be written at a significantly higher grade level than Spanish materials., Conclusions: Shoulder instability surgery online patient education materials in both English and Spanish are written at higher reading levels than recommended by the American Medical Association and National Institutes of Health, though Spanish online patient education materials were more readable on average., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The majority of the current literature on arthroscopic Bankart repair is retrospective, and discrepancies exist regarding clinical outcomes including recurrent instability and return to play among studies of different levels of evidence., Purpose: The purpose of this study is to perform a systematic review of the literature to compare the outcomes of prospective and retrospective studies on arthroscopic Bankart repair., Methods: A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" was used, with all results being analyzed via strict inclusion and exclusion criteria. Three independent investigators extracted data and scored each included study based on the 10 criteria of the Modified Coleman Methodology Score out of 100. A χ 2 test was performed to assess if recurrent instability, revision, return to play, and complications are independent of prospective and retrospective studies., Results: A total of 193 studies were included in the analysis, with 53 prospective studies and 140 retrospective in design. These studies encompassed a total of 13,979 patients and 14,019 surgical procedures for Bankart repair for shoulder instability. The rate of redislocation in the prospective studies was 8.0% vs. 5.9% in retrospective studies (P < .001). The rate of recurrent subluxation in the prospective studies was 3.4% vs. 2.4% in retrospective studies (P = .004). The rate of revision was higher in retrospective studies at 4.9% vs. 3.9% in prospective studies (P = .013). There was no significant difference in terms of overall rate to return to play between prospective and retrospective studies (90% and 91%, respectively; P = .548). The overall rate of non-instability complications in the prospective cohort was 0.27% vs. 0.78% in the retrospective studies (P = .002)., Conclusions: The overall rates of recurrent dislocations-subluxations are higher in prospective studies than retrospective studies. However, rates of revision were reportedly higher in retrospective studies. Complications after arthroscopic Bankart repair are rare in both prospective and retrospective studies, and there was no difference in rates of return to play., (Copyright © 2024. Published by Elsevier Inc.)

Background: Evidence-based care relies on robust research. The fragility index (FI) is used to assess the robustness of statistically significant findings in randomized controlled trials (RCTs). While the traditional FI is limited to dichotomous outcomes, a novel tool, the continuous fragility index (CFI), allows for the assessment of the robustness of continuous outcomes., Purpose: To calculate the CFI of statistically significant continuous outcomes in RCTs evaluating interventions for managing anterior shoulder instability (ASI)., Study Design: Meta-analysis; Level of evidence, 2., Methods: A search was conducted across the MEDLINE, Embase, and CENTRAL databases for RCTs assessing management strategies for ASI from inception to October 6, 2022. Studies that reported a statistically significant difference between study groups in ≥1 continuous outcome were included. The CFI was calculated and applied to all available RCTs reporting interventions for ASI. Multivariable linear regression was performed between the CFI and various study characteristics as predictors., Results: There were 27 RCTs, with a total of 1846 shoulders, included. The median sample size was 61 shoulders (IQR, 43). The median CFI across 27 RCTs was 8.2 (IQR, 17.2; 95% CI, 3.6-15.4). The median CFI was 7.9 (IQR, 21; 95% CI, 1-22) for 11 studies comparing surgical methods, 22.6 (IQR, 16; 95% CI, 8.2-30.4) for 6 studies comparing nonsurgical reduction interventions, 2.8 for 3 studies comparing immobilization methods, and 2.4 for 3 studies comparing surgical versus nonsurgical interventions. Significantly, 22 of 57 included outcomes (38.6%) from studies with completed follow-up data had a loss to follow-up exceeding their CFI. Multivariable regression demonstrated that there was a statistically significant positive correlation between a trial's sample size and the CFI of its outcomes ( r = 0.23 [95% CI, 0.13-0.33]; P < .001)., Conclusion: More than a third of continuous outcomes in ASI trials had a CFI less than the reported loss to follow-up. This carries the significant risk of reversing trial findings and should be considered when evaluating available RCT data. We recommend including the FI, CFI, and loss to follow-up in the abstracts of future RCTs., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: O.R.A. has received speaking fees from Conmed and is a tier 2 Canada Research Chair in Joint Preservation Surgery. 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: Measurement of glenoid bone loss in the shoulder instability can be assessed by CT or MRI multiplanar imaging and is crucial for pre-operative planning. The aim of this study is to determine the intra and interobserver reliability of glenoid deficiency measurement using MRI multiplanar reconstruction with 2D assessment in the sagittal plane (MPR MRI)., Methods: We reviewed MRI images of 80 patients with anterior shoulder instability with Osirix software using MPR. Six observers with basic experience measured the glenoid, erosion edge length, and bone loss twice, with at least one-week interval between measurements. We calculated reliability and repeatability using the intra-class correlation coefficient (ICC) and minimal detectable change with 95% confidence (MDC95%)., Results: Intra and Inter-observer ICC and MDC95% for glenoid width and height were excellent (ICC 0,89-0,96). For erosion edge length and area of the glenoid were acceptable/good (ICC 0,61-0,89). Bone loss and Pico Index were associated with acceptable/good ICC (0,63 -0,86)) but poor MDC95% (45 - 84 %). Intra-observer reliability improved with time, while inter-observer remained unchanged., Conclusion: The MPR MRI measurement of the anterior glenoid lesion is very good tool for linear parameters. This method is not valid for Pico index measurement, as the area of bone loss is variable. The pace of learning is individual, therefore complex calculations based on MPR MRI are not resistant to low experience as opposed to true 3D CT., (© 2024. The Author(s).)

Background: Posterior shoulder instability makes up approximately 10% of all shoulder instability cases and its diagnosis and treatment is less well understood. Recently, however, there has been increased recognition of posterior instability and posterior stabilization. The purpose of this study was to systematically review the literature to ascertain the outcomes on arthroscopic stabilization of posterior shoulder instability., Methods: Two independent reviewers conducted a systematic literature search based on PRISMA guidelines, utilizing the MEDLINE database. Studies were eligible for inclusion if they reported postoperative outcomes for posterior shoulder instability following arthroscopic stabilization., Results: A total of 48 studies met inclusion criteria for review including 2307 shoulders. Majority of patients were male (83.3%), with an average age of 26.1 years and a mean follow-up of 46.8 months. The functional outcome score primarily utilized for postoperative assessment was the American Shoulder and Elbow Surgeons with an average of 84.77. Overall, 90.9% of patients reported being satisfied with their arthroscopic stabilization. Recurrent instability occurred in 7.4% of patients. The total revision rate was 5.2%. 16.6% of patients reported residual pain postoperatively. The rate of return to play was 86.4% with 68.0% of patients returning to play at the same or higher level of play., Conclusion: Arthroscopic stabilization of posterior shoulder instability resulted in good outcomes with high patient satisfaction and low rates of recurrent instability, revisions, and residual pain., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The Latarjet procedure (LP) is performed as a primary stabilization procedure (primary LP) and a salvage procedure when an earlier shoulder stabilization procedure has failed (salvage LP). However, whether primary LP or salvage LP provides better outcomes for anterior shoulder instability remains unknown., Methods: Two independent reviewers performed the literature search based on the PRISMA guidelines. A comprehensive search of PubMed, Embase, web of science and Cochrane Library was performed from their inception date to December 4, 2023. Inclusion criteria mainly included the comparison of postoperative outcomes between primary and salvage LP, English language, and full text availability. Two reviewers independently examined the literature, collected data, and evaluated the methodological robustness of the included studies. The Methodological Index for Nonrandomized Studies was used to evaluate the quality of nonrandomized studies. Recurrent instability, complications, reoperations, return to sports, patient-reported outcomes, and range of motion were assessed. Statistical evaluations were conducted using Manager V.5.4.1 (The Cochrane Collaboration, Software Update, Oxford, UK)., Results: Twelve studies were included in the systematic review, with 940 shoulders undergoing primary LP and 631 shoulders undergoing salvage LP. Statistically significant differences in favor of primary LP were found in 2 of the 11 and 2 of 4 included studies in terms of recurrent instability and returning to the same sports (RTS) at preinjury level, respectively. In terms of the visual analog scale, subjective shoulder value and the Western Ontario Shoulder Instability Index, 2 of the 4, 1 of the 3 and 1 of the 3 included studies reported statistically significant differences in favor of primary LP. Differences were not noticed regarding complications, reoperations, the time to RTS, the Rowe score, the Athletic Shoulder Outcome Scoring System, and forward flexion., Conclusion: Current evidence suggests that compared with primary LP, salvage LP may provide inferior postoperative outcomes in terms of recurrent instability and the rate of RTS at preinjury level. Primary and salvage LP may yield comparable efficacy in terms of complications, reoperations, the rate of RTS, the time to RTS, pain, shoulder function, and range of motion., Prospero Id: CRD42023492027., (© 2024. The Author(s).)

Introduction: To translate, cross-culturally adapt, and psychometric testing the Western Ontario Shoulder Instability index (WOSI) into Persian., Methods: Seventy-two patients diagnosed with shoulder instability participated in reliability, construct validity, and responsiveness analysis. All the patients filled out the WOSI with an interval of two weeks to assess reliability. The shortened Disability of Arm, Shoulder and Hand (Quick-DASH), Shoulder Pain and Disability Index (SPADI), and the 36-Item Short-Form Survey (SF-36) were assessed to evaluate construct validity. In order to assess responsiveness patients filled out WOSI before and after the physiotherapy and global rating of change scale at last session of physiotherapy. Reliability was assessed by intra-class correlation coefficient (ICC (1,2) ), construct validity by two tailed Pearson (r), and responsiveness by longitudinal validity and receiver operating characteristics (ROC) curve analysis., Results: The ICC (1,2) was 0.90 and correlation analysis revealed high level of correlation with: Quick-DASH (r = 0.82); SPADI (r = 0.72); physical SF-36 (r = -0.52); and mental SF-36 (r = -0.48). Responsiveness analysis demonstrated the area under curve was 0.90, with minimal clinical important difference 46.87., Conclusion: We found the Persian-WOSI as a valid, reliable, and responsive questionnaire to evaluate quality of life of patients with shoulder instability.

Introduction: Arthroscopic revision anterior shoulder instability repair has been proposed, and early clinical results have been promising. However, long-term results after this procedure and the probable risk factors for failure have not been sufficiently discussed in the literature., Materials and Methods: Thirty-eight patients who were diagnosed with recurrent anteroinferior shoulder instability after failed Bankart repair, treated with ACRR between September 1998 and November 2003 and able to be contacted were included. Of these patients, 2 were excluded from the study due to the use of SureTak anchors for fixation, and 5 other patients refused to participate in the study due to lack of interest (3 patients) or lack of time (2 patients). The remaining shoulders were clinically examined at a minimum of ten years after surgery via the ASES, Constant, AAOS, Rowe, Dawson and VAS scores for pain and stability. Degenerative arthropathy was assessed with the modified Samilson-Prieto score., Results: All 31 remaining shoulders were evaluated at a mean time of 11.86 years (142.4 months) after surgery. Six patients (19.35%) reported redisolcation after the revision procedure, 4 of whom were affected by a new significant shoulder trauma. The ROWE and Constant scores improved significantly. Moderate to severe dislocation arthropathy was observed in 19.4% of patients. Five patients (16.2%) were not satisfied with the procedure., Conclusion: Long-term follow-up after ACRR shows predictable results, with a high degree of patient satisfaction, good to excellent patient-reported outcome scores and minimal radiological degenerative changes. However, with an average recurrence rate of 19.3% after 11.86 years, the redislocation rate appears high. With careful patient selection, recurrence rates can be significantly reduced., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The incremental biological changes in the synovial microenvironment of the shoulder in acute and chronic instability that may contribute to joint degeneration are poorly understood. Proteomic analysis of synovial fluid in patients with shoulder instability may improve our understanding of proteins that are shed into shoulder synovial fluid after an injury., Hypothesis: Injury-specific factors such as the direction of instability and the severity of glenoid and humeral bone loss are associated with the proteome of synovial fluid in patients with shoulder instability., Study Design: Descriptive laboratory study., Methods: Synovial fluid lavage samples were compared between patients with anterior (n = 12) and posterior (n = 8) instability and those without instability (n = 5). Synovial proteins were identified with liquid chromatography-tandem mass spectrometry. Orthogonal validation of protein targets found to be significant on tandem mass spectrometry was performed in a separate set of prospective patients with Western blotting. Data were processed and analyzed, and P values were adjusted with the Benjamini-Hochberg method for multiple comparisons., Results: A total of 25 patients were included. Tandem mass spectrometry identified 720 protein groups in synovial fluid of patients with shoulder instability. There were 4 synovial proteins that were significantly expressed in patients with anterior instability relative to posterior instability: periostin (POSTN) (adjusted P value = .03; log fold change [logFc] = 4.7), transforming growth factor beta-induced protein ig-h3 (adjusted P value = .05; logFc = 1.7), collagen type VI alpha-3 chain (adjusted P value = .04; logFc = 2.6), and coagulation factor V (adjusted P value = .04; logFc = -3.3). Among these targets, POSTN showed a moderate correlation with the Hill-Sachs lesion size ( r = 0.7). Prospective validation with Western blotting confirmed a significantly higher level of POSTN in synovial fluid of patients with anterior instability ( P = .00025; logFc = 5.1)., Conclusion: Proteomic analysis enriched our understanding of proteins that were secreted into shoulder synovial fluid of patients with shoulder instability. The identification of POSTN, a proinflammatory catabolic protein involved with tissue remodeling and repair, as a significant target in anterior shoulder instability is a novel finding. Therefore, further study is warranted to determine the role that POSTN may play in the progression of bone loss and posttraumatic osteoarthritis., Clinical Relevance: Proteomic analysis of synovial fluid in patients with shoulder instability improved our understanding of this abnormality after an injury., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study was funded through the Musculoskeletal Injury Rehabilitation Research for Operational Readiness program administered by the Geneva Foundation (award No. HU00011920011). J.W.G. has received support for education from Smith & Nephew, Kairos Surgical, Summit Surgical, and ImpactOrtho; consulting fees from FH Orthopedics; and hospitality payments from Encore Medical and Wright Medical. B.M.P. has received support for education from Wright Medical, Stryker, Arthrex, Wardlow Enterprises, and Encore Medical; and hospitality payments from Zimmer Biomet. J.V.N. has received consulting fees from Zimmer Biomet. J.A.B. has received honoraria from the Musculoskeletal Transplant Foundation. B.R.W. has received royalties and consulting fees from Conmed Linvatec. 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.

Background: Several arthroscopic glenoid bone augmentation techniques have been introduced to treat patients affected by anterior shoulder instability associated with critical bone loss. The efficacy of the different arthroscopic bony procedures has not been compared yet., Purpose: To compare the recurrence, complication, and reoperation rates of the arthroscopic Latarjet (AL) and arthroscopic free bone block (ABB) procedures for anterior shoulder instability., Study Design: Meta-analysis and systematic review; Level of evidence, 4., Methods: A systematic search was conducted in MEDLINE/PubMed, Web of Science, and Embase to identify clinical studies reporting the outcomes of the AL and ABB procedures. The following search phrases were used: "Arthroscopic" AND "Bone Block" OR "Bone Graft," and "Arthroscopic" AND "Glenoid Augmentation" OR "Glenoid Reconstruction," and "Arthroscopic" AND "Latarjet" OR "Coracoid Graft" OR "Coracoid Transfer." Exclusion criteria were <24 months of minimum follow-up, sample size <10 cases, revision after previous glenoid bone grafting, epilepsy, and multidirectional instability. Data regarding the study design, patient characteristics, surgical technique, and outcomes were extracted and analyzed. A proportional meta-analysis was conducted to compare the complication, recurrence, and reoperation rates between the 2 groups. Multiple subgroup analyses were performed to analyze the incidence of each complication and assess the weight of different fixation methods (in the whole cohort) or different graft types (in the ABB group). The modified Coleman Methodology Score was used to assess the risk of bias., Results: Of 5010 potentially relevant studies, 18 studies regarding the AL procedure (908 cases) and 15 studies regarding the ABB procedure (469 cases) were included. The 2 groups were comparable in age ( P = .07), sex ( P = .14), glenoid bone loss ( P = .14), number of preoperative dislocations ( P = .62), proportion of primary and revision procedures ( P = .95), length of follow-up ( P = .81), modified Coleman Methodology Score ( P = .21), and level of evidence ( P = .49). There was no difference in the recurrence ( P = .88), reoperation ( P = .79), and complication ( P = .08) rates. The subgroup analyses showed a higher rate of hardware-related complications for screw fixation compared with flexible fixation ( P = .01)., Conclusion: The AL and ABB procedures had similar recurrence, reoperation, and complication rates. Screw fixation of the bone graft was related to an increased risk of complications compared with flexible fixation., Registration: CRD42022368153 (PROSPERO)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.R. has received grants and nonfinancial support from LimaCorporate and nonfinancial support from Smith & Nephew outside the submitted work. 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.

Objectives: Arthroscopic Bankart for anterior shoulder instability has a good safety profile but with a relatively high recurrence index. Open surgery has been used to decrease recurrence rates but with a higher complication rate. Arthroscopic capsular shift from inferior to superior (ACSIS) was designed to decrease the recurrence rates without the added morbidity of open surgery., Methods: An observational retrospective study was conducted to analyze perioperative complications and patient reported outcomes of patients treated with ACSIS to determine the safety profile of the procedure. The patients with anterior traumatic shoulder instability treated with ACSIS between January 2015 and December 2021 were included for the study. The analysis was conducted using SPSS (Version 27). The pre vs. postoperative Western Ontario Shoulder Instability Index scores were compared using a paired sample t-test or Wilcoxon signed ranks test depending on the results of the normality test and Levene's test. The significance level was 0.05 in all analyses. Thirty-six patients were included in this study, the mean age of the population is 30.8 ​± ​11.4 years, with a male dominance of 86.1% (N ​= ​31), and a mean clinical follow-up of 2.7 ​± ​1.2 years., Results: No intraoperative complications, including bleeding or neurovascular injury, were noted. Additionally, no early postoperative complications, including infection or hospital readmission, were noted. During the follow-up, one patient (3%) had persistent apprehension. The mean Western Ontario Shoulder Instability index decreased from 66.6 ​± ​13.10% to 27.9 ​± ​22% postoperatively (P ​< ​0.001)., Conclusions: ACSIS procedure is safe and has good short-term outcomes with a low recurrence rate at 1-year minimum follow-up., Level of Evidence: 3 (Observational study)., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ivan Wong reports a relationship with DePuy Mitek Inc that includes: consulting or advisory and speaking and lecture fees. Ivan Wong reports a relationship with Smith and Nephew Inc. that includes: consulting or advisory and speaking and lecture fees. Ivan Wong reports a relationship with CONMED Corp that includes: consulting or advisory and speaking and lecture fees. Ivan Wong reports a relationship with Bioventus LLC that includes: speaking and lecture fees. Ivan Wong reports a relationship with American Journal of Sports Medicine that includes: board membership. Ivan Wong reports a relationship with Arthroscopy the Journal of Arthroscopic and Related Surgery that includes: board membership. Ivan Wong reports a relationship with AANA that includes: board membership. Ivan Wong reports a relationship with ISAKOS that includes: board membership. Ivan Wong reports a relationship with AAC that includes: board membership. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Given the variability across populations and settings, defining the MCID and the PASS for the Rowe and ASOSS scores and patients undergoing primary and revision Latarjet it is essential to have accurate benchmarks relevant to these groups when interpreting clinical results., Purpose: To determine the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds for the visual analog scale (VAS) for pain during sports, Athletic Shoulder Outcome Scoring System (ASOSS), and Rowe scores after primary and revision Latarjet procedures for treatment of shoulder instability., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: Between January 2018 and January 2020, a retrospective review of 149 patients undergoing primary Latarjet (n = 82) and revision Latarjet (n = 67) to treat shoulder instability was performed in a single institution. Patient-reported outcome measures were collected preoperatively and 1 year postoperatively. The delta was defined as the change between the pre- and postoperative scores. Distribution-based and anchored-based approaches were used to estimate the MCID and the PASS, respectively. The optimal cutoff point and the percentage of patients achieving those thresholds were also calculated., Results: The distribution-based MCIDs after primary Latarjet were 1.1, 7.5, and 9.6 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the MCID thresholds were 93.9%, 98.7%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds after primary Latarjet were ≤1, ≥90, and ≥85 for the VAS, Rowe, and ASOSS scores, respectively. The percentages of patients who achieved PASS thresholds were 82.9%, 89%, and 86.5% for the VAS, Rowe, and ASOSS scores, respectively. The distribution-based MCIDs after revision Latarjet were 0.6, 6.2, and 3.4 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved MCID thresholds were 89.3%, 100%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds were ≤3, ≥87, and ≥86 after revision Latarjet for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the PASS thresholds were 88%, 88%, and 91% for the VAS, Rowe, and ASOSS, respectively., Conclusion: This study identified useful values for the MCID and PASS thresholds in VAS, Rowe, and ASOSS scores after primary and revision Latarjet procedures for treating shoulder instability. Most patients achieved MCID and PASS benchmarks, indicating successful primary and revision Latarjet procedure outcomes. These metrics can serve as valuable parameters when analyzing parameters in future studies and have the potential to enhance patient care by optimizing treatment strategies and surgical decision making., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. 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.

To translate and culturally adapt the shoulder instability-return to sport after injury (SI-RSI) scale into Turkish (SI-RSI-Tr) and examine the psychometric properties of the Turkish version of athletes following a traumatic shoulder instability. The SI-RSI was translated into Turkish using Beaton guidelines. Sixty-nine patients with shoulder instability completed the translated SI-RSI, Western Ontario Shoulder Instability Index (WOSI), the Tampa Scale of Kinesiophobia (TSK), and the Walch-Duplay Scores. We analysed the internal consistency, agreement, reliability, and validity of the SI-RSI-Tr. The SI-RSI-Tr demonstrated excellent internal consistency (Cronbach's alpha = 0.92), test-retest reliability (ICC = 0.95), and feasibility with no ceiling or floor effect. SI-RSI-Tr correlated with WOSI total score (r = -0.824, p < 0.001), its subscales: WOSI-physical (r = -0.683, p < 0.001), WOSI-sports (r = -0.832, p < 0.001), WOSI-lifestyle (r = -0.739, p < 0.001), and WOSI-emotions (r = -0.734, p < 0.001) respectively), Walch-Duplay (r = 0.840, p < 0.001) and TSK (r = -0.828, p < 0.001) scores. The Turkish SI-RSI is a reliable, internally consistent, and valid tool for athletes with shoulder instability. Researchers and clinicians could safely use the SIRSI-Tr to evaluate the shoulder-specific psychological factors on return to sports following an episode of shoulder instability.

Arthroscopic Bankart repair (ABR) has been accepted as a standard procedure for anterior shoulder instability with a minimum or no glenoid bone loss and an on-track Hill-Sachs lesion if present. However, several controversies exist in the surgical treatment of anterior shoulder instability. This article will discuss some of these controversies in, "simple," dislocations (without bone loss) as well as, "complex," (with critical bone loss). Determining which patients will benefit from an arthroscopic procedure depends on multiple factors including age, activity level, adequate determination of bone loss, performed with feasible and reliable imaging techniques. In the absence of concomitant significant bony and soft tissue pathology, ABR alone can provide satisfactory clinical results on a long-term basis. Controversies, including whether to remove cartilage from the edge of the glenoid, knotted versus knotless anchors, and routine rotator interval closure, still exist. In cases with significant bone loss, several bone restoring procedures have been described, such as, the Latarjet procedure, iliac crest bone graft, arthroscopic anatomic glenoid reconstruction with a frozen distal tibial allograft, and fresh distal tibial allograft reconstruction. This article will address these controversies and provide guidance based on available published data., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Raffy Mirzayan, MD reports a relationship with Arthrex Inc that includes: speaking and lecture fees. Ivan Wong reports a relationship with DePuy Mitek Inc that includes: consulting or advisory and speaking and lecture fees. Ivan Wong reports a relationship with Smith and Nephew Inc that includes: consulting or advisory and speaking and lecture fees. Ivan Wong reports a relationship with CONMED Corp that includes: consulting or advisory and speaking and lecture fees. Ivan Wong reports a relationship with Stryker Orthopaedics that includes: consulting or advisory and speaking and lecture fees. Ivan Wong reports a relationship with Arthrex Inc that includes: consulting or advisory. Ivan Wong reports a relationship with Bioventus LLC that includes: speaking and lecture fees., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: The open Trillat Procedure described to treat recurrent shoulder instability, has a renewed interest with the advent of arthroscopy. The suprascapular nerve (SSN) is theoretically at risk during the drilling of the scapula near the spinoglenoid notch. The purpose of this study was to assess the relationship between the screw securing the coracoid transfer and the SSN during open Trillat Procedure and define a safe zone for the SSN., Methods: In this anatomical study, an open Trillat Procedure was performed on ten shoulders specimens. The coracoid was fixed by a screw after partial osteotomy and antero-posterior drilling of the scapular neck. The SSN was dissected with identification of the screw. We measured the distances SSN-screw (distance 1) and SSN-glenoid rim (distance 2). In axial plane, we measured the angles between the glenoid plane and the screw (α angle) and between the glenoid plane and the SSN (β angle)., Results: The mean distance SSN-screw was 8.8 mm +/-5.4 (0-15). Mean α angle was 11°+/-2.4 (8-15). Mean β angle was 22°+/-6.7 (12-30). No macroscopic lesion of the SSN was recorded but in 20% (2 cases), the screw was in contact with the nerve. In both cases, the β angle was measured at 12°., Conclusion: During the open Trillat Procedure, the SSN can be injured due to its anatomical location. Placement of the screw should be within 10° of the glenoid plane to minimize the risk of SSN injury and could require the use of a specific guide or arthroscopic-assisted surgery., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: The Latarjet procedure is commonly performed in the treatment of recurrent shoulder instability and is also indicated as a salvage procedure for recurrence after failed arthroscopic Bankart repair. Although this procedure has shown success, there has been an increased awareness of complications in recent studies, especially graft osteolysis. Most relevant research has focused on the pathophysiology, incidence, or location of graft osteolysis or the risk factors for graft osteolysis; however, the data are limited to primary Latarjet procedures. This study aimed to investigate the effect of previous arthroscopic Bankart repair surgery on coracoid bone graft osteolysis in the Latarjet procedure., Methods: This retrospective case-control study analyzed data from patients who underwent primary Latarjet procedures or revision Latarjet procedures following failed arthroscopic Bankart repair. Clinical outcome measures included range of motion, the Subjective Shoulder Value, and the Rowe score. Volumetric analysis of each transferred coracoid graft was performed using early postoperative and late postoperative computed tomography scan data, and the amount of graft osteolysis was then calculated as the percentage of volume reduction of each graft., Results: A total of 32 patients who met the inclusion criteria were included in this study, with 24 patients in the primary Latarjet group (group I) and 8 patients in the revision Latarjet group (group II). The mean age of the patients was 32.5 ± 7.7 years, and the mean follow-up duration was 52.1 ± 8.9 months. Both study groups showed significant improvement in the Subjective Shoulder Value compared with baseline (P < .05). Comparison of postoperative clinical outcome measures showed no significant difference in any outcome parameter between the 2 study groups (P > .05). No recurrence was observed during the follow-up period. A positive apprehension sign was present in 6 patients (25%) in group I and 4 patients (50%) in group II (P > .05). Analysis of radiologic data revealed that all patients underwent some degree of graft osteolysis, with varying osteolysis ratios between 12% and 98%. The mean osteolysis ratio of the coracoid graft was 67.3% ± 22.6% in group I and 69.4% ± 25.6% in group II, with no significant difference between the 2 groups (P > .05)., Conclusion: The findings of this study suggest that a considerable amount of coracoid graft osteolysis is observed after both primary Latarjet procedures and revision Latarjet procedures following failed arthroscopic Bankart repair. Previous arthroscopic Bankart repair did not seem to have a significant influence on the amount of graft osteolysis, and both primary and revision Latarjet procedures showed satisfactory clinical outcomes., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Hypothesis: This study aimed to investigate the effects of cross education (CE) on rotator cuff (RC) muscle strength recovery and shoulder function in patients who underwent arthroscopic anterior shoulder stabilization surgery., Methods: Twenty-eight patients who underwent shoulder stabilization surgery were included in the study (age, 25 ± 6 years; body mass index, 24.8 ± 3.6 kg/m 2 ). The patients were randomly divided into either the CE group (n = 14) or the control group (n = 14). All patients received a standardized rehabilitation program until the end of the 12th postoperative week. The CE group also received isokinetic training of the nonoperative shoulder focusing on the RC muscles (twice a week, 3 sets of 10 repetitions). RC muscle strength was measured preoperatively and at 3 and 6 months postoperatively using an isokinetic dynamometer at 60°/s and 180°/s angular velocities. Shoulder function was assessed with the Closed Kinetic Chain Upper Extremity Stability Test and Y-Balance Test-Upper Quarter. Analyses of covariance were used for the statistical analyses., Results: At 6 months postoperatively, at 60°/s angular velocity, there was higher internal rotator strength in the CE group (P = .02) and similar external rotator strength (P = .62) between the groups. At 180°/s angular velocity, both internal rotator strength (P = .04) and external rotator strength (P = .02) were higher in the CE group. The Closed Kinetic Chain Upper Extremity Stability Test (P = .47), Y-Balance Test-Upper Quarter (P = .95), and Western Ontario Shoulder Instability Index (P = .12) scores were similar between the groups at 6 months after surgery., Conclusions: CE in the early period of postoperative rehabilitation following stabilization surgery improves RC strength recovery. However, it has no effect on functional outcomes. Integrating a CE program into the postoperative rehabilitation protocol may help to improve dynamic shoulder stability but not functional capacity., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The glenoid track concept is used to determine preoperatively whether a Hill-Sachs defect is engaging or not. Currently, the glenoid track concept relies on measurements of bony structures as well as on the confines and elasticity of the rotator cuff as a reference point, which varies extensively among individuals and therefore limits the reliability and accuracy of this concept., Purpose: To evaluate the reliability of the global track concept, which determines the angular distance of the Hill-Sachs defect from the center of the articular surface of the humeral head as a new reference point with the help of an automated image analysis software and 3-dimensional analysis of the humeral head., Study Design: Controlled laboratory study., Methods: Computed tomography scans of 100 patients treated for anterior shoulder instability with different sizes of Hill-Sachs defects were evaluated manually by 2 orthopaedic surgeons independently using the software OsiriX as well as automatically by using a dedicated prototype software (ImFusion). Obtained manual and automated measurements included the Hill-Sachs length, Hill-Sachs width, and Hill-Sachs depth of the defect; the Hill-Sachs interval (HSI); and the glenoid width for the glenoid track concept, as well as the angular distance of the Hill-Sachs defect from the center of the articular surface of the humeral head (global track concept). The reliability of the different measurement techniques was compared by calculating intraclass correlation coefficients (ICCs)., Results: There was a significant difference for all obtained parameters comparing manual and automatic measurements. For manually obtained parameters, measurements referring to bony boundaries (glenoid width, Hill-Sachs length, and Hill-Sachs width) showed good to excellent agreement (ICC, 0.86, 0.82, and 0.62, respectively), while measurements referring to soft tissue boundaries (HSI and glenoid track; ICC, 0.56 and 0.53, respectively) or not directly identifiable reference points (center of articular surface and global track) only showed fair reliability (ICC middle excursion, 0.42). When the same parameters were measured with the help of an automated software, good reliability for the glenoid track concept and excellent reliability for the global track concept in the middle excursion were achieved., Conclusion: The present study showed that the more complex global track measurements of humeral defects are more reliable than the current standard HSI and glenoid track measurements. However, this is only true when automated software is used to perform the measurements., Clinical Relevance: Future studies using the new proposed method in combination with an automated software need to be conducted to determine critical threshold values for defects prone to engagement., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. 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.

Background: Wrestling is a physically demanding sport with young athletes prone to traumatic shoulder instability and a paucity of data evaluating the results of shoulder instability surgery (SIS)., Purpose: To assess reoperation rates, patient-reported outcomes, and return to wrestling (RTW) after SIS in a cohort of competitive wrestlers., Study Design: Case series; Level of evidence, 3., Methods: All competitive wrestlers with a history of shoulder instability and subsequent surgery at a single institution between 1996 and 2020 were identified. All directions of shoulder instability (anterior shoulder instability [ASI], posterior shoulder instability [PSI], and traumatic multidirectional shoulder instability [TMDI]) were analyzed. Exclusions included revision SIS and <2 years of follow-up. Athletes were contacted for determination of complications, RTW, and Western Ontario Shoulder Instability Index scores., Results: Ultimately, 104 wrestlers were included with a mean age at initial instability of 16.9 years (range, 12.0-22.7 years), mean age at surgery of 18.9 years (range, 14.0-29.0 years), and a mean follow-up of 5.2 years (range, 2.0-22.0 years). A total of 58 (55.8%) wrestlers were evaluated after a single shoulder instability event, while 46 (44.2%) sustained multiple events before evaluation. ASI was the most common direction (n = 79; 76.0%), followed by PSI (n = 14; 13.5%) and TMDI (n = 11; 10.6%). Surgical treatment was most commonly an arthroscopic soft tissue stabilization (n = 88; 84.6%), with open soft tissue repair (n = 13; 12.5%) and open bony augmentation (n = 3; 2.9%) performed less frequently. RTW occurred in 57.3% of wrestlers at a mean of 9.8 months. Recurrent instability was the most common complication, occurring in 18 (17.3%) wrestlers. Revision SIS was performed in 15 (14.4%) wrestlers. Across the entire cohort, survivorship rates free from recurrent instability and revision surgery were 90.4% and 92.5% at 2 years, 71.9% and 70.7% at 5 years, and 71.9% and 66.5% at 10 years, respectively. Preoperative recurrent instability was an independent risk factor for postoperative recurrent instability (hazard ratio, 3.8; 95% CI, 1.33-11.03; P = .012)., Conclusion: Competitive wrestlers with multiple dislocations before initial clinical evaluation were 3.8 times more likely to experience postoperative recurrent instability. Patients should be counseled that despite SIS, only 57.3% returned to wrestling after surgery., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.M.M. has received support for education from Exactech and hospitality payments from Stryker. K.R.O. has received consulting fees from Arthrex, Endo Pharmaceuticals, and Smith & Nephew; research support from Arthrex; support for education from Gemini Medical, Pinnacle Inc, Medwest Associates, and Foundation Medical; and hospitality payments from Stryker, Wright Medical Technology, Medical Device Business Services, and Zimmer Biomet. J.D.B. has received royalties and consulting fees from Stryker and consulting fees, personal, and consulting fees from Arthrex. A.J.K. has received research support from Aesculap/B.Braun; consulting fees, IP royalties, speaking fees, and research support from Arthrex, Arthritis Foundation, Ceterix, and Histogenics; personal fees from Gemini Mountain Medical and Smith & Nephew; consulting fees from JRF Ortho and Vericel; consulting fees and royalties from Responsive Arthroscopy; honoraria from Joint Restoration Foundation and Responsive Arthroscopy; and grants from DJO and Exactech. He also serves on the medical board of trustees for the Musculoskeletal Transplant Foundation. C.L.C. has received consulting fees from Arthrex; consulting fees from Zimmer Biomet and Gemini Medical; and research support from MLB. 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: Adequate position of the bone block during arthroscopic Latarjet procedure is critical for an optimal functional outcome. However, this procedure is complex with a long learning curve. Our aim was to compare the bone block position between a dedicated glenoid posterior instrumentation and suture button fixation versus an anterior screw fixation, on a postoperative computed tomography (CT) scan., Method: Seventy-nine consecutive patients operated on for an anterior shoulder instability were included in this retrospective study. The same surgeon performed arthroscopically the Latarjet procedure either with an anterior drilling and screw fixation (Group A), or with a specific posterior glenoid guide pin, a posterior drilling, and a suture cortical button fixation (Group B). Evaluations were made by two independent observers. The position was evaluated by CT scan in the axial and sagittal planes. Learning curves with operative time, complications and clinical outcomes were assessed at a minimum of 2 years of follow-up., Results: Thirty-five patients were included in Group A and 44 in Group B. In Group A, 27 bone blocks were flush (87.1%) and 38 in Group B (92.7%) (p < 0.01). In Group A, 72% of the bone block height was below the equator and 76%, in Group B (ns). The mean operating time was 123 ± 32.5 min in Group A and 95 ± 34.1 min in Group B (p < 0.0001). At the final follow-up, the mean aggregate Rowe score was respectively 94.6 ± 10.4 and 93.1 ± 9.8 points in Groups A and B. The mean aggregate Walch-Duplay score was respectively 94.2 ± 11.6 and 93.4 ± 10.6 points in Groups A and B. There were 11 complications (31.4%) in Group A and five complications (11.3%) in Group B (ns)., Conclusion: The arthroscopic Latarjet procedure with a posterior drilling guided system and suture-button fixation allows more precise positioning in the axial plane than with anterior drilling and screw fixation. This posterior-guided procedure could reduce intraoperative and short-term complications., Level of Evidence: Level IV., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background: A limited number of studies have reported the long-term effectiveness of and associated factors for recurrence of anterior shoulder instability after arthroscopic Bankart repair (ABR)., Purpose: To report the long-term clinical outcomes after ABR in a recreational sports population and identify the associated factors that influence the final instability status., Study Design: Case series; Level of evidence, 4., Methods: A retrospective study was performed in patients treated with ABR between 2007 and 2013 by a single surgeon. Patient data, magnetic resonance imaging measurements of bone loss and glenoid track, and intra- and perioperative factors were analyzed. After a minimum follow-up of 10 years, patient-reported outcomes including the Western Ontario Shoulder Instability Index score, the Rowe score, the visual analog scale for pain and function, the American Shoulder and Elbow Surgeons score, and sports activity were assessed. The current instability status was classified into 3 groups: stable, apprehensive, and redislocated. These groups were statistically compared with respect to outcomes and associated factors., Results: A total of 100 patients with a mean age of 22.4 ± 5.5 years and a mean follow-up of 12.7 ± 2.1 years were included. At the final follow-up, 38 patients (38%) showed recurrent symptoms: 19 patients (19%) with subjective apprehension and 19 patients (19%) with redislocation, including 10 patients (10%) with revision surgery. At the final follow-up, the redislocated group showed the lowest patient-reported outcomes and return to sports (both P < .001). The apprehensive group also showed a lower Western Ontario Shoulder Instability Index score ( P = .011), Rowe score ( P = .003), American Shoulder and Elbow Surgeons score ( P = .027), and return to sports ( P = .005) than the stable group. Participation in contact sports ( P = .026), glenoid bone loss ( P = .005), size of Hill-Sachs lesion ( P = .009), and off-track lesions ( P = .016) were all associated with recurrent symptoms, whereas age <20 years ( P = .012), participation in contact sports ( P = .003), and off-track lesions ( P = .042) were associated with redislocation., Conclusion: After long-term follow-up in a recreational sports population, ABR demonstrated a 19% rate of subjective apprehension and 19% rate of redislocation, with a gradual decline in clinical outcomes and sports activity over time. Therefore, candidates for ABR should be selected based on consideration of risk factors such as off-track lesions, age <20 years, and participation in contact sports., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. 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.

Background and Objectives : The Western Ontario Shoulder Instability Index (WOSI) is a disease-specific self-administered questionnaire which is designed to measure health-related quality of life for patients with shoulder instability. The objective of this study was to translate and adapt the WOSI questionnaire for the Lithuanian-speaking population and investigate the psychometric properties of the Lithuanian version of the WOSI questionnaire (WOSI-LT): validity, reliability, and responsiveness. Materials and Methods : The WOSI scale was translated into Lithuanian using D. E. Beaton's systematic and standardized guidelines for cross-cultural adaptation of patient-administered scales. Subsequently, the psychometric properties of the Lithuanian version of the scale (WOSI-LT) were investigated. The study involved 40 patients who reported shoulder instability and underwent surgical treatment. All patients completed the WOSI-LT, QuickDASH, and SF-12 scales. A subset of 10 patients was selected for the reproducibility and responsiveness evaluation. Based on the obtained data, the reliability, validity, and responsiveness of WOSI-LT were examined using statistical analysis methods. Results : The Lithuanian adaptation of the WOSI questionnaire exhibited a high degree of internal consistency, evidenced by a Cronbach's alpha of 0.93. Its reproducibility was commendable with an intraclass correlation coefficient (ICC) value of 0.90. When assessing correlations, WOSI-LT demonstrated a stronger relationship with QuickDASH (r = 0.64) than with SF-12 (physical component score (PCS) 0.61, mental component score (MCS) 0.33). Six months post-operation, the responsiveness of the WOSI-LT was particularly notable, with a standardized response mean (SRM) of 0.91, the highest among the three scales. Furthermore, no floor or ceiling effects were identified in the scores of the Lithuanian WOSI. Conclusions : WOSI-LT is a valid, reliable, and responsive questionnaire that correlates excellently with the original English version of the scale. This scale can be used in Lithuanian medical institutions to assess the severity of patients' shoulder instability and evaluate their progress during treatment.

Background: There is scarce literature on clinically significant values after arthroscopic Bankart repair (ABR)., Purpose: To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) thresholds at 1 year for the Rowe and Athletic Shoulder Outcome Scoring System (ASOSS) scores after ABR and to determine the effect of patient characteristics on these metrics after ABR., Study Design: Case series; Level of evidence, 4., Methods: A retrospective review of patients undergoing ABR from a single institution between January 2017 and January 2020 was performed. Patients with at least 1 episode of instability and a minimum follow-up of 12 months were included. The exclusion criteria were as follows: bony defects of >20% on the anteroinferior portion of the glenoid based on a preoperative computed tomography scan; engaging Hill-Sachs lesions at 90° of abduction and 90° of external rotation based on an arthroscopic examination; previous surgery on the same shoulder; multidirectional instability or concomitant repair of full-thickness rotator cuff tears; superior labral anterior to posterior lesions; posterior labral tears; or humeral avulsion of the glenohumeral ligament lesions. Patient-reported outcome measures were collected both preoperatively and 1-year postoperatively. Delta was defined as the change between preoperative and 1-year postoperative scores. Distribution-based (one-half the standard deviation of the difference between pre- and postoperative outcome scores) and anchored-based approaches (response to a satisfaction question at 1 year) were used to estimate the MCID and the PASS, respectively. The optimal cutoff point, where sensitivity and specificity were maximized, and the percentage of patients achieving those thresholds were also calculated., Results: Overall, 190 patients were included. The distribution-based MCID for the Rowe and ASOSS scores were calculated to be 8.2 and 8.7, respectively. The rate of patients who achieved MCID thresholds was 96% for the Rowe and 96% for ASOSS scores. The PASS threshold for the Rowe and ASOSS scores were ≥80 and ≥90, respectively. The rate of patients who achieved PASS scores after ABR were 86% and 83%, respectively. The MCID and PASS values showed great variability based on sex (men: 8.5 and ≥85 for Rowe / 8.9 and ≥90 for ASOSS, respectively, vs women: 6.7 and ≥73 for Rowe / 8.1 and ≥75 for ASOSS), age (≥21: 8.4 and ≥80 / 9.2 and ≥90 vs <21: 7.8 and ≥75 / 7.7 and ≥85), sports participation (sports: 8.8 and ≥85 / 9.5 and ≥90 vs no sports: 8.1 and ≥75 / 8.6 and ≥80), and type of athlete (competitive: 8.4 and ≥85 / 8.9 and ≥87 vs recreational: 7.5 and ≥73 / 8.1 and ≥68)., Conclusion: This study identified the MCID and PASS thresholds for the Rowe and ASOSS scores at 1 year after ABR. However, these values showed great variability when accounting for different patient characteristics such as sex, age, sports participation, and type of athlete, highlighting the importance of considering individual patient-specific characteristics for optimal treatment decision-making and ensuring treatment success tailored to each patient's unique needs and expectations., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. 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.

Background: Distal tibial allograft (DTA) reconstruction for glenoid bone loss is nonanatomic, as it does not match the glenoid radius of curvature (ROC) in the anterior-posterior (AP) plane. The dorsal articular portion of the distal radius has not been previously described as an allograft reconstruction option for glenoid bone loss., Purpose: To evaluate distal radius fresh-frozen allograft (DRA) as a potential match for glenoid reconstruction., Study Design: Controlled laboratory study., Methods: Eighteen fresh-frozen human cadaveric specimens-including 6 shoulder, 6 wrist, and 6 tibia specimens-were used. The ROC and the graft length were measured in the superior-inferior (SI) plane. A 30% defect was created in all glenoid specimens, and both DTAs and DRAs were harvested to assess graft fit after fixation. Computed tomography analysis was used to assess bony ROC and bone mineral density (BMD)., Results: The cadaveric specimens had a mean age of 77 years. The mean SI glenoid length was 39.7 mm compared with 36.8 mm for the DRA and 30 mm for the DTA. The ROC in the SI plane was 29 ± 5.3 mm for the glenoid, 37.8 ± 4.9 mm for the DRA, and 24 ± 3.7 mm for the DTA. In the AP plane, the ROC was 39.6 ± 6.6 mm for the glenoid, 30.4 ± 18.6 mm for the DRA, and 126.3 ± 9.5 mm for the DTA. On computed tomography analysis, the ROC in the SI plane was 30.4 ± 1.5 mm for the glenoid, 30.3 ± 5.6 mm for the DRA, and 24.5 ± 9.4 mm for the DTA. In the AP plane, the ROC was 30.8 ± 2 mm for the glenoid, 19.1 ± 2.3 mm for the DRA, and 46.7 ± 21.7 mm for the DTA. The BMD was 226.3 ± 79 Hounsfield units (HU) for the glenoid, 228.5 ± 94.7 HU for the DRA, 235 ± 96.2 HU for the coracoid process, and 235.1 ± 84.6 HU for the DTA., Conclusion: Compared with the DTA, the DRA had a greater mean graft length in the SI plane, providing utilization in cases of larger bony defects; the DRA has a more acute ROC in the AP plane (closer to that of the glenoid), providing a greater potential buttress to anterior humeral translation. Compared with currently utilized grafts, the DRA BMD was not significantly diminished. This study presents the DRA as a novel allograft reconstruction option in the setting of anterior glenoid bone loss; further biomechanical and clinical investigation is indicated., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Stryker Inc supplied financial support for performing the study without having any input on data analysis or manuscript preparation. A.Z.K. has received support for education from Arthrex, Medical Device Business Services, and Elite Orthopedics and hospitality payments from Stryker and Exactech. J.A.A. has received research support from Arthrex, Lima, Orthofix, Zimmer, and Department of Defense; consulting fees from Bioventus, DJ Orthopedics, Enovis, Globus Medical, Stryker, and Zimmer; royalties from DJ Orthopedics, Enovis, Globus Medical, OsteoCentric Technologies, Smith & Nephew, Stryker, and Zimmer; and publishing royalties from SLACK and Wolters Kluwer Health and Lippincott Williams & Wilkins. He is a board or committee member for Pacira, Orthobullets, and Shoulder 360 and holds stock or stock options in Aevumed, OBERD, Orthobullets, Atreon, OTS Medical, Restore 3D, and Shoulder JAM. 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.

Background: The role of arthroscopic Latarjet as a revision surgery after failed arthroscopic Bankart repair has yet to be established., Purpose: To compare clinical outcomes, recurrences, and complication rates of arthroscopic Latarjet as a revision procedure after failed arthroscopic Bankart repair versus arthroscopic Latarjet as a primary procedure., Design: Cohort study; Level of evidence, 3., Methods: This is a retrospective study of prospectively collected data of patients who were diagnosed with anterior shoulder instability and underwent arthroscopic Latarjet stabilization between 2009 and 2018. Patients were separated into 2 groups depending on whether Latarjet was performed after a previous instability surgery (revision) or as a primary surgery (primary). Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome (CMSO) score, and Single Assessment Numeric Evaluation (SANE) were assessed pre- and postoperatively with a minimum 24 months of follow-up. In addition, pre- and postoperative levels of sports activity, dislocations, subluxations, and complications were assessed., Results: A total of 97 patients (n = 62 revision; n = 35 primary), with a mean age of 31.0 ± 8.8 and 29.4 ± 7.6 years old in the revision and primary Latajet group, respectively, met the inclusion criteria. The mean follow-up in the revision group was 32 months (24-53) and 35.5 months (27.7-42.2) in the primary Latarjet group. No significant differences between groups were observed in Rowe score (revision = 91.4, primary = 94.1; P = .223), CMSO score (revision = 90.7, primary = 94; P = .105), and SANE (revision = 85.8, primary = 87.3; P = .683) postoperatively. However, the postoperative difference in the WOSI score between the revision and primary Latarjet groups was nearly significant (510 ± 334 vs 403 ± 343, respectively; P = .05). Four (6.4%) postoperative dislocations were reported in the revision and 1 (2.8%) in the primary Latarjet group ( P = .14). Patients in the revision group had a lower return to the previous level of sports participation ( P = .008) and decreased external rotation with the arm by the side compared with the primary Latarjet group ( P = .000)., Conclusion: Arthroscopic Latarjet as a revision surgery is a reasonable surgical option in failed Bankart repair cases. The decision to perform arthroscopic Latarjet stabilization as a revision surgery should not be influenced by the potential risk of future complications as it provides comparable clinical outcomes to the primary Latarjet procedure with a low postoperative recurrence rate. However, a decreased level of postoperative sports participation and external rotation with the arm by the side can be expected., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.C. has received consulting fees from DePuy Synthes, Smith & Nephew, and Stryker. 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: The Latarjet procedure is traditionally used to treat chronic anterior shoulder instability associated with glenoid bone loss. However, few series have analyzed outcomes in a female-only population. The objective of this study was to evaluate the clinical and radiological outcomes of a Latarjet bone block in this specific population., Methods: This single-center retrospective study included 15 women (mean age 35 ± 11.3; 19-60) reviewed with a minimum follow-up of 2 years. The procedure was performed using the open bone block screw technique (n = 7) or by arthroscopy with cortical button (n = 8). Clinical evaluation was based on active range of motion measurements, Rowe and Walch-Duplay scores, and subjective shoulder value (SSV). Radiographic analysis explored bone block healing at the last follow-up., Results: At a mean follow-up of 48 months (32-86), no recurrence was reported. The mean Rowe score was 91 points (70-100), Walch-Duplay 90 points (60-100), and SSV 87% (70-100). The active mobilities reached 169° (± 9°) in elevation, 57° (± 15°) in external rotation at side, and 89° (± 6°) in abduction. The return-to-sport rate was 91%. Five patients experienced persistent anterior pain, with screws requiring hardware removal in 2 (p = 0.02). Radiological assessment detected one case of nonunion (7%)., Conclusion: Women treated with the Latarjet procedure experienced satisfactory midterm clinical outcomes. The arthroscopic technique using cortical button fixation seems to avoid residual anterior pain requiring hardware removal., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

This classic discusses the original publication by Burkhart and DeBeer "Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repair" published in 2000 in Arthroscopy. At that time, the authors sought to understand the reasons behind the failure of arthroscopic soft tissue repair. Based on their findings, the authors introduced the concept of the inverted pear glenoid and engaging Hill-Sachs lesion which is now part of the orthopedic lexicon. The importance of bony pathologic changes in anterior glenohumeral instability has become so apparent, that it now forms the basis of clinical understanding and underpins treatment algorithms. Since this publication over 20 years ago, the idea of glenohumeral bone loss has been extensively explored and refined. There is no doubt of the importance of structural bone loss yet there is still uncertainty as to the best management of those with subcritical bone loss. The purpose of revisiting this classic article is to look at where we are in understanding recurrent instability and bony deficiency while appreciating how far we have come. This review begins with a detailed summary of the classic article along with a historic perspective. Next, we look at the current evidence as it pertains to the classic article and how modern technology and innovation has advanced our ability to assess and quantify glenohumeral bone loss. We finish with expert commentary on the topic from two current surgeons with a research interest in shoulder instability to offer an insight into how modern surgeons view and address this issue. One of the original authors also reflects on the topic. The findings of this classic study changed the way we think about shoulder instability and opened the doors to an exciting body of research that is still growing today. Future research offers an opportunity for high quality evidence to guide management in the group of patients with subcritical bone loss and we eagerly await the results., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Traumatic anterior shoulder instability affects athletes at a higher rate compared with the general population. In recent years, indications for arthroscopic remplissage, an adjunct procedure classically used to reduce the recurrence of anterior shoulder instability in patients with off-track Hill-Sachs lesions, have expanded., Purpose: To investigate return-to-sport (RTS) rates, functional outcomes, and adverse events in athletes who underwent arthroscopic Bankart repair with remplissage compared with surgical alternatives such as Bankart repair alone or the Latarjet procedure., Study Design: Systematic review and meta-analysis; Level of evidence, 4., Methods: A literature review of the Embase, PubMed (MEDLINE), and Web of Science databases was conducted for articles published before May 22, 2022. For the systematic review, 16 of 457 studies that reported RTS rates at any time point after remplissage were deemed eligible for inclusion in quantitative analysis and 17 of 457 studies in qualitative analysis. For the meta-analysis, 8 of 457 studies reported RTS rates after remplissage compared with surgical alternatives including Bankart repair alone or the Latarjet procedure and were deemed eligible for inclusion., Results: In total, 538 athletes underwent remplissage and were included in the study. RTS at any level was achieved by 86% (395/457) of patients, and the odds of RTS at any level were significantly higher after remplissage compared with surgical alternatives (odds ratio [OR], 2.71 [95% CI, 1.14-6.43]; P = .02). The odds of RTS at a previous or higher level were also significantly higher after remplissage compared with surgical alternatives (OR, 2.07 [95% CI, 1.29-3.31]; P = .002). The mean Rowe score increased significantly from 43.9 ± 7.77 preoperatively (n = 173) to 92.2 ± 4.02 after remplissage (n = 397) ( P < .001), but there was no significant difference in Rowe scores between remplissage and surgical alternatives ( P = .54). After remplissage, the recurrence rate was 5.0% for athletes (n = 220) and 7.3% for all patients (n = 634), with a mean time to recurrence of 24.0 ± 12.5 months. Reoperations occurred in 3.6% of athletes (n = 110) and 4.1% of all patients (n = 445). Recurrence and reoperations were significantly less likely after remplissage compared with surgical alternatives (OR, 0.18 [95% CI, 0.08-0.39]; P < .001 and OR, 0.17 [95% CI, 0.06-0.50]; P = .001, respectively)., Conclusion: Arthroscopic Bankart repair with remplissage augmentation significantly improved RTS rates among athletes, both at any level and at previous levels of play. Additionally, remplissage appeared to significantly decrease recurrence and reoperation rates compared with surgical alternatives such as Bankart repair alone or the Latarjet procedure., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.C.D. has received hospitality payments from Stryker. N.P. has received consulting fees from Mitek. 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.

Background: The primary aim of this study was to investigate bone loss in the glenoid with magnetic resonance imaging in posterior shoulder instability with only a labral tear., Methods: A total of 76 patients operated on because of posterior and anteroposterior shoulder instability only with a labral tear between 2006 and 2019 (n = 40 and n = 36, respectively) were included in this study. The instability type, a presence of an additional superior labrum anteroposterior (SLAP) lesion, the number of dislocations, and the magnetic resonance imaging-based measurements (the glenoid diameter and the bone defect size in the glenoid, the Hill-Sachs lesion [HSL] and the reverse HSL [rHSL] length, the angle and the arc length of HSL and rHSL, and the humerus head diameter and its area) were analyzed., Results: The size of the anterior glenoid defect, the rHSL measurements (length, angle, and arc length), and the ratio of the anterior glenoid defect size to the glenoid diameter were significantly higher for anteroposterior instability (P < .01) cases. There was no significant difference (P = .49, .64, and .82, respectively) for the presence of an additional SLAP pathology, the glenoid diameter, the posterior glenoid defect, and the ratio of the posterior glenoid defect size to the glenoid diameter in posterior and anteroposterior instability groups. The increased number of dislocations was associated with increased rHSL length and total arc length (P = .04 and .03, respectively). An additional SLAP lesion in posterior shoulder instabilities was not associated with the bone defect size (P = .29)., Conclusion: Although the posterior shoulder instability with only a labral tear is likely to cause a bone defect, we have shown that the instability is not expected to be caused by the bone defect. Therefore, this study points out that only soft tissue repair without considering the bone defect could be promising in this patient group., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: For severe anterior glenoid bone loss due to recurrent shoulder instability, the Latarjet procedure offers a dynamic sling effect in addition to bone augmentation. Yet, it heavily alters the surrounding anatomy, while fixation and graft union issues are also common., Purpose/hypothesis: The purpose of this study was to compare a novel printed 3-dimensional (3D) partial glenoid arthroplasty (PGA) implant with the classic Latarjet procedure. It was hypothesized that by replicating the original glenoid geometry and preserving soft tissue anatomy, PGA may better reproduce normal joint kinematics. In addition, the locking screw construct may offer stronger fixation., Study Design: Controlled laboratory study., Methods: A total of 14 matched cadaveric shoulders were tested. The PGA implant was 3D printed in titanium based on preoperative computed tomography. The intact, 25% anterior glenoid bone loss, and postoperative states were tested in the scapular and coronal planes. The following parameters were measured: articular surface area and stepoff, rotational range of motion and the humeral head apex position during rotation, and load and linear stiffness at 25% anterior translation and at 2-mm construct displacement., Results: The baseline dimensions of the glenoid articular surface were comparable between the groups. The articular surface area after PGA was significantly larger ( P = .006) with less articular stepoff ( P = .030). PGA better approximated the intact state's external ( P = .006) and total ( P = .019) rotational range of motion in the scapular plane. The course of the humeral head apex after PGA better followed that of the intact state ( P < .001). Resistance against anterior translation after PGA was not significantly different compared with after the Latarjet procedure. Greater linear stiffness ( P = .031) and loading ( P = .002) at 2-mm construct displacement were demonstrated in the PGA group., Conclusion: In addressing anterior glenoid bone loss, PGA better approximated intact glenohumeral joint kinematics compared with the Latarjet procedure with less articular stepoff in a cadaveric model. PGA was comparable in resisting anterior translation while being significantly stronger against loading at 2-mm construct displacement. Further clinical studies are warranted to validate this novel procedure., Clinical Relevance: A 3D-printed PGA implant may offer an alternative treatment option for severe glenoid bone loss due to shoulder instability, overcoming the previous drawbacks of the Latarjet procedure, including altered kinematics, fixation failure, and hardware issues.

Background: The influence of bony morphology on the development of posterior shoulder instability is not well known., Purpose: To determine if acromial morphology, as measured on magnetic resonance imaging (MRI), is associated with posterior or anterior shoulder instability., Design: Cross-sectional study; Level of evidence, 3., Methods: MRI measurements of posterior acromial coverage (PAC), posterior acromial height (PAH), posterior acromial tilt (PAT), and anterior acromial coverage (AAC) were completed for 3 separate matched groups who underwent surgical intervention: posterior instability, anterior instability, and a comparison group of patients who underwent arthroscopic surgery for snapping scapula. Inclusion criteria were patients with recurrent instability <40 years of age without multidirectional instability, glenoid bone loss >13.5%, or glenoid retroversion >10%., Results: Overall, 37 patients were included in each group. PAC was significantly less in the posterior instability group than in the anterior instability and comparison groups (68.3° vs 88.7° vs 81.7°; P < .001). PAH was significantly greater in the posterior group than in the anterior instability group (11.0 mm vs -0.1 mm; P < .001) and comparison group (0.7 mm; P < .001). There was no difference between the posterior and anterior groups in terms of PAT or AAC ( P = .45 and P = .05, respectively). PAT was significantly smaller in the posterior instability group than the comparison group (55.2° vs 62.2°; P = .026). The anterior and comparison groups were not significantly different in PAH or PAT ( P = .874 and P = .067, respectively) but were significantly different in AAC ( P = .026)., Conclusion: A higher and flatter posterior acromion, as measured on preoperative MRI, appears to be associated with patients who require arthroscopic capsulolabral repair due to posterior shoulder instability. This information may help clinicians to both diagnose and predict the need for operative intervention for patients with posterior labral tears., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.W.A. has received research support from Arthrex and DJO and hospitality payments from Mid-Atlantic Surgical Systems and Smith & Nephew. P.-C.N. has received support for education from Arthrex. M.T.P. has received consulting fees and royalties from Arthrex, consulting fees and honoraria from Joint Restoration Foundation Inc, consulting fees from Zimmer Biomet Holdings, honoraria from Flexion Therapeutics Inc, and royalties or license from Arthrosurface Inc and Anika Therapeutics. J.P.B. has received royalties and consulting fees from Arthrex and DJO. P.J.M. has received consulting fees and royalties from Arthrex. 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.

Introduction: The purpose of this series is to report on the one-year clinical outcomes of instability related anterior glenoid fractures treated with open repair utilizing the subscapularis split technique., Methods: Patients with displaced anterior glenoid fractures who underwent open surgical treatment via deltopectoral incision and subscapularis split were identified from a single surgeons database. Fractures were repaired using screw fixation or with distal tibia osteochondral allograft reconstruction. Patient Reported Outcome Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE), PROMIS Pain interference (PI), PROMIS pain intensity (Pi), American Shoulder and Elbow Surgeons (ASES), Visual Analog Scale (VAS) pain, and Subjective Shoulder Value (SSV) scores were obtained at minimum one-year follow-up., Results: Twelve patients with a mean age of 54 (range 28-72) years were included in our study with a follow-up at an average of 16.6 (range 12-30) months. Ten patients underwent internal fixation and two patients underwent allograft reconstruction. Postoperative imaging (n = 10) at latest follow-up demonstrated healed fractures without any hardware complication. Mean postoperative range of motion included forward elevation of 147 ± 44.0° and external rotation of 44 ± 17°. Postoperative PROMs were obtained from nine patients with a mean PROMIS UE, PI, and Pi score of 49.4 ± 4.1, 39.9 ± 3.8 and 35.6 ± 4.3, respectively. The respective mean ASES, VAS, and SSV scores were 91.8 ± 7.2, 1.2 ± 1.0, and 91.0 ± 8.0., Conclusion: Open surgical repair of anterior glenoid fractures utilizing subscapularis split results in good functional outcomes and low complications including risk of recurrent instability., Level of Evidence: III case series., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: All-suture anchors and knotless anchors are increasingly used in the repair of anteroinferior labral tears in patients with shoulder instability. Optimal repair constructs may limit recurrent instability., Purpose: To perform a quantitative biomechanical comparison of 3 labral fixation devices for soft tissue Bankart lesions: knotless soft-body tensionable anchor (SB knotless), knotted soft-body anchor (SB knotted), and knotless hard-body PEEK (polyether ether ketone) interference anchor (HB knotless)., Study Design: Controlled laboratory study., Methods: A total of 21 glenoid specimens were randomized into 3 groups: SB knotless, SB knotted, and HB knotless. Artificial Bankart lesions were created at the anteroinferior labrum. Anchors were placed at the 3:30, 4:30, and 5:30 clockface positions, and sutures were passed through 1 cm of tissue. Anchors were tested simultaneously as one construct by pulling capsular tissue connected to the anteroinferior quadrant. Cyclic loading (5-25 N, 100 cycles) was followed by load-to-failure testing (15 mm/min). Biomechanical testing variables were collected, and failure mechanisms were recorded per individual anchor., Results: There were no differences in baseline specimen characteristics. There was no difference in elongation during cyclic loading ( P = .40). The ultimate load to failure between SB knotless (309.7 ± 125.6 N), SB knotted (226.4 ± 34.8 N), and HB knotless (256.5 ± 90.5 N) did not significantly differ ( P = .25). Failure mechanisms differed among groups ( P = .008); mechanisms included anchor pullout (SB knotless: 33.3%; SB knotted: 23.8%; HB knotless: 28.6%), suture pull-through (SB knotless: 66.7%; SB knotted: 38.1%; HB knotless: 33.3%), and anchor fixation method failure, defined as knot failure for knotted anchors or locking mechanism failure for knotless anchors (SB knotless: 0.0%; SB knotted: 38.1%; HB knotless: 38.1%).)., Conclusion: The SB knotless, SB knotted, and HB knotless labral fixation anchors studied exhibited comparable elongation during cyclic loading, stiffness, and ultimate loads to failure in a cadaveric model. However, the failure mechanisms significantly differed, as SB knotless anchors failed primarily from suture pull-through, while SB knotted and HB knotless anchors were subject to knot failure and locking mechanism failure, respectively., Clinical Relevance: These data support the benefit of SB knotless anchors for anteroinferior labral repair in limiting knot failure typically seen with knotted anchors, perhaps demonstrating that all-suture anchors may have better locking mechanism quality than their PEEK counterparts.

Purpose: Although the morphological relationship of the scapula and the humeral head has been claimed to be related to shoulder pathologies, few studies examined the relationship between subscapularis (Ssc) tears and lesser tuberosity (LT)-humeral head (HH) and between Ssc tears and HH-glenoid. This study aims to evaluate the relationship of LT with HH and glenoid in patients with Ssc tears and anterior shoulder instability (ASI). We hypothesized that the glenoid, HH, and their combined relationship with LT may impact Ssc tears and ASI., Material and Methods: The study included 34 patients with ASI, 28 patients with isolated Ssc tears, and 40 patients as the control group. The radius of HH (Hr), the distance between the center of HH and LT (LTr), and the glenoid radius (Gr) were measured in shoulder magnetic resonance (MR) images. The LTr to Hr (LTr/Hr) ratio was defined as the lesser tuberosity-humeral head index (LTHHI), whereas the LTr to Gr (LTr/Gr) ratio was defined as the lesser tuberosity-glenoid index (LTGI). The three groups were compared regarding LTHHI, LTGI, LTr, Hr, and Gr., Results: There was a significant difference between each group concerning LTGI (p < 0.001). LTGI values below 1.99 showed 93.1% sensitivity and 93.3% specificity for Ssc tears, while values above 2.24 showed 86.7% sensitivity and 86.2% specificity for ASI. Also, there was a significant difference when the groups were compared for LTHHI (p < 0.001). This rate was lowest for Ssc tears, and LTHHI values below 1.17 showed 82.8% sensitivity and 80.1% specificity., Conclusion: LTGI may be a new predictive factor showing 93.1% sensitivity and 93.3% specificity for Ssc tears and 86.7% sensitivity and 86.2% specificity for ASI. In addition, LTHHI may be a new predictive factor showing 82.8% sensitivity and 80.1% specificity for Ssc tears., Level of Evidence: III retrospective comparative study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Previous studies have shown an association between shoulder instability and the development of glenohumeral arthritis leading to total shoulder arthroplasty (TSA). The primary goal of this study was to evaluate if a history of shoulder instability was more common in patients aged <50 years undergoing TSA. The secondary objective was to determine if a history of prior surgical stabilization is more common in patients aged <50 years undergoing TSA., Methods: Using the military health system data repository (MDR) and the Military Analysis and Reporting Tool (M2), we identified 489 patients undergoing primary TSA from October 1, 2013, to May 1, 2020, within the Military Health System (MHS). Patients aged <50 years were matched 1:2 with patients aged ≥50 years based on sex, race, and military status, with the final study population comprising 240 patients who underwent primary TSA during the study period. Electronic medical records were examined, and factors showing univariate association (P < .2) were included in a binary logistic regression analysis to determine associations between demographic or clinical factors and TSA prior to age 50 years., Results: The groups differed significantly in shoulder arthritis subtype, with the older group having significantly more primary osteoarthritis (78% vs. 51%, P < .001). The younger group had significantly more patients with a history of shoulder instability (48% vs. 12%, P < .001), prior ipsilateral shoulder surgery of any type (74% vs. 34%, P < .001), and prior ipsilateral shoulder stabilization surgery (31% vs. 5%, P < .001). In the resultant logistic regression model, a history of shoulder instability (OR 5.0, P < .001) and a history of any prior ipsilateral shoulder surgery (OR 3.5, P < .001) were associated with TSA prior to the age of 50 years., Conclusions: Shoulder instability is a risk factor for TSA before age 50 years. It is unclear how surgical stabilization influences the development of secondary glenohumeral arthritis in shoulder instability. Patients should be counseled that recurrent instability could lead to earlier TSA, regardless of whether surgical stabilization is performed., (Published by Elsevier Inc.)

Background: The Latarjet coracoid transfer procedure reliably stabilizes the glenohumeral joint for shoulder instability. However, complications such as graft osteolysis, nonunion and fracture continue to affect patient clinical outcomes. The double-screw (SS) construct is regarded as the gold standard method of fixation. SS constructs are associated with graft osteolysis. More recently, a double-button technique (BB) has been suggested to minimize graft-related complications. However, BB constructs are associated with fibrous nonunion. To mitigate this risk, a single screw combined with a single button (SB) construct has been proposed. It is thought that this technique incorporates the strength of the SS construct and allows micromotion superiorly to mitigate stress shielding-related graft osteolysis., Aims: The primary aim of this study was to compare the failure load of SS, BB, and SB constructs under a standardized biomechanical loading protocol. The secondary aim was to characterize the displacement of each construct throughout testing., Methods: Computed tomography scans of 20 matched-pair cadaveric scapulae were performed. Specimens were harvested and dissected free of soft tissue. SS and BB techniques were randomly assigned to specimens for matched-pair comparison with SB trials. A patient-specific instrument (PSI)-guided Latarjet procedure was performed on each scapula. Specimens were tested using a uniaxial mechanical testing device under cyclic loading (100 cycles, 1 Hz, 200 N/s) followed by a load-to-failure protocol (0.5 mm/s). Construct failure was defined by graft fracture, screw avulsion, and/or graft displacement of more than 5 mm., Results: Forty scapulae from 20 fresh frozen cadavers with a mean age of 69.3 years underwent testing. On average, SS constructs failed at 537.8 N (SD 296.8), whereas BB constructs failed at 135.1 N (SD 71.4). SB constructs required a significantly greater load to fail compared with BB constructs (283.5 N, SD 162.8, P = .039). Additionally, SS (1.9 mm, IQR 0.87) had a significantly lower maximum total graft displacement during the cyclic loading protocol compared with SB (3.8 mm, IQR 2.4, P = .007) and BB (7.4 mm, IQR 3.1, P < .001) constructs., Conclusion: These findings support the potential of the SB fixation technique as a viable alternative to SS and BB constructs. Clinically, the SB technique could reduce the incidence of loading-related graft complications seen in the first 3 months of BB Latarjet cases. The study is limited to time-specific results and does not account for bone union or osteolysis., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: The primary objective of this study was to assess the incidence of recurrent glenohumeral instability in patients over 40 years with isolated rotator cuff (RC) repair for traumatic shoulder dislocation. The secondary objectives were to identify risk factors for glenohumeral recurrence after RC repair and to describe the causes and incidences of re-intervention., Materials and Methods: In this retrospective cohort study, data of consecutive patients at a single trauma center between January 2014 and July 2019 were reviewed, and 84 patients with a mean age of 57 (range: 40-75) years and follow-up duration of 3.9 (2-6) years were included. The inclusion criteria were as follows: first traumatic anterior shoulder dislocation, reparable RC tear, primary arthroscopic RC repair, no labral or bony Bankart lesion repair, and at least 2 years of follow-up. Patients less than 40 years of age were excluded. Shoulder instability recurrences and surgical reinterventions were reviewed with medical records. Statistical analysis was performed for qualitative variables using the Chi-squared test. Statistical significance was set at P ≤ 0.05., Results: There was one patient with a redislocation episode (1.2%) at 2.5 years after surgery, who was surgically treated. Age, subscapular tears, bony Bankart injuries, humeral defects, and associated neurological injuries were not risk factors for recurrence in this study. Ten patients (11.9%) required reintervention. Nine patients (10.7%) re-tore their RCs., Conclusions: Recurrent glenohumeral instability in active patients over 40 years with isolated RC repair after traumatic shoulder dislocation was infrequent, despite the incidence of significant Hill-Sachs defects, anterior glenoid defects, bipolar bone defects, size of the RC injury, and tendon re-tears. The incidence of re-interventions was 11.9%, with symptomatic RC retear as the main cause., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Bone augmentation techniques show a relatively high complication rate, which might be due to graft non-union and resorption. It is unclear which augmentation techniques demonstrate the highest amount of non-union and resorption and whether this leads to worse clinical or functional outcomes. Therefore, the aim of this review was (i) to compare non-union and resorption rates between surgical approaches, procedures, graft types, donor sites and fixation methods regarding clinical and functional outcomes and (ii) determine whether high non-union or resorption rates lead to less favorable clinical or functional outcomes., Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements were followed. PubMed, EMBASE (Ovid) and Cochrane Library were searched on December 15th 2021 for studies examining bone graft non-union or resorption using radiograph or CT following glenoid augmentation to treat anterior shoulder dislocation., Results: The search resulted in 103 inclusions, comprising 5,128 glenoid augmentations. When comparing pooled proportions of bony union, graft fracture rate, hardware failure rate, recurrence rate, return to sports and Rowe score, most results were similar between approaches, procedures, graft types, donor sites and fixation methods. High resorption rates were seen for allograft augmentation (74.3; 95% CI: 39.8-92.7) compared to autograft augmentation (15.5; 95% CI 10.1-23.2), but this was not associated with higher recurrence rates or worse clinical outcomes. Meta-analyses (8 studies; 494 patients) demonstrated no difference in incomplete and complete non-union rates between arthroscopic and open procedures; however, both analyses showed substantial heterogeneity. Higher partial resorption rates were observed on CT (48.0; 95% CI 43.3-52.7) compared to radiograph (14.1; 95% CI 10.9-18.1). Three studies comprising 267 shoulders demonstrated a higher rate of non-union and recurrence in smokers, whereas one study comprising 38 shoulders did not., Conclusion: Non-union and resorption rates were similar among procedures, grafts and fixation methods. Higher resorption rates were observed in allografts, but this was not associated with higher recurrence rates or worse clinical outcomes. Pooling data demonstrated substantial heterogeneity and definitions varied among studies, warranting more standardized measuring., Level of Evidence: IV., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Background: No previous systematic reviews have reported on athletes who fail to return to sports after arthroscopic Bankart repair., Purpose: To review the literature on athletes who fail to return to sports after arthroscopic Bankart repair to determine the rate of athletes who did not return to sports and to identify the specific reasons for failure to return to sports by nonreturning athletes., Study Design: Systematic review and meta-analysis., Methods: A meta-analysis was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Three electronic databases (PubMed, Scopus, Web of Science) were queried for articles meeting the inclusion criteria. Studies were considered eligible only if reporting the rate of failure for return to sports and providing the specific reasons why athletes were unable to return to sports. All records were screened by title, abstract, and full text by 2 authors independently, with any discrepancies resolved by a third senior author. For articles selected for inclusion, data were collected on the number of athletes, average age, average follow-up time, type of sport played, rate of failure to return to sports, and specific reasons for failure to return. A random-effects model was used to conduct the meta-analysis., Results: Seventeen studies were selected for inclusion reporting on a total of 813 athletes. The calculated weighted rate of failure to return to sports after arthroscopic Bankart repair was 15.6% (95% CI, 10.9%-21.1%). A significantly higher proportion of athletes cited shoulder-dependent versus shoulder-independent reasons for failure to return to sports (81.7% vs 18.3%; P < .0001). The most cited reasons for failure to return included recurrent or persistent instability (33.3%), fear of reinjury (17.7%), apprehension (9.9%), changes in priorities or personal interest (8.5%), lack of time (7.1%), and discomfort or pain with sports (6.4%)., Conclusion: Our study estimated the rate of failure to return to sports after arthroscopic Bankart repair to be 15.6%, with most athletes citing shoulder-related reasons as the primary factor precluding return. Identifying the potential reasons preventing successful return to sports can guide surgeons in counseling athletes regarding postoperative expectations and addressing hesitations for returning to sports.

Background: Traumatic anterior shoulder instability is common in the adolescent athlete, and when it is untreated, the recurrence rate is high. Atypical lesions-such as anterior glenoid periosteal sleeve, humeral glenohumeral ligament, and insertional tendon avulsions-may occur within this population, and accurate diagnosis and appropriate lesion management are key to treatment success., Purpose: To evaluate the age, skeletal immaturity, bone loss, and uncommon soft tissue lesions as correlates of posttraumatic anterior shoulder instability lesion patterns in an adolescent population., Study Design: Cross-sectional study, Level of evidence, 3., Methods: Consecutive patients ≤18 years of age (160 shoulders) treated within a single institution for traumatic anterior shoulder instability between June 2013 and June 2021 were reviewed. Demographics, injury mechanism, radiographic and magnetic resonance imaging of lesions, the presence of any bone loss, operative findings, and physeal status were recorded. An overall 131 shoulders met the inclusion criteria. Instability lesion type was analyzed categorically by age <15 or ≥15 years; individual age was assessed for correlation with any bone loss present. Atypical lesions-anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, subscapularis avulsion-were assessed for correlations with age, open physeal status, and the presence of any bone loss., Results: An overall 131 shoulders (mean, 15.3 years; range, 10.5-18.3) were identified for this study: 55 in patients <15 years old and 76 in patients ≥15 years old. Bony injuries such as Bankart and Hill-Sachs lesions were more common in the ≥15-year-old group ( P = .044 and P = .024, respectively). Bony Bankart injuries were found at a rate of 18.2% in the <15-year-old group, as compared with 34.2% in the ≥15-year-old group ( P < .05). Anterior labral periosteal sleeve avulsions were more common in the <15-year-old group (n = 13 [23.6%] vs n = 8 [10.5%]; P < .044), as were all atypical lesions combined (n = 23 [41.8%] vs n = 13 [17.1%]; P < .0018]., Conclusion: In this series of anterior shoulder instability in children and adolescents, instability lesions varied significantly by age. Bone loss was associated with older age at presentation, and atypical lesions were more common in patients <15 years of age. Treatment teams should be aware of less common soft tissue injuries in this young age group and ensure careful review of adequate imaging for proper diagnosis and treatment in these younger patients.

Background: The amount of glenoid width that must be restored with a Latarjet procedure in order to reestablish glenohumeral stability has not been determined., Purpose/hypothesis: The purpose of this article was to determine the percentage of glenoid width restoration necessary for glenohumeral stability after Latarjet by measuring anterior humeral head translation and force distribution on the coracoid graft. The hypothesis was that at least 100% of glenoid width restoration with Latarjet would be required to maintain glenohumeral stability., Study Design: Controlled laboratory study., Methods: Nine cadaveric shoulders were prepared and mounted on an established shoulder simulator. A lesser tuberosity osteotomy (LTO) was performed to allow accurate removal of glenoid bone. Coracoid osteotomy was performed, and the coracoid graft was sized to a depth of 10 mm. Glenoid bone was sequentially removed, and Latarjet was performed using 2 screws to reestablish 110%, 100%, 90%, and 80% of native glenoid width. The graft was passed through a subscapularis muscle split, and the LTO was repaired. A motion tracking system recorded glenohumeral translations, and force distribution was recorded using a TekScan pressure sensor secured to the glenoid face and coracoid graft. Testing conditions included native; LTO; Bankart tear; and 110%, 100%, 90%, and 80% of glenoid width restoration with Latarjet. Glenohumeral translations were recorded while applying an anteroinferior load of 44 N at 90° of humerothoracic abduction and 0° or 45° of glenohumeral external rotation. Force distribution was recorded without an anteroinferior load., Results: Anterior humeral head translation progressively increased as the proportion of glenoid width restored decreased. A marked increase in anterior humeral head translation was found with 90% versus 100% glenoid width restoration (10.8 ± 3.0 vs 4.1 ± 2.6 mm, respectively; P < .001). Greater glenoid bone loss also led to increased force on the coracoid graft relative to the native glenoid bone after Latarjet. A pronounced increase in force on the coracoid graft was seen with 90% versus 100% glenoid width restoration ( P < .001)., Conclusion: Anterior humeral head translation and force distribution on the coracoid graft dramatically increased when <100% of the native glenoid width was restored with a Latarjet procedure., Clinical Relevance: If a Latarjet is unable to fully restore the native glenoid width, surgeons should consider alternative graft sources to minimize the risk of recurrent instability or coracoid overload.

The surgical Latarjet procedure aims to stabilise the glenohumeral joint following anterior dislocations. Despite restoring joint stability, the procedure introduces alterations of muscle paths which likely modify the shoulder dynamics. Currently, these altered muscular functions and their implications are unclear. Hence, this work aims to predict changes in muscle lever arms, muscle and joint forces following a Latarjet procedure by using a computational approach. Planar shoulder movements of ten participants were experimentally assessed. A validated upper-limb musculoskeletal model was utilised in two configurations, i.e., a baseline model, simulating normal joint, and a Latarjet model simulating its related muscular alterations. Muscle lever arms and differences in muscle and joint forces between models were derived from the experimental marker data and static optimisation technique. Lever arms of most altered muscles, hence their role, were substantially changed after Latarjet. Altered muscle forces varied by up to 15% of the body weight. Total glenohumeral joint force increased by up to 14% of the body weight after Latarjet, mostly due to increase in compression force. Our simulation indicated that the Latarjet muscular alterations lead to changes in the muscular recruitment and contribute to the stability of the glenohumeral joint by increasing compression force during planar motions., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. All the authors would like to gratefully acknowledge funding received through the Australian Research Council (ARC) Industrial Transformation Training Centre for Joint Biomechanics (IC190100020). Saulo Martelli would also like to acknowledge the support received through the following funding schemes of the Australian Research Council: DP180103146; FT180100338., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose: To investigate the effectiveness of two home-based exercise programs for treating multidirectional shoulder instability (MDI) in patients diagnosed with Hypermobile Ehlers-Danlos syndrome (hEDS) or Hypermobility Spectrum Disorders (HSD)., Methods: Twenty-one hEDS/HSD patients with MDI were recruited from the Center for Medical Genetics of the Ghent University Hospital. Patients were randomly assigned to either the experimental or the control group. Both groups received a 6-month home-based exercise program. The primary outcome measure was the Western Ontario Shoulder Index (WOSI). Secondary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH), Tampa Scale for Kinesiophobia (TSK), Patient-Specific Functional Scale (PSFS), Global Rating of Change (GROC), and pain pressure thresholds. Outcomes were assessed at baseline, after 6 weeks, 12 weeks, and 24 weeks., Results: Significant main effects for time were observed for all questionnaires, except for the TSK ( p  = 0.12). Patients improved 240 and 325 points on the WOSI after 12 ( p  = 0.02) and 24 weeks ( p  = 0.001), respectively. Additionally, patients improved 8.6 points on the DASH ( p  = 0.002), 4.3 points on the PSFS ( p  = 0.01), and 1.02 points on the GROC ( p  = 0.001) after 24 weeks., Conclusion: No significant differences were found between group A and B. Both home-based exercise programs led to significant improvements in shoulder function. IMPLICATIONS FOR REHABILITATIONHome-based exercise therapy may be effective for treating MDI in the hEDS/HSD population.Home-based training is beneficial for improving shoulder function, but a multidisciplinary, supervised approach might be more effective for altering kinesiophobia in this patient population.

Introduction: Posterior shoulder instability (PSI) is a rare and challenging pathology to manage. The aim of this review was to assess and compare whether open and arthroscopic iliac crest bone graft (ICBG) bone block procedures succeeded in improving functional and clinical outcomes as well as radiological outcomes of union and graft resorption., Hypothesis: We hypothesised that there will be no difference in recurrence rate and functional outcome between open and arthroscopic procedures but there will be a higher complication rate with open bone block procedures., Methods: A systematic review was conducted in accordance with PRISMA guidelines using the online databases MEDLINE and Embase. The review was registered on the PROSPERO database. Studies of open or arthroscopic ICBG bone block procedures reporting patient reported outcome measures, recurrence, complications and progression to osteoarthritis and radiological outcomes of graft union and resorption were selected. Studies were appraised using the Methodical index for non-randomised studies (MINORS) tool., Results: 14 studies satisfied the inclusion criteria; five studies were arthroscopic and nine used open techniques. A total of 183 patients and 201 shoulders were included, mean age was 25 years range (14-75 years). Recurrent instability ranged from 0% to 12.5% for arthroscopic and 0% to 36.4% for open studies. Arthroscopic studies had statistically significant increases in numerous functional outcome scores but there was no evidence for similar improvements in open studies. Osteoarthritis at follow-up ranged from 12.5% to 47% in arthroscopic and 0% to 81.8% for open studies. Arthroscopic complication rate ranged from 6.7% to 75% compared to 0% to 80% for open studies. Majority of complications were metalware related requiring surgical intervention. Partial graft resorption ranged from 7.7-100% after arthroscopic and 4.8-100% after open procedures. High union rates were seen with both open and arthroscopic techniques., Conclusion: This study highlights a lack of high-level evidence for arthroscopic and open posterior bone block procedures using ICBG to manage PSI. Functional and instability outcome scores showed significant improvement with arthroscopic ICBG bone block procedures however limited evidence was available for open studies. Metalwork related complications requiring revision and radiographic progression to osteoarthritis was high in both arthroscopic and open studies., Level of Evidence: IV, systematic review., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)