Johannes E. Plath

Prevalence of and Risk Factors for Dislocation Arthropathy Radiological Long-term Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13-Year Follow-up

Background: Glenohumeral osteoarthritis is a well-documented, long-term complication of open stabilization procedures. However, there is a lack of knowledge about long-term radiographic outcome after arthroscopic Bankart procedures. Hypothesis: Glenohumeral osteoarthritis will develop less frequently in arthroscopic Bankart repair compared with open repairs reported in the literature. Study Design: Case series; Level of evidence, 4. Methods: The inclusion criteria for this study were (1) all-arthroscopic Bankart repair for a (2) symptomatic anteroinferior shoulder instability and (3) a minimum follow-up of 10 years. True anteroposterior and lateral radiographs were obtained to evaluate the prevalence and grade of osteoarthritis according to the Samilson classification. Patients were assessed by the Constant score and examined for passive external rotation deficits. Results: Of 165 shoulders that fulfilled the inclusion criteria, 100 were available for evaluation. The median Constant score at an average ± SD 156.2 ± 18.5 months after Bankart repair was 94 (range, 46-100). Twenty-one shoulders (21%) sustained a recurrent dislocation. Overall, 31% of shoulders showed no evidence of glenohumeral osteoarthritis; 41% showed mild, 16% moderate, and 12% severe degenerative changes. Osteoarthritis did not correlate with Constant score results (P = .427). The grade of osteoarthritis was significantly associated with the number of preoperative dislocations (P = .016), age at initial dislocation (P = .005) and at surgery (P = .002), and the number of anchors used (P = .001), whereas time from initial dislocation to surgery (P = .854) and external rotation deficit at 0° and 90° of abduction (P = .104 and .348, respectively) showed no significant correlation. Recurrent dislocation did not affect the presence or grade of osteoarthritis (P = .796 and .665, respectively). Conclusion: At an average 13 years after arthroscopic Bankart repair, osteoarthritic changes are a common finding and, overall, are comparable with reports in the literature regarding open procedures as well as nonoperative treatment. The extent of trauma sustained during preoperative dislocations and the age of the patient seem to be more relevant for long-term dislocation arthropathy than the kind of treatment. Accordingly, the study hypothesis must be rejected. Avoiding preoperative dislocations is more important for the prevention of osteoarthritis than short-term treatment. The number of anchors used was found to be a predictor for long-term development of osteoarthritis.

Results of Arthroscopic Bankart Repair for Anterior-Inferior Shoulder Instability at 13-Year Follow-up.

Background: Anterior-inferior shoulder instability is a common injury in young patients, particularly those practicing overhead-throwing sports. Long-term results after open procedures are well studied and evaluated. However, the long-term results after arthroscopic repair and risk factors of recurrence require further assessment. Hypothesis: Arthroscopic Bankart repair results are comparable with those of open repair as described in the literature. Study Design: Case series; Level of evidence, 4. Methods: A total of 180 shoulders with anterior-inferior shoulder instability were stabilized arthroscopically, met the inclusion criteria and the patients were able to be contacted at a minimum of 10-year follow-up. Of these patients, 143 agreed to participate in the study. Assessment was performed clinically in 104 patients using the American Shoulder and Elbow Surgeons score, Constant score, American Academy of Orthopaedic Surgeons score, Rowe score, and the Dawson 12-item questionnaire. The Samilson-Prieto score was used to assess degenerative arthropathy in radiographs available for 100 shoulders. Additionally, 15 patients participated through a specific questionnaire and 24 patients through a telephone survey. Results: The overall redislocation rate was 18.18%. Redislocation rates for the different types of fixation devices were as follows: FASTak/Bio-FASTak, 15.1% (17/112); SureTac, 26.3% (5/19); and Panalok, 33.3% (4/12). Concomitant superior labral anterior-posterior repair had no effect on clinical outcome. Redislocation rate was significantly affected by the patient’s age and duration of postoperative rehabilitation. Redislocation rate tended to be higher if there had been more than 1 dislocation preoperatively (P = .098). Severe dislocation arthropathy was observed in 12% of patients, and degenerative changes were significantly correlated with the number of preoperative dislocations, patient age, and number of anchors. The patient satisfaction rate was 92.3%, and return to the preinjury sport level was possible in 49.5%. Conclusion: Clinical outcome at a mean follow-up of 13 years after arthroscopic repair of anterior-inferior shoulder instability is comparable with the reported results of open Bankart repair in the literature and allows management of concomitant lesions arthroscopically. Modifiable risk factors of postoperative redislocation and arthropathy must be considered. Stabilization after the first-time dislocation achieves better clinical and radiological outcomes than after multiple dislocations.

Patients’ expectations of shoulder instability repair

PurposeTo analyze and compare patient expectations of primary and revision shoulder stabilization and to assess the factors associated with patients’ expectations.MethodsPre-operative patient expectations after shoulder instability repair were prospectively assessed using a self-designed questionnaire. The survey included questions on the expected level and type of return to sports, instability, pain, risk of osteoarthritis, and overall shoulder condition.ResultsOne-hundred and forty-five patients (99 primary; 46 revision repair) were included. A return to sport at the same level with slight to no restrictions was expected in 95%, a return to high-risk activities in 34%, to moderate in 58%, and to low-risk activities in 9%. No pain [instability] independent of the activity level was expected by 71% [79%] and occasional pain [instability] during contact and overhead activities by 25% [19%]. 61% expected to have no risk of glenohumeral osteoarthritis, 37% a slight, and 2% a significant risk. The overall expectation for the post-operative shoulder was indicated to be normal or nearly normal in 99% of patients. The revision group did not differ from the primary repair group in any variable. High pre-operative sport performance was positively correlated with post-operative sport expectations. The number of dislocations, the duration of instability, and the subjective instability level were negatively correlated with return to sport expectations.ConclusionPatient expectations for primary and revision shoulder instability repair are high. Realistic patient expectations regarding the surgical procedure are necessary to avoid low patient satisfaction, especially in pre-operatively highly active and demanding athletes. The surgeon must not solely base the treatment on the pathology and possible risk factors for failure but should also take the individual expectation of the patient into account.Level of evidenceIII.

Does the Arthroscopic Latarjet Procedure Effectively Correct “Off-Track” Hill-Sachs Lesions?:

Background: The glenoid track concept describes the dynamic interaction of bipolar bone loss in anterior glenohumeral instability. Initial studies have successfully demonstrated this concept’s application in clinical populations. In clinical practice, the Latarjet procedure is commonly the preferred treatment in addressing “off-track” Hill-Sachs lesions. The effectiveness of this procedure in restoring such lesions to an “on-track” state, however, has not yet been evaluated or described in the literature. Hypothesis: The Latarjet procedure would transform “off-track” Hill-Sachs lesions to “on-track” lesions. Lesions would remain “on-track” during follow-up, despite glenoid remodeling. Study Design: Case series; Level of evidence, 4. Methods: Patients with “off-track” Hill-Sachs lesions treated with the arthroscopic Latarjet procedure between March 2013 and May 2014 were included. Glenoid track and coracoid graft contact surface area measurements using 3-dimensional computed tomography (3D-CT) were performed preoperatively and at 6-week, 6-month, and at least 12-month (final) follow-up. The mean final follow-up was 23 months. The glenoid diameter, as a percentage of the native glenoid, was also calculated from this imaging. Results: Twenty-six patients met the inclusion criteria. 3D-CT scans were available for all patients preoperatively and postoperatively, with 21 patients (81%) undergoing 6-month follow-up CT and 19 patients (73%) undergoing final follow-up CT. Hill-Sachs lesions remained “on-track” at all follow-up time points. The mean glenoid diameter changed significantly from 84.6% preoperatively to 122.8% at 6 weeks (P < .001) and from 120.5% at 6 months to 113.9% at final follow-up (P = .005). This was also reflected in significant remodeling seen in the coracoid graft articular contact area (6 weeks to 6 months, P = .024; 6 months to final follow-up, P = .002). This persisting glenoid arc enlargement at final follow-up avoided “off-track” Hill-Sachs lesions in 6 of 19 patients (32%), which would otherwise have occurred had the coracoid graft remodeled to native glenoid dimensions. Conclusion: The Latarjet procedure provides an effective treatment for “off-track” engaging Hill-Sachs lesions, despite an evident glenoid remodeling process. At a mean of 23 months postoperatively, a mean persisting enlargement of the glenoid arc of 14% beyond native dimensions remained, avoiding a recurrent “off-track” lesion in 32% of patients, which would otherwise have occurred with complete remodeling.

Arthroscopic Repair of Subscapularis Tendon Tears

The subscapularis is the largest and strongest muscle of the rotator cuff, and it plays an essential role in global shoulder function. Beyond its primary function as an internal rotator, the subscapularis also acts to pull the humeral head posteriorly on the glenoid and is an important dynamic and static anterior stabilizer of the glenohumeral joint. In comparison with tears of the tendons of the rest of the rotator cuff, isolated tears of the subscapularis have a tendency for both early retraction and fatty infiltration. Consequently, full-thickness tears of the subscapularis tendon generally require surgical management. Arthroscopic suture-anchor repair allows anatomic reconstruction of the anterior aspect of the rotator cuff, with all of the benefits of arthroscopic surgery. The principal steps of this procedure include (1) verifying the subscapularis tear and identifying any concomitant lesions during diagnostic arthroscopy, (2) exposing the subscapularis tendon, (3) releasing tendon adhesions and so enabling anatomic reduction, (4) placing suture anchors at the anatomic subscapularis footprint on the lesser tuberosity and anatomically repairing the subscapularis tendon to its anatomic insertion, and (5) performing biceps tenodesis or tenotomy, if indicated. Postoperatively, patients with an isolated subscapularis tear are managed with immobilization in a sling for 6 weeks, while those with combined anterosuperior rotator cuff tears are managed with an abduction pillow. Arthroscopic subscapularis reconstruction provides a good structural repair, substantially restores shoulder mobility and strength, reduces pain, and results in high levels of patient satisfaction and return of shoulder function as measured by functional outcome scores.