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Objective: To perform a systematic review and meta-analysis to compare the results of the Latarjet procedure performed using screws (S) or suture-button for coracoid graft fixation. Methods: A systematic search in Pubmed, EMBASE, and The Cochrane Library databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Cohort studies comparing outcomes in the Latarjet procedure with screw fixation versus the Latarjet procedure with suture-button fixation were included. Results: Five studies with 877 patients were included. There was a significantly lower rate of recurrent instability in those with S fixation compared to the suture-button fixation (1.5% vs 5%, p = 0.001). There was a significantly higher rate of reoperations with S fixation compared to suture-button fixation (4.3% vs 0%, p = 0.001). There were no significant differences between the groups regarding total complications (S: 7.5% vs suture-button: 3.6% p = 0.12) graft fracture (S: 0.8% vs suture-button: 0.5% p = 0.62) and symptomatic hardware (S: 2.7% vs suture-button: 0% p = 0.12). Conclusion: The Latarjet surgery was associated with favorable results and a low rate of complications regardless of the type of fixation used. Screw fixation was associated with a significantly lower rate of recurrences, but greater reoperations due to irritation or pain after surgery. Level of evidence: Systematic review and meta-analysis, level III. [ABSTRACT FROM AUTHOR]

Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions are associated with recurrent shoulder instability and higher rates of failure after capsulolabral repair compared with similarly treated Bankart lesions. Although these lesions can portend poor outcomes, there are limited data on the associated conditions and postoperative course in a young, active population. Purpose: To evaluate the mid- to long-term clinical course and failure rates after ALPSA repairs and assess features associated with these outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: The authors identified all patients who underwent primary arthroscopic anterior or combined anterior and posterior labral repair between January 2010 and January 2020 at a single US military academy. Patient and injury characteristics were retrospectively reviewed while excluding patients with follow-up of <2 years. Patients were divided into 2 cohorts based on the presence of an ALPSA lesion as identified using arthroscopy, and patients with non-ALPSA lesions were matched to those with ALPSA lesions in a 5:1 ratio based on age, sex, time from injury to surgery, glenoid bone loss, and follow-up duration. The primary outcome measures were failure and revision surgery. Any recurrent shoulder instability event was considered a failure, including subjective or objective subluxation and/or dislocation, recurrence of pain consistent with instability, or functionally limiting apprehension. Survival analysis and both univariate and multivariate logistic regression analyses were performed to identify factors associated with ALPSA lesions and propensity for failure. Results: The authors compared 225 patients with non-ALPSA labral tears against 45 patients with ALPSA lesions. ALPSA lesions were associated with multiple preoperative dislocations (odds ratio [OR], 3.0; 95% CI, 1.5-5.9; P =.00096) and increased prevalence of Hill-Sachs lesions (HSLs) (OR, 6.7; 95% CI, 2.8-16.0; P <.0001) and near-track HSLs (OR, 3.6; 95% CI, 1.7-7.6; P =.00049). At the final follow-up, there was no difference in overall failure or recurrent instability between patients with and without ALPSA lesions (20% vs 16% [ P =.563] and 17.8% vs 10.2% [ P =.147], respectively). On multivariate regression, ALPSA did not affect the likelihood of failure (P =.625). However, those with ALPSA lesions experienced failure earlier (1.7 vs 3.1 years; P =.020). When revision ALPSA repairs were performed, 43% failed. Conclusion: In patients with anterior instability treated with primary arthroscopic stabilization, ALPSA lesions were associated with HSLs and multiple dislocations. Although ALPSA repair failure occurred at a similar frequency in the mid- to long term compared with Bankart repairs, ALPSA repair failure tended to occur early in the postoperative course. [ABSTRACT FROM AUTHOR]

Background: The use of a distal tibial allograft (DTA) for reconstruction of a glenoid defect in anterior shoulder instability has grown significantly over the past decade. However, few large-scale clinical studies have investigated the clinical and radiographic outcomes of the DTA procedure. Purpose: To conduct a systematic review and meta-analysis of clinical studies with data on outcomes and complications in patients who underwent the DTA procedure for recurrent anterior shoulder instability with glenoid bone loss. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A comprehensive search of major bibliographic databases was conducted for articles pertaining to the use of a DTA for the management of anterior shoulder instability with associated glenoid bone loss. Postoperative complications and outcomes were extracted and compiled in a meta-analysis. Results: Of the 8 included studies with 329 total participants, the mean patient age was 28.1 ± 10.8 years, 192 (83.8%) patients were male, and the mean follow-up was 38.4 ± 20.5 months. The overall complication rate was 7.1%, with hardware complications (3.8%) being the most common. Partial graft resorption was observed in 36.5% of the participants. Recurrent subluxation was reported in 1.2% of the participants, and recurrent dislocation prompting a reoperation was noted in 0.3% of the participants. There were significant improvements in clinical outcomes, including American Shoulder and Elbow Surgeons score (40.9-point increase; P <.01), Single Assessment Numeric Evaluation (47.2-point increase; P <.01), Western Ontario Shoulder Instability Index (49.4-point decrease; P <.01), Disabilities of the Arm, Shoulder and Hand (20.0-point decrease; P =.03), and visual analog scale (2.1-point decrease; P =.05). Additionally, postoperative shoulder range of motion significantly increased from baseline values. Conclusion: The DTA procedure was associated with a low complication rate, good clinical outcomes, and improved range of motion among patients with anterior shoulder instability and associated glenoid defects. [ABSTRACT FROM AUTHOR]

The debate surrounding the influence of the open Latarjet procedure on postoperative scapular motions persists, and there is no evidence regarding its effects on periscapular muscle activation. This study aimed to assess the short-term influence of the open Latarjet procedure on scapular kinematics and periscapular muscle activity during arm raising and lowering based on comparisons between patients and healthy athletes. 22 healthy male athletes and 22 male athletes scheduled for glenohumeral stabilization surgery by the open Latarjet procedure were included. Scapular kinematics, periscapular muscle activities, and shoulder-related quality of life were recorded before surgery and 3 months postoperatively for the Latarjet group. For the healthy group, same assessments were performed 3 months apart. Bilateral differences in both scapular kinematics and periscapular muscle activation ratios and the Western Ontario Shoulder Instability (WOSI) index were defined as dependent variables. Scapular kinematics of the operated shoulder, namely scapular upward/downward rotation, internal/external rotation, and anterior/posterior tilt recorded between 20° and 120° of humerothoracic elevation, showed no alterations 3 months after surgery (P >.05) and did not differ from those observed in healthy athletes (P >.05). Similarly, all periscapular muscle activations were not different within time and between groups (P >.05). The WOSI index of the operated shoulder was significantly improved postoperatively (871.9 ± 443.7 vs. 1346.3 ± 552.3) but remained higher than the WOSI indices of the nonoperated shoulder or those of the healthy group (52.7 ± 75.6). This study emphasizes the short-term effects of the open Latarjet procedure, demonstrating an improvement in the shoulder-related quality of life 3 months after surgery. Notably, during this period, both kinematics and periscapular muscle activity remained consistent and similar to the patterns observed for healthy athletes. [ABSTRACT FROM AUTHOR]

In patients with traumatic posterior shoulder instability, little is known about the precise location and size of the reverse Hill-Sachs lesion. Forty-nine shoulders of 47 patients with traumatic posterior instability were included in this study based on the following inclusion criteria: (1) a primary or recurrent traumatic posterior shoulder dislocation and (2) the initial event being caused by trauma. Patients were excluded if they had (1) no history of trauma, (2) prior shoulder surgery, (3) no computed tomographic (CT) examination, or (4) were seizure cases. Three-dimensional images of the humerus reconstructed from CT images were reviewed using an image analysis software. The location and size of the reverse Hill-Sachs lesion were measured and described on a clock face on the humeral head. The reverse Hill-Sachs lesion was observed in 25 of 49 shoulders (51%). The reverse Hill-Sachs lesions were located between 1:37 and 2:48. The depth of the reverse Hill-Sachs lesion (mean ± standard deviation) was 5.8 ± 2.2 mm. The extent of the reverse Hill-Sachs lesion was 35° ± 12°. The average orientation of the reverse Hill-Sachs lesion, represented by an angle measured from the 12 o'clock position, was 64° ± 12° and pointing toward 2:09 on a clock face. The mean length and width of reverse Hill-Sachs lesions were 9.7 ± 4.7 mm and 11.1 ± 3.6 mm, respectively. The reverse Hill-Sachs lesion was a semicircular compression fracture located on the anteromedial aspect of the humeral head. Compared with shoulders with anterior shoulder instability, the humeral defect was smaller and located more inferiorly in shoulders with posterior instability. [ABSTRACT FROM AUTHOR]

Background: Glenohumeral instability is a complex clinical problem with underlying pathology in the bony, labral, and capsular tissues. The rate of specific capsular injuries varies widely in the literature and the clinical importance of these specific injury patterns remains unclear. Methods: Following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, a systematic review was performed of multiple databases for all primary research articles between 2008 and 2023 which included advanced imaging and included rates of capsular injury in patients with glenohumeral instability. Results: Twelve studies met inclusion criteria. The most prevalent capsular injury seen was in the inferior glenohumeral ligament (34.1%) across all studies, followed by anterior labroligamentous periosteal sleeve avulsions with 24.9% prevalence. Humeral avulsions of the glenohumeral ligaments lesions were the least common (6.2%) of subjects, followed closely by capsular tears (8.3%) of subjects. Conclusion: Capsular injury is commonly seen in magnetic resonance imaging of patients with anterior shoulder instability. Significant heterogeneity in language and imaging techniques was found in the existing literature. Further research is needed to explore these specific capsular lesions’ clinical implications and rehabilitation strategies.

The popularity of arthroscopic Latarjet has increased significantly in recent years due to its perceived advantages. The latter include a smaller surgical incision, faster recovery, quicker return to sports, and ability to treat concomitant intra-articular pathology. Nevertheless, the arthroscopic technique is more technically challenging, has a more significant learning curve, longer operating time, and is less cost-effective. The study aimed to identify the various factors influencing patient decision-making between undergoing arthroscopic or open Latarjet using a stepwise questionnaire model. All patients with a primary, whether arthroscopic or open Latarjet procedure were subjected to a stepwise interviewing process and were asked to select between arthroscopic and open approaches at each step. Fifty patients with a mean age of 28.8 ± 8.8 year old participated in the study. Twenty (40%) consistently selected an arthroscopic approach after analysis of the incision's aspect, whereas 34 (68%) had a final decision different from their initial choice. In addition, out of the 15 patients who chose arthroscopy or were undetermined after presentation of the incisional aspect, 9 (60%) changed their decision to open surgery after presentation of the pros and cons of each approach. Twenty-three (46%) patients were unable to choose and left the choice to their surgeon. The faith in their surgeon and recovery were identified as the 2 most important factors influencing patients' final decisions. The minimally invasive nature of arthroscopic incisions was not considered to be more cosmetically appealing than that of a single open incision. The advantages of the arthroscopic procedure may not be as valued by patients as by surgeons. Patients were more interested in the equivalent short- and mid-term outcomes of both approaches and the shorter surgical duration of the open option. It is crucial to adequately inform patients during preoperative counseling to achieve the best consensus. [ABSTRACT FROM AUTHOR]

A 17-year-old right-handed high school pitcher sustained a first-time anterior shoulder dislocation. The patient's imaging revealed a small Hill–Sachs lesion; however, the clinical team's decision was to manage it nonoperatively. In this case, the patient underwent 7 weeks of rehabilitation, which included general upper extremity strengthening exercises, a modified interval throwing program, and a pitching progression adapted specifically for the patient. After rehabilitation, the patient returned to live pitching with improvements in his pitching statistics. The uniqueness of this case is that it is a less common intervention approach posttreatment. [ABSTRACT FROM AUTHOR]

Background: Nonoperative management of posterior shoulder instability is common. However, limited data are available to assess the pathomorphologic factors associated with its failure. Purpose/Hypothesis: The purpose of this study was 2-fold: (1) to determine glenohumeral pathomorphologic features predictive of nonoperative management failure of posterior instability; and (2) to determine the relationship between nonoperative management failure and posterior glenoid bone loss (pGBL) progression. It was hypothesized that greater posterior acromial height (PAH) would adversely affect nonoperative survivorship and that shoulders treated nonoperatively would have pGBL progression compared with those undergoing surgical stabilization. Study Design: Case-control study; Level of evidence, 3. Methods: This was a retrospective review of a consecutive series of patients with isolated posterior shoulder instability, defined as isolated posterior labral tear on magnetic resonance imaging (MRI) with corresponding physical examination findings, who underwent nonoperative management for 6 months and had no previous related surgical history. The primary outcome of interest was the failure of nonoperative management, defined as the inability to return to full military duty or requiring surgical intervention. The morphologic features assessed for association with nonoperative management failure included pGBL, glenoid version, acromial morphology, and posterior humeral head subluxation. We secondarily sought to determine the progression of pGBL on serial MRI scans. Cox proportional hazard analysis was used to evaluate risk factors for failure. Results: In this study, 42 of 90 (46.7%) patients had failed nonoperative management and went on to receive an arthroscopic stabilization procedure. The group with failed treatment demonstrated a greater humeral head subluxation ratio than those with successful nonoperative management (0.65 ± 0.2 vs 0.62 ± 0.2; P =.038). Cox proportional hazard analysis identified pGBL, greater PAH, less posterior acromial coverage, and posterior humeral subluxation as significant risk factors for failure. Of those with failed nonoperative management, 17 had repeat MRI scans at a mean of 488.2 ± 87 days after index MRI for comparison, demonstrating a statistically significant progression of pGBL (index MRI, 2.68% ± 1.71%) versus after nonoperative treatment failure (6.54% ± 1.59%; P =.003). Conclusion: Failure occurred 47% of the time in patients who underwent nonoperative management for isolated posterior glenohumeral instability for a minimum of 6 months, and it was associated with a greater posterior humeral head subluxation, less posterior acromial coverage, greater PAH, and greater amounts of glenoid retroversion on index MRI. Additionally, those who had repeat MRI approximately 1 year after the index MRI demonstrated greater pGBL compared with the index MRI. [ABSTRACT FROM AUTHOR]

Coracoid nonunion is a relevant complication following the Latarjet procedure and is influenced by multiple factors, including the method of graft fixation. The purpose of this study was to evaluate and characterize the biomechanical properties of various two-screw fixation constructs used for coracoid graft fixation in the Latarjet procedure. Forty model scapulae (Sawbones Inc., Vashon, WA, USA) were used for this study. A 15% anterior inferior glenoid bone defect was created. The coracoid was osteotomized at the juncture of the vertical and horizontal aspects, transferred to the anterior-inferior edge of the glenoid, and fixed with either two 3.5 mm fully threaded cannulated cortical screws, two 3.5 mm fully threaded solid cortical screws, two 3.5 mm partially threaded cannulated screws, or two 4.5 mm partially threaded malleolar screws (MS). Biomechanical testing was performed with an Instron material testing machine (Instron Corp., Norwood, MA, USA) by applying loads to the lateral aspect of the transferred coracoid graft. The constructs were preconditioned with nondestructive cyclical loading (0N-20N) to determine construct stiffness. After 100 cycles of dynamic loading, the construct was loaded to failure to determine ultimate failure load, yield displacement, and mode of failure. All failures were associated with plastic deformation of the screws and coracoid graft fracture. There was a significantly lower initial stiffness for partially threaded cannulated screws compared to MS (186 ± 49.3 N/mm vs. 280 ± 65.5 N/mm, P =.01) but no significant differences among the other constructs. There was no difference in ultimate failure load (P =.18) or yield displacement (P =.05) among constructs. Two screw coracoid fixation of the coracoid in a simulated classic Latarjet procedure with 3.5 mm fully threaded cortical and cannulated screws is comparable to 4.5 mm MS in strength, stiffness, and displacement at failure. On the other hand, partially threaded 3.5 mm cannulated screws provide inferior fixation stiffness and could potentially affect clinical outcomes. [ABSTRACT FROM AUTHOR]

Posterior glenohumeral instability represents a wide spectrum of pathoanatomic processes. A key consideration is the interplay between the posterior capsulolabral complex and the osseous anatomy of the glenoid and humeral head. Stability is dependent upon both the presence of soft tissue pathology (eg, tears to the posteroinferior labrum or posterior band of the inferior glenohumeral ligament, glenoid bone loss, reverse Hill Sachs lesions, and pathologic glenoid retroversion or dysplasia) and dynamic stabilizing forces. This review highlights unique pathoanatomic features of posterior shoulder instability and associated biomechanics that may exist in patients with posterior glenohumeral instability. [ABSTRACT FROM AUTHOR]

Utilizing fresh distal tibia allograft in anterior glenoid reconstruction has emerged as a highly advantageous approach in addressing instances of failed anterior shoulder stabilization with glenoid bone loss. This procedure offers several benefits, including the absence of donor-site morbidity, restoration of significant glenoid defects, reestablishment of joint congruity with the humeral head, restoration of glenoid biomechanics, and the addition of cartilage to the glenoid. Furthermore, it provides a robust and reliable alternative for managing failed stabilization procedures, leading to improved clinical outcomes and a high graft healing rate, while maintaining a low occurrence of recurrent instability. [ABSTRACT FROM AUTHOR]

Historically considered the gold standard technique for glenohumeral instability, the open Bankart repair is being performed at decreased rates because of the current trends favoring arthroscopic Bankart repair and the lack of consistent training of the open technique. However, open Bankart repairs may be more appropriate for certain high-risk populations (ie, high-level collision athletes) because of their reduced recurrent instability rates. Further investigations are needed to identify the indications for arthroscopic versus open Bankart repair and compare their outcomes in high-level athletes. This review highlights the indications, surgical technique, and clinical outcomes following open Bankart repairs in athletes. [ABSTRACT FROM AUTHOR]

Purpose: Instability of the glenohumeral joint remains a complex clinical issue with high rates of surgical failure and significant morbidity. Advances in specific radiologic measurements involving the glenoid and the humerus have provided insight into glenohumeral pathology, which can be corrected surgically towards improving patient outcomes. The contributions of capsular pathology to ongoing instability remain unclear. The purpose of this study is to provide a systematic review of existing glenohumeral capsular measurement techniques published in the last 15 years. Methods: A systematic review of multiple databases was performed following PRISMA guidelines for all primary research articles between 2008 and 2023 with quantitative measurements of the glenohumeral capsule in patients with instability, including anterior, posterior and multi‐directional instability. Results: There were a total of 14 articles meeting the inclusion criteria. High variability in measurement methodology across studies was observed, including variable amounts of intra‐articular contrast, heterogeneity among magnetic resonance sequence acquisitions, differences in measurements performed and the specific approach taken to compute each measurement. Conclusion: There is a need for standardization of methods in the measurement of glenohumeral capsular pathology in the setting of glenohumeral instability to allow for cross‐study analysis. Level of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Background: After arthroscopic Bankart repair (ABR) for anterior glenohumeral instability (GHI), adolescent athletes have higher rates of subsequent recurrent GHI than any other subpopulation. Elucidating which adolescents are at highest risk of postoperative recurrent GHI may optimize surgical decision-making. Purpose: To identify prognostic factors associated with subsequent recurrent GHI requiring revision stabilization surgery (RSS) after ABR. Study Design: Case-control study; Level of evidence, 3. Methods: The study included patients 12 to 21 years old who had undergone ABR for anterior GHI at a pediatric tertiary care hospital by 1 of 5 sports medicine fellowship–trained surgeons between 2000 and 2020. A multivariate Cox proportional hazards model, with percentage of patients with recurrent GHI undergoing subsequent RSS, was used with a time-to-event outcome analysis. The Cox model effects were expressed as the hazard ratio (HR). All tests were 2-sided, with an alpha of.05. Results: Records of 488 adolescent patients with ABR (78% male; mean age, 16.9 ± 1.98 years) were analyzed. Of these, 86 patients (17.6%) underwent subsequent RSS for recurrent GHI, yielding a cumulative risk of 8.8% at 2 years, 16.5% at 5 years, and 20% at 15 years. RSS occurred at a mean of 2.6 ± 2.1 years after ABR. Risk factors for RSS included >1 preoperative dislocation (2 dislocations: HR = 7.4, P =.0003; ≥3 dislocations: HR = 10.9, P <.0001), presence of a Hill-Sachs lesion (small: HR = 2.5, P =.0114; medium-large: HR = 4.2, P =.0004), younger age (1-year decrease: HR = 1.2, P =.0015), and participation in contact sports (HR = 1.8, P =.01). Adolescents with only 1 preoperative dislocation had a cumulative incidence of RSS (3.2%), which was significantly lower than those with 2 (24.2%) or ≥3 preoperative dislocations (33.5%). Conclusion: The number of dislocations before index ABR was the strongest risk factor for recurrent GHI requiring RSS in adolescents with anterior GHI, with 2 dislocations conferring >7-fold increased risk compared with a single preoperative dislocation. Other significant risk factors included the presence of a Hill-Sachs lesion, younger age, and participation in contact sports. [ABSTRACT FROM AUTHOR]

Background: Reports of glenohumeral translation in shoulders with traumatic anterior instability have been presented. The aim of this systematic review was to investigate anterior-posterior translation in shoulders with traumatic anterior instability. Methods: This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies including patients aged ≥15 years with previous traumatic anterior shoulder dislocation or subluxation were included. The outcome was anterior-posterior glenohumeral translation. A search of PubMed, Embase, and Cochrane library was performed on July 17, 2022. Two reviewers individually screened titles and abstracts, reviewed full text, extracted data, and performed quality assessment. Results: Twenty studies (582 unstable shoulders in total) of varying quality were included. There was a lack of standardization and unity across studies. Radiography, ultrasound, computed tomography, magnetic resonance imaging, motion tracking, instrumentation, and manual testing were used to assess the glenohumeral translation. The glenohumeral translation in unstable shoulders ranged from 0.0 ± 0.8 mm to 11.6 ± 3.7 mm, as measured during various motion tasks, arm positions, and application of external force. The glenohumeral translation was larger or more anteriorly directed in unstable shoulders than in stable when contralateral healthy shoulders or a healthy control group were included in the studies. Several studies found that the humeral head was more anteriorly located on the glenoid in the unstable shoulders. Conclusion: This systematic review provides an overview of the current literature on glenohumeral translation in traumatic anterior shoulder instability. It was not able to identify a threshold for abnormal translation in unstable shoulders, due to the heterogeneity of data. The review supports that not only the range of translation but also the direction hereof as well as the location of the humeral head on the glenoid seem to be part of the pathophysiology. Technical development and increased attention to research methodology in recent years may provide more knowledge and clarity on this topic in the future.

Background: Shoulder instability encompasses a spectrum of glenohumeral pathology ranging from subluxation to dislocation. While dislocation frequently leads to removal from play, athletes are often able to play through subluxation. Previous research on glenohumeral instability among athletes has largely focused on missed-time injuries, which has likely disproportionately excluded subluxation injuries and underestimated the overall incidence of shoulder instability. Purpose: To describe the epidemiology of shoulder instability injuries resulting in no missed time beyond the date of injury (non–missed time injuries) among athletes in the National Football League (NFL). Study Design: Descriptive epidemiology study. Methods: The NFL's electronic medical record was retrospectively reviewed to identify non–missed time shoulder instability injuries during the 2015 through 2019 seasons. For each injury, player age, player position, shoulder laterality, instability type, instability direction, injury timing, injury setting, and injury mechanism were recorded. For injuries that occurred during games, incidence rates were calculated based on time during the season as well as player position. The influence of player position on instability direction was also investigated. Results: Of the 546 shoulder instability injuries documented during the study period, 162 were non–missed time injuries. The majority of non–missed time injuries were subluxations (97.4%), occurred during games (70.7%), and resulted from a contact mechanism (91.2%). The overall incidence rate of game-related instability was 1.6 injuries per 100,000 player-plays and was highest during the postseason (3.5 per 100,000 player-plays). The greatest proportion of non–missed time injuries occurred in defensive secondary players (28.4%) and offensive linemen (19.8%), while kickers/punters and defensive secondary players had the highest game incidence rates (5.5 and 2.1 per 100,000 player-plays, respectively). In terms of direction, 54.3% of instability events were posterior, 31.9% anterior, 8.5% multidirectional, and 5.3% inferior. Instability events were most often anterior among linebackers and wide receivers (50% and 100%, respectively), while posterior instability was most common in defensive linemen (66.7%), defensive secondary players (58.6%), quarterbacks (100.0%), running backs (55.6%), and tight ends (75.0%). Conclusion: The majority of non–missed time shoulder instability injuries (97.4%) were subluxations, which were likely excluded from or underreported in previous shoulder instability studies due to the inherent difficulty of detecting and diagnosing shoulder subluxation. [ABSTRACT FROM AUTHOR]

The acromion morphology in a shoulder with posterior instability differs from that of a shoulder without glenohumeral instability. Specifically, the acromion with a flatter sagittal tilt, greater posterior acromial height, and less posterior coverage is associated with posterior instability. However, the association between acromion morphology and glenoid bone loss (GBL) in the setting of posterior glenohumeral instability has not previously been investigated. The purpose of this study was to determine whether acromial morphology influences the extent or pattern of posterior GBL in a cohort of patients with posterior glenohumeral instability. This multicenter retrospective study identified 89 shoulders with unidirectional posterior glenohumeral instability. Total area GBL was measured using the best-fit circle method on magnetic resonance imaging (MRI). Shoulders were divided into 3 groups: (1) no GBL (n = 30), (2) GBL 0%-13.5% (n = 45), or (3) GBL ≥13.5% (n = 14). Acromion measurements were performed on MRI and included acromial tilt, posterior acromial height, anterior acromial coverage, and posterior acromial coverage. Patients without GBL had a steeper acromial tilt (58.5° ± 1.4°) compared with those with 0%-13.5% GBL (64.3° ± 1.5°) or GBL ≥13.5% (67.7° ± 1.8°) (P =.004). Patients without GBL also had greater posterior coverage (65.4° ± 1.7°) compared with those with GBL (60.3° ± 1.4°) (P =.015). Posterior acromion height was not significantly different among groups. The results demonstrate that an acromion with a flatter sagittal tilt and less posterior coverage is associated with GBL in the setting of posterior glenohumeral instability. This is important to consider as posterior GBL has been identified as a risk factor for failure of posterior soft tissue–stabilizing procedures. [ABSTRACT FROM AUTHOR]

Intra-articular soft arthroscopic Latarjet technique (in-SALT) involves augmentation of arthroscopic Bankart repair (ABR) with soft tissue tenodesis of long head of biceps to upper subscapularis. This study was conducted to investigate superiority of outcomes of in-SALT–augmented ABR over those of concurrent ABR and anterosuperior labral repair (ASL-R) in management of type V superior labrum anterior-posterior (SLAP) lesion. This prospective cohort study (conducted between January 2015 and January 2022) included 53 patients with arthroscopic diagnosis of type V SLAP lesion. Patients were allocated into 2 consecutive groups: group A of 19 patients managed with concurrent ABR/ASL-R and group B of 34 patients managed with in-SALT–augmented ABR. Outcome measurements included 2-year postoperative pain, range of motion, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Rowe instability scores. Failure was defined as frank/subtle postoperative recurrence of glenohumeral instability or objective diagnosis of Popeye deformity. The statistically matched studied groups showed significant postoperative improvement in outcome measurements. However, group B demonstrated significantly better 3-month postoperative visual analog scale score (3.6 vs. 2.6, P =.006) and 24-month postoperative external rotation at 0° abduction (44° vs. 50°, P =.020) and ASES (84 vs. 92, P <.001) and Rowe (83 vs. 88, P =.032) scores. Rate of postoperative recurrence of glenohumeral instability was relatively lower in group B (10.5% vs. 2.9%, P =.290). No Popeye deformity was reported. For management of type V SLAP lesion, in-SALT–augmented ABR yielded a relatively lower rate of postoperative recurrence of glenohumeral instability and significantly better functional outcomes compared with concurrent ABR/ASL-R. However, currently reported favorable outcomes of in-SALT should be validated via further biomechanical and clinical studies. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose of Review: Anterior glenohumeral instability is a common injury in contact and collision athletes, and in-season management remains a controversial topic. Recent Findings: Several recent studies have examined non-operative and operative management of in-season athletes after instability events. Non-operative treatment is associated with faster return to play and higher rates of recurrent instability. Dislocations and subluxations have similar rates of recurrent instability but non-operatively treated subluxations have a quicker return to play than dislocations. Operative treatment is often a season ending decision but is associated with high rates of return to sport and significantly lower rates of recurrent instability. Summary: Indications for in-season operative intervention may include critical glenoid bone loss (>15%), an off-track Hill-Sachs lesion, an acutely reparable bony Bankart lesion, high-risk soft tissue injures such as a humeral avulsion of the glenohumeral ligament or displaced anterior labral periosteal sleeve avulsion, recurrent instability, insufficient time remaining in season to rehabilitate from injury, and inability to successfully return to sport with rehabilitation. It is the role of the team physician to appropriately educate athletes on risks and benefits of operative and non-operative treatment strategies and guide athletes through the shared decision-making process that balances these risks against their long-term health and athletic career goals. [ABSTRACT FROM AUTHOR]

Background: Several reports have shown that shoulder stabilizing procedures lead to postoperative external rotation (ER) deficits. However, no study on arthroscopic Latarjet procedures has investigated the effect on ER when the arm is abducted at 0° (ER0) and 90° (ER90). This study examined the relationship between the arthroscopic Latarjet procedure and the subsequent effect on ER0 and ER90. Methods: Patients who underwent an arthroscopic Latarjet procedure from December 2015 to April 2021 were retrospectively evaluated. Preoperative ER0 and ER90 values were obtained from the contralateral shoulder. ER0 and ER90 values from the operative side were collected at both 3 and 6 months postoperatively. A repeated measures ANOVA was performed to assess the mean preoperative and postoperative values. Results: Forty-six patients met the inclusion criteria. Mean ER0 for the 3- and 6-month time frames measured 44.2° and 54.6°, respectively. Mean ER90 for the 3- and 6-month time frames measured 78.4° and 90.4°, respectively. Comparison to the contralateral arm at the 3-month follow-up period showed a deficit of 14.9° (P = .0001) and 17.2° (P = .0001) for ER0 and ER90, respectively. At the 6-month follow-up period, patients demonstrated an average decline in ER0 and ER90 of 4.57° (P = .063) and 5.11° (P = .008), respectively. Conclusion: A nominal deficit in ER occurred for both ER0 and ER90 status post arthroscopic Latarjet procedure. Despite loss of ER90 at 6 months achieving statistical significance, the clinical impact is arguably inconsequential. Such limited loss of ER provides more information regarding bony procedures being a more definitive treatment for glenohumeral instability and the ability to restore native motion.

Introduction: Posterior shoulder dislocation in association with reverse Hill–Sachs lesion is a rather rare injury. Few studies reporting results after joint-preserving surgery in these cases are available. This current study presents the clinical outcomes 10 years postoperatively. Materials and methods: In a prospective case series, we operatively treated 12 consecutive patients (all males) after posterior shoulder dislocation with associated reverse Hill–Sachs lesion using joint-preserving techniques. Patients received surgery in a single center between January 2008 and December 2011. The joint-preserving surgical procedure was chosen depending on the defect size and bone quality. The following outcome-measures were analyzed: Constant-Score, DASH-Score, ROWE-Score, and SF-12. Results 1, 5, and 10 years postoperatively were compared. Results: Out of 12 patients, ten patients (83.3%) were followed-up with a mean follow-up interval of 10.7 years (range 9.3–12.8). The mean patient age at the time of the last follow-up was 51 years (32–66). The outcome scores at the final follow-up were: Constant 92.5 (range 70.0–100), DASH 3.2 (0.0–10.8), ROWE 91.0 (85.0–100), and SF-12 87.8 (77.5–98.3). Clinical results had improved from 1 to 5 years postoperatively and showed a tendency for even further improvement after 10 years. Conclusions: Joint-preserving surgical therapy of posterior shoulder dislocation provides excellent results when the morphology of the reverse Hill–Sachs lesion is respected in surgical decision-making. Trial registration: 223/2012BO2, 02 August 2010. [ABSTRACT FROM AUTHOR]

Background: Lesions that involve humeral avulsions of the glenohumeral ligament (HAGLs), although less common, are primary contributors to recurrent events of dislocation and subluxation of the glenohumeral joint. Purpose: To describe the clinical presentation, examination, and surgical outcomes of patients presenting with HAGL lesions who underwent repair using an arthroscopic or open technique. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective review of prospectively collected data was performed of skeletally mature patients without glenohumeral arthritis who presented with HAGL lesions and subsequently underwent arthroscopic or open repair between 2005 and 2017. Independent variables included patient characteristics, clinical presentation, physical examination findings, and arthroscopic findings. Dependent variables included pre- and postoperative Single Assessment Numeric Evaluation (SANE) score, Western Ontario Shoulder Instability Index (WOSI) score, and range of motion outcomes. Results: Eighteen patients diagnosed with a HAGL lesion who underwent primary arthroscopic repair (n = 7) or open repair (n = 11) were included. There were 17 male patients and 1 female patient with a mean age of 24.9 years (range, 16-38 years). Mean follow-up duration was 50.9 months (range, 24-160 months). Seventeen patients (94.4%) reported pain as the most common symptom, and 7 (38.9%) reported sensation of instability. Scores significantly improved from pre- to postoperative for the arthroscopic and open groups (P <.001): SANE (mean ± SD; arthroscopic, 30.7 ± 15.7 to 92.1 ± 12.2; open, 45.5 ± 8.50 to 90.7 ± 5.24) and WOSI (arthroscopic, 51.4 ± 11.4 to 2.49 ± 3.70; open, 45.5 ± 7.37 to 11.5 ± 5.76). The magnitude of improvement in SANE scores was significantly higher for patients treated arthroscopically (Δ60.0; open, Δ46.5; P =.012). Postoperative WOSI scores were also significantly better in the arthroscopic cohort (2.49 ± 3.70; open, 11.5 ± 5.76; P =.00094). Conclusion: Symptomatic HAGL tears present primarily with pain as opposed to instability, necessitating a high index of suspicion for injury. The tears may be treated successfully with an arthroscopic or open technique with significant improvements in patient-reported outcomes and stability. [ABSTRACT FROM AUTHOR]

Subcritical bone loss has been identified as a risk factor for potentially inferior outcomes following typical arthroscopic soft tissue repair. One alternative that has been presented as an option for patients with bone loss is the Latarjet, an ipsilateral coracoid transfer to the anteroinferior glenoid. The purpose of this study is to compare the outcomes between the arthroscopic Bankart repair and the open Latarjet for the treatment of anterior shoulder instability in patients with subcritical bone loss. We hypothesize that the open Latarjet will provide higher patient-reported outcome measure scores and lower rates of dislocation. A retrospective cohort comparison of patients with anterior glenohumeral instability procedures was performed. Inclusion criteria included symptomatic anterior shoulder instability, subcritical glenoid bone loss (13.5%-24%), surgical treatment with arthroscopic Bankart repair or open Latarjet, and minimum follow-up of 2 years. Outcomes included recurrent instability (defined as postoperative dislocation or subjective subluxation), permanent physical restrictions, Western Ontario Shoulder Index (WOSI), and Single Assessment Numeric Evaluation (SANE) scores. Forty-seven patients were included, 25 of whom underwent an arthroscopic Bankart repair and 23 patients an open Latarjet. The average bone loss was 17.8% and 19.3%, respectively. Overall, 8 patients experienced recurrent instability, 6 in the arthroscopic Bankart group and 2 in the open Latarjet group (P =.162). The average postoperative SANE score for arthroscopic Bankart group was 48% and for the open Latarjet group, 84% (P <.001). The average postoperative WOSI score for the arthroscopic Bankart group was 53.6% and for the open Latarjet group, 67.9% (P =.069). There were significantly more patients placed on permanent physical restrictions in the arthroscopic Bankart repair group (16) compared with open Latarjet (3) (P <.001). In patients with subcritical glenoid bone loss (defined as 13.5%-24%), patients treated with an open Latarjet have insignificantly higher SANE and WOSI scores and lower permanent physical restrictions than patients treated with an arthroscopic Bankart repair. We found no statistically significant difference in recurrent instability rates between the open Latarjet and arthroscopic Bankart repair (P =.162). [ABSTRACT FROM AUTHOR]

Isolated deltoid paralysis is a rare pathology that can occur after axillary nerve injury due to shoulder trauma or infection. This condition leads to loss of deltoid function that can cause glenohumeral instability and inferior subluxation, resulting in rotator cuff muscle fatigue and pain. To establish dynamic glenohumeral stability, a novel technique was invented. Humeral suspension is achieved using a double button implant with non-resorbable high strength cords between the acromion and humeral head. This novel technique was used in two patients with isolated deltoid paralysis due to axillary nerve injury. The results indicate that the humeral suspension technique is a method that supports centralizing the humeral head and simultaneously dynamically stabilizes the glenohumeral joint. This approach yielded high patient satisfaction and reduced pain. Glenohumeral alignment was improved and remained intact 5 years postoperative. The humeral suspension technique is a promising surgical method for subluxated glenohumeral joint instability due to isolated deltoid paralysis.

Background: Anterior and posterior glenoid bone loss morphology have both been individually and morphologically described in previous studies. While there exists substantial literature on anterior bone loss, and emerging evidence describing posterior bone loss, a direct comparison between the two is lacking in the current literature. The purpose of this study is to quantitatively compare the anatomic and morphological differences in glenoid bone loss (GBL) in operative patients with anterior versus posterior glenohumeral instability. Methods: All patients over a 3-year period indicated for operative stabilization with posterior glenohumeral instability and suspected glenoid bone loss who underwent a computed tomography (CT) scan were reviewed. Included patients were then singularly matched by gender, laterality, and age (±3 years) to a collection of patients who presented for operative stabilization of anterior glenohumeral instability. GBL parameters were assessed based on the following characterizing measurements: (1) percentage of GBL, (2) glenoid vault version, (3) slope of the glenoid defect relative to the glenoid surface, (4) superior-inferior defect height, and (5) anterior-posterior defect width. Results: Sixty patients (30 anterior GBL, 30 posterior GBL) were included in the final analysis (60 males), with a mean age of 28.8 ± 8.15 years (range 16.0 to 51.0 years). Patients with anterior instability presented with higher GBL (24.94% ± 7.69 vs. 9.22% ± 5.58, P

Distal tibial allograft (DTA) reconstruction for glenoid bone loss (GBL) has gained popularity. While recent studies have demonstrated that glenoid concavity is an important factor in native glenohumeral stability, there remains a paucity of data regarding concavity restoration during reconstructive procedures for GBL and its biomechanical effect.To compare the restoration of anterior glenohumeral stability and glenoid concavity after DTA and classic Latarjet procedures.Controlled laboratory study.Nine human cadaveric specimens (mean age, 62.2 years; range, 52-69 years) underwent pretesting computed tomography (CT) to assess native glenoid concavity as determined by the glenoid depth and bony shoulder stability ratio (BSSR). GBL was created so the DTA and Latarjet graft could restore 100% of the native glenoid width. The rotator cuff tendons were loaded, and anterior stability testing was performed using a KUKA robot to apply a controlled anterior force with the shoulder in 90° of abduction and neutral external rotation. A motion capture system recorded humeral head translation. The following conditions were tested: intact, soft tissue Bankart lesion; bone loss model with DTA reconstruction; classic Latarjet procedure without conjoint tendon loaded; and classic Latarjet procedure with conjoint tendon loaded (sling effect). All specimens underwent posttesting CT to measure the BSSR of the DTA and Latarjet reconstructions. A repeated-measures analysis of variance was performed to compare the BSSR and anterior translations between the DTA and Latarjet reconstructions.DTA produced greater concavity than the Latarjet procedure (BSSR: 0.45 vs 0.35; P < .001). There was no difference in anterior translation between the DTA and Latarjet procedures with the sling effect (5.1 mm vs 4.7 mm; P > .999). However, maximum anterior translation was decreased after the DTA procedure when compared with the Latarjet technique without the sling effect (5.1 mm vs 10.3 mm; P = .045).DTA produces a more concave reconstruction and decreased anterior translation compared with the flatter reconstruction produced by the classic Latarjet procedure without the sling effect. DTA and the classic Latarjet procedure with conjoint tendon loading, however, yielded equivalent reductions in anterior translation.Distal tibial allograft reconstruction is a biomechanically equivalent alternative to the classic Latarjet due to the restoration of glenoid concavity in addition to glenoid width. Surgeons should consider the role of concavity when addressing glenohumeral instability with bone loss. [ABSTRACT FROM AUTHOR]

While risk factors for recurrent instability (RI) after arthroscopic Bankart repair (ABR) for anterior glenohumeral instability (aGHI) have been well established in adult populations, there is much less evidence in pediatric and adolescent patients, despite being the most affected epidemiologic subpopulation.To identify the clinical, demographic, radiologic, and operative risk factors for RI after ABR for aGHI in pediatric and adolescent patients.Systematic review; Level of evidence, 4.This systematic review was performed according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Three databases (PubMed, Embase, and Ovid [MEDLINE]) were searched from data inception to July 5, 2023, using the terms “pediatric,”“shoulder instability,” and “Bankart repair,” allowing data on patients with age up to 19 years. The Methodological Index for Non-randomized Studies tool was used to assess the quality of included studies.Eleven studies met the criteria, with 767 patients (770 shoulders) with a mean age of 16.4 years (range, 12-19; 18% female). The pooled RI rate was 28%, and the revision aGHI surgery rate was 20%. The following risk factors were identified for RI after ABR, in descending order of frequency of identification, in terms of number of studies: younger age and greater glenoid bone loss, as well as the presence and/or greater size of a Hill-Sachs lesion (HSL) (2 studies each), followed by off-track HSL, >1 dislocation before index surgery, overhead and/or contact sports participation, larger anterior labral tear size, loss of glenoid retroversion, greater number of anchors used, lower postoperative patient-reported outcome scores (PROs), nonunion after bony Bankart repair, and absence of concomitant remplissage (1 study each).In pediatric and adolescent patients with aGHI, the most common risk factors identified for RI after ABR were younger age, greater glenoid bone loss, and the presence and greater size of an HSL. Other risk factors included >1 dislocation before index surgery, participation in overhead and/or contact sports, larger anterior labral tear size, loss of glenoid retroversion, greater number of anchors used, lower postoperative PROs, nonunion after bony Bankart repair, and absence of concomitant remplissage. [ABSTRACT FROM AUTHOR]

Background: Few studies have compared conventional and self-assisted shoulder reduction maneuvers. The goal of this study was to evaluate the results of self-assisted Davos vs. traction/countertraction (T/Ct) techniques in the treatment of acute anterior shoulder dislocations. Methods: This was a single-center, prospective study carried out at a tertiary hospital emergency department. Patients aged 18-69 years old, with radiographic confirmation of anterior glenohumeral dislocations, were consecutively allocated to treatment groups. Recorded data included pain at admission (visual analog scale [VAS] score at admission), analgesia before reduction, maximum pain during reduction (maximum VAS score), demographic characteristics, lesion mechanism, laterality, prior dislocation, and immediate complications. The primary outcomes were reduction success rate and pain. Results: Eighty individuals were included (40/group). Regarding the success rate, no statistically significant differences were found between Davos or T/Ct (87.5% vs. 85%; P = .058). The maximum VAS score was significantly lower in Davos than that in T/Ct (4.18 ± 2.00 vs. 6.30 ± 2.13; P

ObjectiveTo utilize the 3D inversion recovery prepared ultrashort echo time with cones readout (IR-UTE-Cones) MRI technique for direct imaging of lamellar bone with comparison to the gold standard of computed tomography (CT).Materials and methodsCT and MRI was performed on 11 shoulder specimens and three patients. Five specimens had imaging performed before and after glenoid fracture (osteotomy). 2D and 3D volume-rendered CT images were reconstructed and conventional T1-weighted and 3D IR-UTE-Cones MRI techniques were performed. Glenoid widths and defects were independently measured by two readers using the circle method. Measurements were compared with those made from 3D CT datasets. Paired-sample Student's t tests and intraclass correlation coefficients were performed. In addition, 2D CT and 3D IR-UTE-Cones MRI datasets were linearly registered, digitally overlaid, and compared in consensus by these two readers.ResultsCompared with the reference standard (3D CT), glenoid bone diameter measurements made on 2D CT and 3D IR-UTE-Cones were not significantly different for either reader, whereas T1-weighted images underestimated the diameter (mean difference of 0.18 cm, p = 0.003 and 0.16 cm, p = 0.022 for readers 1 and 2, respectively). However, mean margin of error for measuring glenoid bone loss was small for all modalities (range, 1.46-3.92%). All measured ICCs were near perfect. Digitally registered 2D CT and 3D IR-UTE-Cones MRI datasets yielded essentially perfect congruity between the two modalities.ConclusionsThe 3D IR-UTE-Cones MRI technique selectively visualizes lamellar bone, produces similar contrast to 2D CT imaging, and compares favorably to measurements made using 2D and 3D CT.

Introduction: The glenohumeral joint serves as the attachment for the upper extremity to the axial skeleton and is both the most mobile and one of the most commonly injured articulations of the human body. The glenoid labrum, glenohumeral ligaments, and posterior capsular ligaments comprise the main connective tissue supports to the joint. Trauma to this tissue is common in overhead athletics. Case Report: A 15-year-old female high school softball player with no prior history of either shoulder or elbow pathologies presented with pain in the elbow of her throwing arm that progressed to her shoulder during her high school softball team's fall season. The athlete received an MRI showing the presence of a Buford complex, a normal anatomical variation of the glenoid labrum in which the anterosuperior portion of the labrum is undeveloped in conjunction with an overdeveloped cord like middle glenohumeral ligament that originates upon the superior portion of the glenoid at the same location of the base of the biceps tendon. The athlete underwent a supervised rehabilitation program and continued athletic participation until she eventually developed glenohumeral multidirectional instability and secondary cubital tunnel syndrome with associated ulnar nerve subluxation. The athlete was managed through rehabilitation until the development of the secondary pathologies which were treated surgically. Clinical Implications for Practice: Athletic trainers and all allied health care professionals should be aware of the Buford complex, particularly if they deal with athletes in overhead sports. The Buford should be considered a predisposing factor to glenohumeral and glenoid labrum pathologies, and proper prophylactic practices may serve to reduce the incidence of injury or reinjury to the affected shoulder in these individuals. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic status has been shown to influence patients' ability to access health care. Purpose: To evaluate the socioeconomic status and/or insurance provider of patients and to determine whether these differences influence the management of shoulder instability. Study Design: Descriptive epidemiology study. Methods: The Rhode Island All-Payers Claims Database (APCD) was used to identify all patients between the ages of 5 and 64 years who made an insurance claim related to a shoulder instability event between January 1, 2011, and December 31, 2019. Chi-square analysis and multivariate logistic regression were utilized to determine whether insurance status, social deprivation index (SDI), or median income by zip code were significant predictors of treatment methodology and recurrent instability. Kaplan-Meier failure analysis and Cox regression were used to assess for variation in the cumulative rates of surgical intervention and recurrent instability over 20-year age groups (5-24, 25-44, and 45-64 years). Results: There were 3310 patients from the APCD query included in the analysis. Bivariate analysis demonstrated significant variation in the rates of surgical stabilization between patients with public and commercial insurance providers (P <.001). Patients with public insurance received surgery 1.8% of the time compared with 5.8% of the time in patients with commercial insurance. After controlling for recurrent instability, age, instability type (subluxation or dislocation) and directionality, and sex, patients with public insurance were 79% less likely to receive surgery within 30 days (P =.035) and 64% less likely to receive surgery within 1 year (P =.002). This disparity was most notable in the 5- to 24-year (hazard ratio [HR] = 0.28; 95% CI, 0.13-0.61) and 25- to 44-year (HR = 0.26; 95% CI, 0.08-0.89) age groups. Neither SDI quartile nor income quartile based on patient primary zip code had a clinically significant influence on rates of surgery or recurrent instability. Conclusion: These data demonstrate that patients with public insurance have a decreased likelihood of undergoing surgical stabilization to address glenohumeral instability compared with patients with commercial insurance. [ABSTRACT FROM AUTHOR]

Simple Summary: By osteotomizing the coracoid process from the scapula and transferring it, along with the conjoint tendon, to the anteroinferior glenoid rim, the Latarjet procedure treats recurrent anterior glenohumeral (GH) instability in patients with large anterior glenoid bone defects. One key factor affecting its efficacy is the positioning of the graft on the glenoid rim, which impacts not only GH joint stability, through the so-called bone block effect, but also the joint contact mechanics; however, limited data exist on the best graft placement. In this study, finite element models that consider different medial–lateral graft placements for the Latarjet procedure were applied to evaluate GH joint stability and articular contact pressures. The results showed that the contribution of the bone block effect to GH joint stability increased with bone graft lateralization; however, the lateralization of the bone graft was also associated with an increase in peak contact pressures, which raises concerns regarding the risk of osteoarthritis. A trade-off seems to exist between GH joint stability provided by the bone block effect and the risk of osteoarthritis. This study provides valuable information regarding the influence of bone graft placement on the bone block effect of the Latarjet procedure. The Latarjet procedure is the most popular surgical procedure to treat anterior glenohumeral (GH) instability in the presence of large anterior glenoid bone defects. Even though the placement of the bone graft has a considerable influence on its efficacy, no clear indications exist for the best graft position. The aim of this study was to investigate the influence of the medial–lateral positioning of the bone graft on the contact mechanics and GH stability due to the bone block effect. Four finite element (FE) models of a GH joint, with a 20% glenoid bone defect, treated by the Latarjet procedure were developed. The FE models differed in the medial–lateral positioning of the bone graft, ranging from a flush position to a 4.5 mm lateral position with respect to the flush position. All graft placement options were evaluated for two separate shoulder positions. Anterior GH instability was simulated by translating the humeral head in the anterior direction, under a permanent compressive force, until the peak translation force was reached. Joint stability was computed as the ratio between the shear and the compressive components of the force. The lateralization of the bone graft increased GH stability due to the bone block effect after a 3 mm lateralization with respect to the flush position. The increase in GH stability was associated with a concerning increase in peak contact pressure due to the incongruous contact between the articulating surfaces. The sensitivity of the contact pressures to the medial–lateral positioning of the bone graft suggests a trade-off between GH stability due to the bone block effect and the risk of osteoarthritis, especially considering that an accurate and consistent placement of the bone graft is difficult in vivo. [ABSTRACT FROM AUTHOR]

Background: The scapular spine has been described as a relatively new bone graft alternative used in glenoid augmentation. The classic Latarjet procedure, which transfers the coracoid as a graft, is regarded as the gold standard. The comparison of these 2 techniques has not been fully reported. Purpose: To compare the anatomic and biomechanical properties of glenoid augmentation using scapular spine graft or coracoid graft. Study Design: Controlled laboratory study. Methods: The study used 20 fresh-frozen human cadaveric shoulders. A 25% anterior glenoid defect was created, and the specimens were divided randomly to receive glenoid augmentation by scapular spine or coracoid grafts. For both procedures, the grafts were secured to the glenoid defect with 2 screws. Morphometric data, including the glenoid articular area, amount of restoration, and graft dimensions, were obtained. A biomechanical test was conducted in a direct-loading scenario. The construct stiffness, cyclic displacement, and ultimate failure of each specimen were collected. Results: No significant difference was found in glenoid articular restoration between the scapular spine group and the coracoid group (31% vs 33%, respectively; P =.311). Morphometric analysis indicated that coracoid grafts exhibited significantly greater thickness and height than scapular spine grafts. In biomechanical results, the scapular spine group exhibited significantly greater construct stiffness than the coracoid group (206.3 ± 58.8 vs 148.3 ± 76.0 N/mm, respectively; P =.023). The average failure load in the scapular spine group was not significantly higher than that in the coracoid group. No significant differences in cyclic displacement were found between the 2 techniques. Conclusion: In a simulated 25% anterior glenoid bony defect, a scapular spine graft was comparable with the classic Latarjet procedure in restoring the glenoid articular dimension and exhibited superior construct stiffness in a cadaveric model. Clinical Relevance: The scapular spine may serve as an alternative graft choice in glenoid augmentation surgery considering the amount of articular restoration and initial fixation stability. [ABSTRACT FROM AUTHOR]

To determine whether the addition of 3-dimensional (3D) magnetic resonance imaging (MRI) to standard MRI sequences is comparable to 3D computed tomographic (CT) scan evaluation of glenoid and humeral bone loss in glenohumeral instability. Eighteen patients who presented with glenohumeral instability were prospectively enrolled and received both MRI and CT within 1 week of each other. The MRI included an additional sequence (volumetric interpolated breath-hold examination [VIBE]) that underwent postprocessing for reformations. The addition of a VIBE protocol, on average, is an additional 4-4.5 minutes in the scanner. CT data also underwent 3D postprocessing, and therefore each patient had 4 imaging modalities (2D CT, 2D MRI, 3D CT reformats, and 3D MRI reformats). Each sequence underwent the following measurements from 2 separate reviewers: glenoid defect, glenoid defect percentage, humeral defect, humeral defect percentage, and evaluation of glenoid track and version. Paired t tests were used to assess differences between imaging modalities and χ2 for glenoid track. Intra- and interobserver reliability were evaluated. Bland-Altman tests were also performed to assess the agreement between CT and MRI. In addition, we determined the cost of each imaging modality at our institution. 3D MRI measurements for glenoid and humeral bone loss measurements were comparable to 3D CT (Table 1). There were no significant differences for glenoid defect size and percentage, or humeral defect size and percentage (P >.05) (Table 2). Bland-Altman analysis demonstrated strong agreement, with small measurement errors for 3D CT and 3D MRI percentage glenoid bone loss. There was also no difference in evaluation for determining on vs. off track between any of the imaging modalities. Inter- and intrarater reliability was good to excellent for all CT and MRI measurements (r ≥ 0.7). 3D MRI measurements for bone loss in glenohumeral instability through use of VIBE sequence were equivalent to 3D CT. At our institution, undergoing MRI with 3D reconstruction was 1.67 times cheaper than MRI and CT with 3D reconstructions. 3D MRI may be a useful adjuvant to standard MRI sequences to allow concurrent soft tissue and accurate assessment of glenoid and humeral bone loss in glenohumeral instability. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY This study aimed to evaluate the clinical outcomes and the rate of recurrence in patients who had undergone arthroscopic Bankart repair with remplissage for anterior instability of the glenohumeral joint. MATERIAL AND METHODS The study included 96 arthroscopic Bankart procedures with remplissage performed between 2013 and 2019 at our department in 93 patients (81 men and 12 women; with the mean age of 33 years). We gathered and analysed preoperative data, including a 3D-CT scan of the affected shoulder. Apart from stability, the functional results were assessed postoperatively using the WOSI, SSV, Rowe score, and by measuring the strength of shoulder girdle muscles. The non-parametric Mann- Whitney U-test was used to identify the predisposing factors for recurrence of glenohumeral instability. RESULTS The arthroscopic Bankart repair with remplissage was indicated in 74 shoulders for primary TUBS and in 22 shoulders as a revision procedure. The recurrent instability was observed in 13 of 96 operated shoulders (13.5%). Subjective instability (positive apprehension test in the extreme positions of the shoulder joint, in abduction and external rotation in particular) was reported by 10 patients (10/13; 77%), three patients experienced a redislocation of the glenohumeral joint in the postoperative follow-up (3/13 patients; 23%). The risk of recurrence of the glenohumeral instability was not correlated with either the number of previous stabilisation procedures, or any other preoperative or intraoperative parameters. Conversely, a new postoperative injury was a factor of key importance. The patients with recurrent instability (subjective instability or glenohumeral dislocation) achieved a significantly lower Rowe score, SSV, postoperative VAS, and worse overall satisfaction with the procedure compared to the group with no recurrent instability. The remplissage induced minor limitations of external rotation at 0° abduction and internal rotation at 90° abduction. After rehabilitation, the muscle strength of the operated shoulder in both groups was comparable to that of the untreated shoulder in all planes of the shoulder range of motion. DISCUSSION Our study confirms the clinical relevance of the addition of remplissage to the arthroscopic Bankart procedure for reducing the rate of recurrent glenohumeral instability in TUBS with a clinically significant Hill-Sachs lesion. Satisfaction with the surgical outcome is high; the functional outcomes are very good, including muscle strength. Surprisingly, though, the risk of recurrent instability does not correlate with the number of implants used in the stabilisation procedure. CONCLUSIONS Addition of remplissage to the arthroscopic Bankart stabilisation in patients with a clinically significant Hill-Sachs lesion shows a low risk of recurrence of glenohumeral instability after surgery compared to the conventional arthroscopic Bankart repair alone. The remplissage does cause minor restrictions in the glenohumeral joint external rotation, but it was not reflected in the satisfaction of patients or a lower clinical score of the shoulder joint. The preoperative assessment of the Hill- Sachs lesion using the “glenoid track” on a 3D-CT scan helps improve the preoperative planning and prediction of outcomes of the stabilisation procedure. [ABSTRACT FROM AUTHOR]

Purpose: The primary aim of this study was to investigate medium-term survivorship following arthroscopic Bankart repair (ABR) for anterior glenohumeral instability. The secondary aim was to determine whether the pre-operative magnetic resonance (MR) arthrography glenoid track measurement predicted recurrent instability following ABR. Methods: Over a 9-year period (2008–2017), 215 patients underwent ABR. Median age was 26 years (IQR 22–32.5; range 14–77). There were 173 males (81%). 175 patients (81%) had available pre-operative MR arthrography, which was used to determine the presence of "off-track" bone loss. Retrospective analysis was undertaken to determine recurrence of instability at a median follow-up of 76 months (range 21–125 months). Survivorship analysis was undertaken using Kaplan–Meier methodology: the endpoints examined were repeat dislocation, revision stabilisation, and symptomatic instability. Results: 56 patients (26%) presented with further instability, including 29 patients with recurrent dislocation and 15 patients required revision stabilisation. Cumulative incidence of instability was 10% at 1 year, 27% at 5 years and 28% at 7 years. No significant difference in instability was seen between men and women 7 years after stabilisation (19% vs 17%; p = 0.87). Age at time of surgery did not predict recurrence. "Off-track" lesions were identified in 29 patients (16.1%). The incidence of redislocation was significantly higher in these patients (24% vs 3%; p = 0.01; relative risk 7.2; 95% CI 2.45–20.5; p = 0.001). Recurrent instability without frank redislocation was also significantly higher in this group (60% vs 18%; RR 3.33, 95% CI 2.02–5.20; p < 0.0001). Conclusions: This study has reported a significant rate of recurrent instability in longer-term follow-up after ABR. It has also identified pre-operative MR arthrography as an important predictor of recurrent instability, which may be used to risk stratify patients with anterior instability in a typical UK population. Level of evidence: III (cohort study). [ABSTRACT FROM AUTHOR]