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Pasqualini I, Turan OA, Hurley ET, Frangiamore SJ, Levin JM, Dickens JF, Klifto CS, Rossi LA. Return to sports following arthroscopic Bankart repair in collision athletes: A systematic review. Shoulder Elbow 2025; 17:288-297. [PMID: 39552662 PMCID: PMC11562237 DOI: 10.1177/17585732241249959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 11/19/2024]
Abstract
Background The purpose of this study was to systematically review the rate and time frame to return to sports in collision athletes following arthroscopic Bankart repair. Methods A systematic literature search based on Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases was performed. Manuscripts were included if they studied collision or contact athletes, reported on return to play rates or percentages, underwent arthroscopic Bankart repair, published in a peer-reviewed journal, and published in English. The study characteristics and clinical outcomes were extracted. Results A total of 19 studies with 1077 patients were included. Among collision athletes undergoing arthroscopic Bankart repair, the overall rate of return to sports was 89.8% (range 72%-100%). The mean time to return to sports was 5 months (range 3-6). The overall rate of returning to the same level of play was 80.8% (range 71.1%-100%). There were high return to sports rates among all collision sports. Specific return-to-play criteria were reported in most of the studies (95%), with time to return to sport being the most reported item (89.4%). Conclusion Although overall return to sport among collision athletes following arthroscopic Bankart repair remains high, the proportion of athletes returning to their preoperative level of play was substantially lower.
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Affiliation(s)
- Ignacio Pasqualini
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Oguz A Turan
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Eoghan T Hurley
- Department of Orthopedic Surgery, Division of Hand and Upper Extremity, Duke University, Durham, NC, USA
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Jay M Levin
- Department of Orthopedic Surgery, Division of Hand and Upper Extremity, Duke University, Durham, NC, USA
| | - Jonathan F Dickens
- Department of Orthopedic Surgery, Division of Hand and Upper Extremity, Duke University, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopedic Surgery, Division of Hand and Upper Extremity, Duke University, Durham, NC, USA
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Wang C, Liu Y, Ding M, Wan S, Lin K, Tian Z, Li L. Knotless versus knotted arthroscopic Bankart repairs for anterior shoulder instability: a systematic review and meta-analysis. BMC Musculoskelet Disord 2025; 26:571. [PMID: 40483425 PMCID: PMC12144794 DOI: 10.1186/s12891-025-08832-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2024] [Accepted: 05/30/2025] [Indexed: 06/11/2025] Open
Abstract
BACKGROUND Arthroscopic Bankart repair can be performed via a more contemporary knotless procedure or a more traditional knotted procedure. Nonetheless, comparisons between these two techniques remain controversial. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search of PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science was conducted. Randomized controlled trials (RCTs) and cohort studies directly comparing the knotless and knotted arthroscopic Bankart procedures were included. The primary outcomes were rates of recurrent instability and revision surgeries. Secondary outcomes encompassed number of anchors, operative time, improvements in functional scores including Rowe score and Constant-Murley score (CMS), pain level assessed by the visual analogue scale (VAS) score, range of motion (ROM), adverse events, and radiological results. Quality assessment was performed using RoB2 and MINORS tools. Meta-analysis pooled RCT data using Review Manager 5.4.1, and non-pooled outcomes from cohort studies or limited RCT data were reported separately. RESULTS This meta-analysis included nine studies with a total of 729 patients. Pooled data from three RCTs demonstrated no significant differences between the two techniques in terms of re-dislocation (P = 0.78), recurrent anterior subluxation and positive apprehension test (P = 0.78), revision surgery (P = 0.94), number of anchors used (P = 0.26), or improvements in Rowe score (P = 0.15). For outcomes not suitable for pooling, qualitative analysis of trends indicated comparable outcomes between the groups, except a slightly reduced operative time in the knotless repair group. Adverse events were infrequently reported and occurred at similar rates in both groups. Limited radiological data from one RCT showed no significant differences in MRI parameters at the 24-month follow-up. CONCLUSION Both techniques demonstrate comparable clinical outcomes. The only potential advantage of the knotless technique is a possible reduction in operative time, though its clinical significance remains uncertain. Given the limitations of the evidence, these findings should be interpreted cautiously. CLINICAL TRIAL NUMBER Not applicable. PROSPERO REGISTRATION ID CRD42024586135.
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Affiliation(s)
- Cheng Wang
- Department of Orthopedics, Chengdu Jinniu District Traditional Chinese Medicine Hospital, Chengdu, 610041, People's Republic of China
| | - Yanhang Liu
- Department of Orthopedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, 610041, People's Republic of China
| | - Meng Ding
- Department of Rehabilitation, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, 610041, People's Republic of China
| | - Sha Wan
- Department of Orthopedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, 610041, People's Republic of China
| | - Kefu Lin
- Department of Orthopedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, 610041, People's Republic of China
| | - Zhen Tian
- Department of Orthopedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, 610041, People's Republic of China
| | - Lang Li
- Department of Orthopedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, 610041, People's Republic of China.
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Hanai H, Hirose T, Nakai H, Jacob G, Kotani Y, Kuratani K, Fujii T, Nakami H, Sahara W, Okada S, Hayashida K, Tanaka M. Early muscular training and immobilization in external rotation could reduce the recurrence rate in first-time shoulder dislocators among young rugby athletes. J Shoulder Elbow Surg 2025; 34:e446-e454. [PMID: 39805392 DOI: 10.1016/j.jse.2024.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 11/05/2024] [Accepted: 11/10/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND Among rugby players, anterior shoulder dislocation is challenging to treat during the in-season period. It often leads to recurrent shoulder instability and requires prolonged rest postsurgery. No studies have determined the effectiveness of immobilization, early muscle strength training, or both in preventing reinjury in this population. Thus, the present study aimed to determine the impact of treatment outcomes between different immobilization methods and early muscle strength training in the conservative treatment of first-time anterior shoulder dislocation among young rugby players. METHODS Rugby players under 23 years of age who chose conservative treatment for first-time anterior shoulder dislocation were included. The recurrence rate and recurrence-free period in a season and 2 years after return to sport (RTS) were retrospectively investigated for each immobilization method. The subjects were classified into 3 groups based on the immobilization method used: IIR group (incomplete immobilization in internal rotation was advised), iER group (strength training was started after 3-4 weeks of immobilization in external rotation [ER]), and iER + T group (early muscle strength training was combined immediately after the start of ER immobilization). All groups were allowed to RTS 8 weeks after injury or later. The endpoint was defined as a dislocation episode or the subjective feeling of shoulder subluxation, to a degree where the player could no longer continue to play the rest of the season. RESULTS Thirty-four shoulders of 34 patients (31 males and 3 females; median age at injury: 17 [range: 15-22] years) were included (IIR group, 8 shoulders; iER group, 8 shoulders; and iER + T group 18 shoulders). The recurrence rates during the first season after RTS were 100%, 87.5%, and 55.6% in the IIR, iER, and iER + T groups, respectively, with statistically significant difference between groups (P = .037). Compared with the IIR and iER groups, the iER + T group showed a longer survival curve with significant difference in the transition of each curve for the treatment success rate (P = .045). In the IIR, iER, and iER + T groups, approximately 0%, 11.7%, and 50.0% of patients were able to continue to play for more than half of the remaining season without any recurrence of instability, and the overall probability of recurrence in 2 years was estimated to be 100%, 100%, and 81.7%, respectively. CONCLUSION The combination of iER and early muscle strength training may be an effective treatment for anterior shoulder dislocation during the in-season period.
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Affiliation(s)
- Hiroto Hanai
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Orthopaedic Surgery, Osaka University Hospital, Osaka, Japan
| | - Takehito Hirose
- Department of Orthopaedic Surgery, Osaka International Medical & Science Center, Osaka, Japan
| | - Hidekazu Nakai
- Department of Orthopaedic Surgery, Osaka International Medical & Science Center, Osaka, Japan
| | - George Jacob
- Department of Orthopaedics, VPS Lakeshore Hospital, Ernakulam, Kerala, India
| | - Yuki Kotani
- Department of Orthopaedic Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Kosuke Kuratani
- Department of Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Takahiro Fujii
- Department of Rehabilitation, Osaka International Medical & Science Center, Osaka, Japan
| | - Hitoshi Nakami
- Department of Rehabilitation, Osaka International Medical & Science Center, Osaka, Japan
| | - Wataru Sahara
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenji Hayashida
- Department of Orthopaedic Surgery, Osaka Central Hospital, Osaka, Japan
| | - Makoto Tanaka
- Department of Orthopaedic Surgery, Osaka International Medical & Science Center, Osaka, Japan; Center for Sports Medicine, Osaka International Medical & Science Center, Osaka, Japan.
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Russo R, Fontanarosa A, Montemagno M, Fedele A, De Crescenzo A, Di Pietto F, Calbi R, Garofalo R. Return to sport after arthroscopic xenograft bone block associated with Bankart repair and subscapularis augmentation in competitive contact athletes with recurrent anterior shoulder instability. J Shoulder Elbow Surg 2025; 34:886-894. [PMID: 39067662 DOI: 10.1016/j.jse.2024.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/19/2024] [Accepted: 05/28/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Open Bankart repair and Latarjet stabilization are 2 widely used surgical procedures in the treatment of shoulder instability in contact athletes. This study evaluates the outcomes of bone block arthroscopic procedures, performed with a xenograft, in combination with Bankart repair and selective subscapularis augmentation for contact athletes with recurrent anterior shoulder instability. METHODS We retrospectively assessed contact athletes who underwent arthroscopic bone block with xenograft and Bankart repair with selective augmentation of the subscapularis for recurrent anterior shoulder instability between January 2017 and December 2021. Shoulders with posterior instability or multidirectional instability were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score, Western Ontario Shoulder Instability index [WOSI] score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form ASES score) were assessed. A computed tomography scan at 2-year follow-up was performed to assess the status of bone block integration, its displacement and restoration of glenoid surface. RESULTS Sixteen patients with a mean age of 24 years were included in the study. None of the patients treated with arthroscopic bone block and subscapularis augmentation presented new dislocation episodes. An increase in preoperative scores was observed at the last follow-up; in particular, the ASES, Rowe, and WOSI scores increased from 69 ± 7, 31 ± 9, and 1235 ± 46, respectively, to 96.1 ± 3.2, 94 ± 6, and 119 ± 51. All athletes returned to sporting activity at or near the same level as presurgery. The glenoid bone surface increase from 83% to 116% at the last follow-up. CONCLUSION Bone block treatment with xenograft combined with Bankart repair and arthroscopic subscapularis augmentation procedures has been shown to be effective in treating instability in contact athletes with significant glenoid deficit. All athletes returned to athletic activity at a level similar to the preintervention period.
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Affiliation(s)
- Raffaele Russo
- Department of Orthopedics and Traumatology, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Alberto Fontanarosa
- Department of Orthopedics and Traumatology, Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy.
| | - Marco Montemagno
- Department of Orthopedics and Traumatology, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Alfonso Fedele
- Department of Orthopedics and Traumatology, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Angelo De Crescenzo
- Department of Orthopedics and Traumatology, Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Francesco Di Pietto
- Department of Radiology, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Roberto Calbi
- Department of Radiology, Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Raffaele Garofalo
- Department of Orthopedics and Traumatology, Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
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Arce G, Deimundo M, Previgliano JP. "Bankart Repair and Beyond. Anticipating difficulties and managing complications. Current concepts". J Clin Orthop Trauma 2025; 62:102919. [PMID: 39898293 PMCID: PMC11786085 DOI: 10.1016/j.jcot.2025.102919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Revised: 01/04/2025] [Accepted: 01/10/2025] [Indexed: 02/04/2025] Open
Abstract
Anterior shoulder instability is a frequent complaint among young athletes. The Arthroscopic Bankart Repair (ABR) is a highly successful technique for restoring the native anatomy after a capsular and labrum avulsion lesion from the glenoid. The procedure has a low complication rate, and a large proportion of patients return to sports at the same pre-injury level. As a reliable surgical technique, ABR is rarely associated with intraoperative complications, but surgical details are critical to avoid struggling during the procedure. Postoperative complications, such as neurovascular injuries, infections, and stiffness, are significant concerns. In the long term, ABR's most common complications are the recurrence of instability and shoulder arthritis after the procedure. This article focuses on 1) the complications of ABR and the critical measures to prevent them, 2) additional techniques that can enhance primary ABR outcomes or address recurrences and failures, and 3) best practices to prevent shoulder arthritis after ABR.
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Affiliation(s)
- Guillermo Arce
- Instituto Argentino de Diagnóstico y Tratamiento IADT, Marcelo T. de Alvear 2439, 1423, Buenos Aires, Argentina
| | - Marcos Deimundo
- Instituto Argentino de Diagnóstico y Tratamiento IADT, Marcelo T. de Alvear 2439, 1423, Buenos Aires, Argentina
| | - Juan Pablo Previgliano
- Instituto Argentino de Diagnóstico y Tratamiento IADT, Marcelo T. de Alvear 2439, 1423, Buenos Aires, Argentina
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Sacolick DA, Williams RR, Wu SJ, Kraeutler MJ, McCulloch PC. Surgical treatment of anterior glenohumeral instability: a historical review. J Shoulder Elbow Surg 2024; 33:2766-2779. [PMID: 39245257 DOI: 10.1016/j.jse.2024.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Glenohumeral instability is a common pathology, particularly in young, active patients. METHODS A narrative review was performed to describe the history of surgical treatments for anterior shoulder instability. RESULTS Open surgical techniques were first described by Bankart in 1923. Techniques include both anatomic soft tissue repairs and nonanatomic procedures to provide constraint to motion and dislocation. Osseous techniques to address glenoid bone loss include both autograft techniques, such as the Latarjet procedure, and the use of various allografts. Technologic advances, particularly arthroscopy, have continued to drive the evolution of treatments. The concept of the glenoid track has furthered our understanding of this pathology to guide appropriate treatment to reduce recurrence. CONCLUSIONS Surgical treatment for anterior shoulder instability continues to evolve in an effort to restore function and prevent additional injury.
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Affiliation(s)
| | - R Ryan Williams
- Houston Methodist Orthopedic & Sports Medicine, Houston, TX, USA
| | - Samuel J Wu
- Houston Methodist Orthopedic & Sports Medicine, Houston, TX, USA
| | - Matthew J Kraeutler
- Houston Methodist Orthopedic & Sports Medicine, Houston, TX, USA; Sports Medicine, University of Colorado, Boulder, CO, USA
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Minokawa S, Shibata Y, Shibata T, Kosaka H, Izaki T. Bone formation of the coracoid bone graft after the Bristow procedure assessed using three-dimensional computed tomography. J Orthop Sci 2024; 29:1382-1388. [PMID: 38030446 DOI: 10.1016/j.jos.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND The Bristow procedure has been shown to be a reliable method to prevent recurrent anterior shoulder instability by compensating for glenoid bone loss and producing the sling effect. The degree of postoperative morphological change in the coracoid bone graft is speculated to influence glenohumeral joint stability; however, the details of these changes after the Bristow procedure remain unknown. This study was performed to quantify the postoperative change in the coracoid bone graft volume as assessed by three-dimensional computed tomography (3D-CT). METHODS The Bristow procedure was performed on 17 shoulders in 17 patients from August 2018 to January 2020. All patients were men, and their mean age at surgery was 17.9 years. The mean follow-up duration was 21.4 months. Within the first week after the operation (Time 0) and at the final follow-up, 3D-CT was used to determine the total coracoid bone graft volume. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) shoulder score, the University of California Los Angeles (UCLA) shoulder score, and the Western Ontario Shoulder Instability Index (WOSI). RESULTS The mean volume of the total coracoid bone graft was 1.26 ± 0.29 cm3 at Time 0 and 1.90 ± 0.36 cm3 at the final follow-up (p < 0.0001). The mean JOA score, UCLA score, and WOSI were significantly better at the final follow-up than preoperatively (p < 0.001). No postoperative infection, neurovascular injury, or recurrent instability of the glenohumeral joint occurred. CONCLUSIONS In the Bristow procedure, the volume of the total coracoid bone graft as shown by 3D-CT was significantly greater at the final follow-up than at Time 0, and bone formation of the coracoid bone graft was found after the Bristow procedure.
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Affiliation(s)
- So Minokawa
- Department of Orthopaedic Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka 818-8502, Japan.
| | - Yozo Shibata
- Department of Orthopaedic Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka 818-8502, Japan
| | - Terufumi Shibata
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Hidetomo Kosaka
- Department of Orthopaedic Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka 818-8502, Japan
| | - Teruaki Izaki
- Department of Orthopaedic Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka 818-8502, Japan
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Greco V, Descamps J, Catalan NM, Chelli M, Joyce CD, Boileau P. High Rate of Return to Sport in Contact and Collision Athletes After Arthroscopic Latarjet With Cortical Button Fixation. Am J Sports Med 2024; 52:3094-3102. [PMID: 39324536 DOI: 10.1177/03635465241274797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
BACKGROUND Contact and collision athletes face a higher risk of recurrent anterior shoulder instability after surgical stabilization. The Latarjet procedure is often preferred given the high incidence of bony lesions. However, this stabilizing procedure, performed either open or arthroscopically, is met with concerns regarding complications and revision surgery rates. PURPOSE To evaluate the return to sport (RTS) and assess complication and instability recurrence rates in contact/collision athletes undergoing the arthroscopic Latarjet procedure using a guided technique with suture buttons for coracoid fixations. STUDY DESIGN Case series; Level of evidence, 4. METHODS A retrospective analysis was conducted on contact/collision athletes who underwent the arthroscopic Latarjet procedure for recurrent anterior shoulder instability between January 2011 and March 2018. All patients were operated on arthroscopically using glenoid and coracoid guides and suture button fixation of the transferred coracoid. RTS was defined as the patient being able to participate in his or her activity without any restriction postoperatively. Two independent observers assessed patients using postoperative computed tomography (CT) scans to evaluate coracoid positioning and healing. A multivariate analysis was performed to identify predictive factors associated with persistent apprehension. A group comparison was performed to assess RTS failure risk factors. RESULTS In 136 contact/collision athletes (mean age, 25 ± 7 years), 93% were satisfied, and 98% achieved shoulder stability at a mean follow-up of 60 months (range, 24-117 months). No suture button-related complications or neurovascular issues were reported. Overall, 82% (112/136) returned to contact/collision sports. The mean time to RTS was 5.3 ± 1.2 months (range, 3-7.3 months). In a CT study performed 2 weeks after surgery, 87% (118/136) of bone grafts were positioned below the equator and 93% (126/136) were flush to the glenoid surface. At the 6-month postoperative CT examination, complete bone block healing was achieved in 84% (114/136). On clinical examination at the latest follow-up, 36 patients (26%) reported some anterior apprehension on testing. On multivariate analysis, patients with severe humeral bone defects (medium to large Hill-Sachs lesions, Calandra grade 2 or 3) had a higher risk of postoperative persistent apprehension. On group comparison, a visual analog scale score >3 and persistent anterior apprehension were found to be associated with failure of RTS. CONCLUSION The arthroscopic Latarjet procedure with suture button fixation allowed 82% of athletes with recurrent anterior shoulder instability to return to contact or collision sports. Patients with severe humeral bone defects have a higher risk of persistent anterior apprehension and decreased RTS. The arthroscopic-guided procedure with suture button fixation is safe; accurate, with a high rate of anatomic graft positioning and healing; and reliable, with a low recurrence rate.
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Affiliation(s)
- Valentina Greco
- ICR-Institut de Chirurgie Réparatrice Locomoteur & Sport-Groupe KANTYS, Nice, France
| | - Jules Descamps
- ICR-Institut de Chirurgie Réparatrice Locomoteur & Sport-Groupe KANTYS, Nice, France
- Orthopedic and Traumatology Unit, Hospital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Natalia-Martinez Catalan
- ICR-Institut de Chirurgie Réparatrice Locomoteur & Sport-Groupe KANTYS, Nice, France
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Mikaël Chelli
- ICR-Institut de Chirurgie Réparatrice Locomoteur & Sport-Groupe KANTYS, Nice, France
| | - Christopher D Joyce
- ICR-Institut de Chirurgie Réparatrice Locomoteur & Sport-Groupe KANTYS, Nice, France
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Pascal Boileau
- ICR-Institut de Chirurgie Réparatrice Locomoteur & Sport-Groupe KANTYS, Nice, France
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Herman ZJ, Nazzal EM, Engler ID, Kaarre J, Drain NP, Sebastiani R, Tisherman RT, Rai A, Greiner JJ, Hughes JD, Lesniak BP, Lin A. Overhead athletes have comparable intraoperative injury patterns and clinical outcomes to non-overhead athletes following surgical stabilization for first-time anterior shoulder instability at average 6-year follow-up. J Shoulder Elbow Surg 2024; 33:1219-1227. [PMID: 38081472 DOI: 10.1016/j.jse.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND AND HYPOTHESIS Anterior shoulder instability is a common problem affecting young, athletic populations that results in potential career-altering functional limitations. However, little is known regarding the differences in clinical outcomes after operative management of overhead vs. non-overhead athletes presenting with first-time anterior shoulder instability. We hypothesized that overhead athletes would have milder clinical presentations, similar surgical characteristics, and diminished postoperative outcomes when compared with non-overhead athletes after surgical stabilization following first-time anterior shoulder instability episodes. METHODS Patients with first-time anterior shoulder instability events (subluxations and dislocations) undergoing operative management between 2013 and 2020 were included. The exclusion criteria included multiple dislocations and multidirectional shoulder instability. Baseline demographic characteristics, imaging data, examination findings, and intraoperative findings were retrospectively collected. Patients were contacted to collect postoperative patient-reported outcomes including American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy activity index score, and Subjective Shoulder Value, in addition to return-to-work and -sport, recurrent dislocation, and revision rates. RESULTS A total of 256 patients met the inclusion criteria, of whom 178 (70%) were non-overhead athletes. The mean age of the entire population was 23.1 years. There was no significant difference in concomitant shoulder pathology, preoperative range of motion, or preoperative strength between cohorts. A greater proportion of overhead athletes presented with instability events not requiring manual reduction (defined as subluxations; 64.1% vs. 50.6%; P < .001) and underwent arthroscopic surgery (97% vs. 76%, P < .001) compared with non-overhead athletes. A smaller proportion of overhead athletes underwent open soft-tissue stabilization compared with non-overhead athletes (1% vs. 19%, P < .001). Outcome data were available for 60 patients with an average follow-up period of 6.7 years. No significant differences were found between groups with respect to recurrent postoperative instability event rate (13.0% for overhead athletes vs. 16.8% for non-overhead athletes), revision rate (13.0% for overhead athletes vs. 11.1% for non-overhead athletes), American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy score, Subjective Shoulder Value, or rates of return to work or sport. CONCLUSION Overhead athletes who underwent surgery after an initial instability event were more likely to present with subluxations compared with non-overhead athletes. With limited follow-up subject to biases, this study found no differences in recurrence or revision rates, postoperative patient-reported outcomes, or return-to-work or -sport rates between overhead and non-overhead athletes undergoing shoulder stabilization surgery following first-time instability events. Although larger prospective studies are necessary to draw firmer conclusions, the findings of this study suggest that overhead athletes can be considered in the same treatment pathway for first-time dislocation as non-overhead athletes.
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Affiliation(s)
- Zachary J Herman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Ehab M Nazzal
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Janina Kaarre
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nicholas P Drain
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Romano Sebastiani
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert T Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ajinkya Rai
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Jonathan D Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Albert Lin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Plancher KD, Briggs KK, Zuccaro P, Tucker EE, Petterson SC. Arthroscopic Labral Reconstruction With a Modified Inferior Capsular Shift Allows Return to Sport and Excellent Outcomes in Contact and Noncontact Athletes With Anterior Shoulder Instability at Minimum 5-Year Follow-Up. Arthroscopy 2024; 40:1420-1430. [PMID: 37898306 DOI: 10.1016/j.arthro.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/22/2023] [Accepted: 10/18/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE To compare return to sport, functional outcomes, recurrence of instability, and osteoarthritis (OA) between collision/contact and limited/noncontact athletes following arthroscopic labral reconstruction with a modified inferior capsular shift for anterior shoulder instability. METHODS Athletes underwent an arthroscopic labral reconstruction with a modified inferior capsular shift by the senior author between 1999 and 2018. Inclusion criteria were labral stripping from 12 (just beyond the biceps anchor) to 6 o'clock, less than 20% glenoid bone loss, active sports participation, and no previous surgery. Athletes were divided into collision/contact and limited/noncontact groups. Outcome measures, physical examination, and radiographic evaluation were collected at a minimum 5-year follow-up. Reoperations or any subjective laxity were considered failures. Radiographs were analyzed for OA using the Samilson-Prieto Radiological Classification. RESULTS Ninety-two patients underwent arthroscopic labral reconstruction with a modified inferior capsular shift. Sixty-four met the inclusion criteria. Thirty-eight (age = 26.0 ± 8.0 years) participated in at least 1 collision/contact sport, and 26 (age = 38.0 ± 9.0 years) participated in limited/noncontact sports. Two (5%) collision/contact and 3 (12%) limited/noncontact athletes had traumatic reinjury requiring revision surgery. Of the remaining athletes (59/64), minimum 5-year follow-up was obtained on 54 (92%), with a mean follow-up of 12 ± 4 years (range 5-23 years). All athletes returned to their original sport at the same level. There was no significant difference between collision/contact and limited/noncontact athletes in timing of return to sports (5.2 ± 1.9 and 6.0 ± 3.1 months, respectively; P = .389). There were no significant differences between groups on any outcomes scores. CONCLUSIONS Arthroscopic labral reconstruction with a modified inferior capsular shift addressed anterior instability with return to sport for both collision/contact and limited/noncontact athletes with excellent functional and clinical outcomes, full shoulder range of motion, and a low prevalence of advanced OA at minimum 5-year follow-up. This modified technique resulted in a low failure rate in both limited/noncontact and collision/contact athletes. LEVEL OF EVIDENCE Level III, retrospective case control study.
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Affiliation(s)
- Kevin D Plancher
- Department of Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, U.S.A.; Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, U.S.A.; Plancher Orthopaedics & Sports Medicine, New York, New York, U.S.A.; Orthopaedic Foundation, Stamford, Connecticut, U.S.A..
| | | | - Philip Zuccaro
- Plancher Orthopaedics & Sports Medicine, New York, New York, U.S.A
| | - Erin E Tucker
- Plancher Orthopaedics & Sports Medicine, New York, New York, U.S.A
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11
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Griffith R, Tibone JE, McGarry MH, Adamson GJ, Lee TQ. Biomechanical comparison of open Bankart repair vs. conjoint tendon transfer in a 10% anterior glenoid bone loss shoulder instability model. J Shoulder Elbow Surg 2024; 33:757-764. [PMID: 37871791 DOI: 10.1016/j.jse.2023.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 09/06/2023] [Accepted: 09/10/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND The treatment of shoulder instability in patients with subcritical glenoid bone loss poses a difficult problem for surgeons as new evidence supports a higher failure rate when a standard arthroscopic Bankart repair is used. The purpose of this study was to compare a conjoint tendon transfer (soft-tissue Bristow) to an open Bankart repair in a cadaveric instability model of 10% glenoid bone loss. METHODS Eight cadaveric shoulders were tested using a custom testing system that allows for a 6-degree-of-freedom positioning of the glenohumeral joint. The rotator cuff muscles were loaded to simulate physiologic muscle conditions. Four conditions were tested: (1) intact, (2) Bankart lesion with 10% bone loss, (3) conjoint tendon transfer, and (4) open Bankart repair. Range of motion, glenohumeral kinematics, and anterior-inferior translation at 60° of external rotation with 20 N, 30 N, and 40 N were measured in the scapular and coronal planes. Glenohumeral joint translational stiffness was calculated as the linear fit of the translational force-displacement curve. Force to anterior-inferior dislocation was also measured in the coronal plane. Repeated measures analysis of variance with a Bonferroni correction was used for statistical analysis. RESULTS A Bankart lesion with 10% bone loss increased the range of motion in both the scapular (P = .001) and coronal planes (P = .001). The conjoint tendon transfer had a minimal effect on the range of motion (vs. intact P = .019, .002), but the Bankart repair decreased the range of motion to intact (P = .9, .4). There was a significant decrease in glenohumeral joint translational stiffness for the Bankart lesion compared with intact in the coronal plane (P = .021). The conjoint tendon transfer significantly increased stiffness in the scapular plane (P = .034), and the Bankart repair increased stiffness in the coronal plane (P = .037) compared with the Bankart lesion. The conjoint tendon transfer shifted the humeral head posteriorly at 60° and 90° of external rotation in the scapular plane. The Bankart repair shifted the head posteriorly in maximum external rotation in the coronal plane. There was no significant difference in force to dislocation between the Bankart repair (75.8 ± 6.6 N) and the conjoint tendon transfer (66.5 ± 4.4 N) (P = .151). CONCLUSION In the setting of subcritical bone loss, both the open Bankart repair and conjoint tendon transfer are biomechanically viable options for the treatment of anterior shoulder instability; further studies are needed to extrapolate these data to the clinical setting.
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Affiliation(s)
| | | | | | | | - Thay Q Lee
- Congress Medical Foundation, Pasadena, CA USA.
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12
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Mouchantaf M, Bastard C, Corsia S, Métais P, Nourissat G. High Rates of Return to Play and Low Recurrence Rate After Arthroscopic Latarjet Procedure for Anterior Shoulder Instability in Rugby Players. Arthrosc Sports Med Rehabil 2024; 6:100912. [PMID: 38590787 PMCID: PMC10999816 DOI: 10.1016/j.asmr.2024.100912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/09/2024] [Indexed: 04/10/2024] Open
Abstract
Purpose To analyze the rate of return to play, changes in athletic level, and recurrence rate and to report subjective outcomes in a series of rugby players with anterior shoulder instability who underwent an arthroscopic Latarjet procedure. Methods A multicenter retrospective study done in 2 centers on rugby players who were operated on between January 2011 and December 2020 was performed. Rugby players who underwent arthroscopic Latarjet procedure for anterior shoulder stabilization with a minimum follow-up period of 2 years were included. Rugby players were grouped according to their competitive level in their country (recreational, regional, national, and international). Data collected included return to sport after surgery, time to return to rugby, athletic level before and after surgery, patient satisfaction, and subjective scores. Recurrence and apprehension rates were also evaluated. Results A total of 73 subjects were included. Mean age at time of surgery was 23 ± 5 years. Mean duration of follow-up was 5 ± 2.6 years. Eighty-four percent of rugby players returned to rugby within a mean period of 6.6 months. Initial athletic level was a significant factor (P = .012) for not returning to sport, with 67% of patients who initially played at a recreational level not returning to rugby and 33% of patients who initially played at a regional league level not returning. All national and international players returned to play. Of the 12 non-returning rugby players, only 30% did not return because of their shoulder. Mean Subjective Shoulder Value was 90 ± 9%. Recurrence rate was 7%. Conclusions Arthroscopic Latarjet procedure proved its efficacy in managing recurrent anterior shoulder instability in rugby players. Return to play was achieved in almost all cases, with low recurrence rates. Despite high global return to the same level of sport, the higher the level of competition, the harder it is for rugby players to resume sport at the same level. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Mark Mouchantaf
- Clinique de l’épaule–Paris, Clinique Maussins-Nollet, Ramsay Sante, Paris, France
| | - Claire Bastard
- Service de Chirurgie Orthopedique–Hôpital Saint-Antoine, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Simon Corsia
- Service de Chirurgie Orthopédique–Hôpital Cochin, Assistance Publique–Hôpitaux de Paris, Paris, France
| | | | - Geoffroy Nourissat
- Clinique de l’épaule–Paris, Clinique Maussins-Nollet, Ramsay Sante, Paris, France
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13
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Wang L, He S, Wu X, Lv X, Wang T, Tan H. Efficacy and safety of the Latarjet procedure for the treatment of athletes with glenoid bone defects ≥ 20%: a single-arm meta-analysis. J Orthop Surg Res 2024; 19:159. [PMID: 38429849 PMCID: PMC10908040 DOI: 10.1186/s13018-024-04641-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/22/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND The shoulder joint is the most commonly dislocated joint in the human body, and the recurrence rate exceeds 50% after nonsurgical treatment. Although surgical treatment reduces the recurrence rate, there is controversy regarding the optimal surgical approach. Previous studies suggest that the Latarjet procedure yields favourable outcomes for specific populations at risk of recurrence, such as competitive athletes with significant glenoid defects. However, most of the existing related research consists of nonrandomized controlled trials with small sample sizes, and there is a lack of strong evidence regarding the efficacy and safety of the Latarjet procedure. METHODS The PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched. Athletes with ≥ 20% glenoid defects were selected for inclusion. The following data were extracted: general patient information, instability rates, return to sports (RTS) rates, imaging features (graft positioning rate and graft healing rate), functional assessments [Rowe score, Athletic Shoulder Outcome Scoring System(ASOSS), visual analogue scale (VAS), forward flexion function, and external rotation function], and complications. RESULTS After excluding suspected duplicate cases, a total of 5 studies were included in this meta-analysis. The studies involved a total of 255 patients, including 237 males (93%) and 18 females (7%). The average age at the time of surgery was 25.4 ± 8.5 years. All the studies had a minimum follow-up period of 2 years, with an average follow-up time of 48.7 ± 18.9 months. The pooled rate of return to sport (RTS) was 94.3% (95% CI: 87.3%, 98.8%), and 86.1% (95% CI: 78.2%, 92.5%) of patients returned to their preoperative level of activity. The pooled redislocation rate was 1.1% (95% CI: 0%, 3.8%). Regarding the imaging results, the combined graft retention rate was 92.1% (95% CI: 88.1%, 95.5%), and the graft healing rate was 92.1% (95% CI: 88%, 95.4%). Postoperative functional evaluation revealed that the combined Rowe score, ASOSS score, and VAS score were 93.7 ± 6.5 points, 88.5 ± 4.4 points, and 1.1 ± 10 points, respectively. The forward flexion and external rotation angles were 170.9 ± 6.9 degrees and 65.6 ± 4.5 degrees, respectively. After excluding one study with unclear complications, the combined complication rate was 9.4% (95% CI: 1.0%, 23.6%). CONCLUSION For athletes with shoulder instability and a total of ≥ 20% glenoid bone defects, the Latarjet procedure can achieve excellent functional outcomes, with the majority of patients returning to preoperative levels of sports activity. This procedure also leads to a low recurrence rate. Therefore, the Latarjet procedure has been proven to be a safe and effective treatment.
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Affiliation(s)
- Ling Wang
- People's Liberation Army Joint Logistic Support Force 920th Hospital, Kunming, 650100, China
| | - ShengRong He
- The Third Affiliated Hospital of Kunming Medical University (Yunnan Cancer Hospital/Yunnan Cancer Center), Kunming, 650100, China
| | - Xia Wu
- The Third People's Hospital of Kunming, Kunming, 650041, China
| | - XiaoYu Lv
- People's Liberation Army Joint Logistic Support Force 920th Hospital, Kunming, 650100, China
| | - Tao Wang
- People's Liberation Army Joint Logistic Support Force 920th Hospital, Kunming, 650100, China
| | - HongBo Tan
- People's Liberation Army Joint Logistic Support Force 920th Hospital, Kunming, 650100, China.
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14
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Pasqualini I, Rossi LA, Franco JVA, Denard PJ, Fieiras C, Escobar Liquitay C, Tanoira I, Ranalletta M. Results After Arthroscopic Bankart Repair in Contact Athletes Should Not Be Reported Globally Because of the High Variability in Recurrences Among the Different Contact or Collision Sports: A Systematic Review. Arthroscopy 2024; 40:523-539.e2. [PMID: 37394151 DOI: 10.1016/j.arthro.2023.06.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE To describe and compare the recurrence rates in contact or collision (CC) sports after arthroscopic Bankart repair (ABR) and to compare the recurrence rates in CC versus non-collision athletes after ABR. METHODS We followed a prespecified protocol registered with PROSPERO (registration No. CRD42022299853). In January 2022, a literature search was performed using the electronic databases MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials), as well as clinical trials records. Clinical studies (Level I-IV evidence) that evaluated recurrence after ABR in CC athletes with a minimum follow-up period of 2 years postoperatively were included. We assessed the quality of the studies using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, and we described the range of effects using synthesis without meta-analysis and described the certainty of the evidence using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations). RESULTS We identified 35 studies, which included 2,591 athletes. The studies had heterogeneous definitions of recurrence and classifications of sports. The recurrence rates after ABR varied significantly among studies between 3% and 51% (I2 = 84.9%, 35 studies and 2,591 participants). The range was at the higher end for participants younger than 20 years (range, 11%-51%; I2 = 81.7%) compared with older participants (range, 3%-30%; I2 = 54.7%). The recurrence rates also varied by recurrence definition (I2 = 83.3%) and within and across categories of CC sports (I2 = 83.8%). CC athletes had higher recurrence rates than did non-collision athletes (7%-29% vs 0%-14%; I2 = 29.2%; 12 studies with 612 participants). Overall, the risk of bias of all the included studies was determined to be moderate. The certainty of the evidence was low owing to study design (Level III-IV evidence), study limitations, and inconsistency. CONCLUSIONS There was high variability in the recurrence rates reported after ABR according to the different types of CC sports, ranging from 3% to 51%. Moreover, variations in recurrence among CC sports were observed, with ice hockey players being in the upper range but field hockey players being in the lower range. Finally, CC athletes showed higher recurrence rates when compared with non-collision athletes. LEVEL OF EVIDENCE Level IV, systematic review of Level II, III, and IV studies.
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Affiliation(s)
- Ignacio Pasqualini
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A
| | - Luciano Andrés Rossi
- Shoulder Unit, Department of Orthopedic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Juan Victor Ariel Franco
- Institute of General Practice, Medical Faculty of the Heinrich-Heine - University Dusseldorf, Dusseldorf, Germany
| | | | - Cecilia Fieiras
- Shoulder Unit, Department of Orthopedic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Ignacio Tanoira
- Shoulder Unit, Department of Orthopedic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Maximiliano Ranalletta
- Shoulder Unit, Department of Orthopedic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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15
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Harada Y, Iwahori Y, Kajita Y, Takahashi R, Yokoya S, Sumimoto Y, Deie M, Adachi N. Return to sports after arthroscopic Bankart repair in teenage athletes: a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:64. [PMID: 36694133 PMCID: PMC9872416 DOI: 10.1186/s12891-023-06145-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Anterior shoulder instability is frequent among young athletes. Surgical treatment for this injury aims to facilitate an early return to sports (RTS). However, the rate of recurrent instability after surgery is reportedly high among young patients, and it is unclear whether surgery ensures satisfactory RTS. The purpose of this study was to verify the clinical outcomes and RTS after arthroscopic Bankart repair in competitive teenage athletes without critical bone loss in the glenoid. METHODS We retrospectively reviewed competitive teenage athletes who underwent arthroscopic Bankart repair. Patients with large bony defects in the glenoid, larger than 20% of the healthy side, were excluded. Clinical outcomes, recurrent instability, the final level of RTS, and the time needed for RTS were analyzed. RESULTS In total, 50 patients with a mean follow-up period of 44.5 ± 19.6 (range, 24-85 months) months were included. The mean age at surgery was 16.8 ± 1.7 (range, 13-19 years) years. Two patients (4.0%) experienced recurrent instability. All patients returned to sports, 96% of patients participated competitively, and 76% achieved a complete return to the pre-injury level without any complaints. The time for RTS was 6.6 ± 2.7 months (range, 3-18 months), to competitions was 9.3 ± 4.0 (range, 6-24 months) months, and to complete return was 10.6 ± 4.3 (range, 8-24 months) months. The complete return rates varied by sports type, with 82% in contact athletes, 59% in dominant-hand overhead athletes, and 100% in other athletes (P = 0.026). Other preoperative factors or concomitant lesion such as bony Bankart, superior labrum tear, or humeral avulsion of glenohumeral ligament lesion did not affect the complete RTS. CONCLUSION Arthroscopic Bankart repair is an effective surgical procedure for anterior shoulder instability, even among competitive teenage athletes. Sports type was the only factor associated with complete RTS after surgery.
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Affiliation(s)
- Yohei Harada
- grid.257022.00000 0000 8711 3200Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima City, Hiroshima, 734-8551 Japan ,grid.411234.10000 0001 0727 1557Department of Orthopaedic Surgery, Aichi Medical University, School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Yusuke Iwahori
- grid.413946.dSports Medicine and Joint Center, Asahi Hospital, 2090 Shimoharacho Azamurahigashi, Kasugai, Aichi 486-0819 Japan
| | - Yukihiro Kajita
- grid.411234.10000 0001 0727 1557Department of Orthopaedic Surgery, Aichi Medical University, School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan ,Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, 1 Azahira, Kaimei, Ichinomiya City, Aichi 494-0001 Japan
| | - Ryosuke Takahashi
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, 1 Azahira, Kaimei, Ichinomiya City, Aichi 494-0001 Japan
| | - Shin Yokoya
- grid.257022.00000 0000 8711 3200Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima City, Hiroshima, 734-8551 Japan
| | - Yasuhiko Sumimoto
- grid.257022.00000 0000 8711 3200Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima City, Hiroshima, 734-8551 Japan
| | - Masataka Deie
- Department of Orthopaedic Surgery, Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, Hiroshima, 730-8518 Japan
| | - Nobuo Adachi
- grid.257022.00000 0000 8711 3200Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima City, Hiroshima, 734-8551 Japan
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16
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Trasolini NA, Dandu N, Azua EN, Garrigues GE, Verma NN, Yanke AB. Inconsistencies in Controlling for Risk Factors for Recurrent Shoulder Instability After Primary Arthroscopic Bankart Repair: A Systematic Review. Am J Sports Med 2022; 50:3705-3713. [PMID: 34591717 DOI: 10.1177/03635465211038712] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging. PURPOSE The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score. RESULTS After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis. CONCLUSION Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.
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Affiliation(s)
| | - Navya Dandu
- Rush University Medical Center, Chicago, Illinois, USA
| | - Eric N Azua
- Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Adam B Yanke
- Rush University Medical Center, Chicago, Illinois, USA
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17
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Li L, McGuinness BK, Layer JS, Song Y, Jensen MA, Dai B. Longitudinal assessments of strength and dynamic balance from pre-injury baseline to 3 and 4 months after labrum repairs in collegiate athletes. Physiother Theory Pract 2022; 38:2505-2513. [PMID: 34098835 PMCID: PMC8648851 DOI: 10.1080/09593985.2021.1934925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/26/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND There is a lack of quantitative assessments of athletes' functional strength and dynamic balance following labrum repairs. PURPOSE To compare the upper extremity strength and dynamic balance among pre-injury baseline and approximately 3 and 4 months after labrum surgeries in collegiate athletes to identify critical values to inform rehabilitation. METHODS Fifteen male and one female collegiate athletes between 18 and 22 years old were tested at pre-injury baseline (n = 14) and 2.7 (n = 16) and 3.8 months (n = 12) after labrum surgeries. Strength was assessed using the peak forces produced in a maximal push-up test. Dynamic balance was assessed using the reaching distances in a reaching test. RESULTS The injured side's peak forces significantly decreased from the baseline to the 3-month post-surgery and then significantly increased between the 3-month and 4-month post-surgery assessments but remained significantly less at the 4-month post-surgery compared to the baseline (p ≤ 0.024; Cohen's dz ≥ 0.75). Peak force asymmetries were greater at the 3-month and 4-month post-surgery assessments than the baseline (p ≤ 0.005; Cohen's dz ≥ 1.02). CONCLUSION With a relatively small sample size, the results support the use of objective functional assessments for rehabilitation and return-to-play decisions among collegiate athletes following labrum repairs.
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Affiliation(s)
- Ling Li
- Division of Kinesiology and Health, University of Wyoming, 1000 E. University Ave. Laramie, WY, USA
| | - Brenna K. McGuinness
- Division of Kinesiology and Health, University of Wyoming, 1000 E. University Ave. Laramie, WY, USA
| | - Jacob S. Layer
- Division of Kinesiology and Health, University of Wyoming, 1000 E. University Ave. Laramie, WY, USA
| | - Yu Song
- Division of Kinesiology and Health, University of Wyoming, 1000 E. University Ave. Laramie, WY, USA
| | - Megan A. Jensen
- Department of Sports Medicine, 1000 E. University Ave.University of Wyoming, Laramie, USA
| | - Boyi Dai
- Division of Kinesiology and Health, University of Wyoming, 1000 E. University Ave. Laramie, WY, USA
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18
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Lee HM, Lim JR, Lee WW, Kim SJ, Yoon TH, Chun YM. Comparison of arthroscopic primary and revision Bankart repair for capsulolabral restoration: a matched-pair analysis. Arch Orthop Trauma Surg 2022; 143:3183-3190. [PMID: 36282315 DOI: 10.1007/s00402-022-04651-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/08/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION There have been no previous studies comparing serial radiologic results between primary and revision Bankart repair despite the significance of capsulolabral height and slope restoration. The purpose of this study was (1) to compare serially the height and slope of the repaired labrum in the early postoperative period among primary and revision Bankart repair groups, and (2) to compare clinical outcomes between the two groups. MATERIALS AND METHODS This study included each 24 patients who underwent arthroscopic primary Bankart repair (Group A) and revision Bankart repair (Group B) matched by age, sex, and glenoid defect ratio. Postoperative serial radiologic assessment of the repaired labral height and slope was proceeded using magnetic resonance imaging (MRI) or computed tomographic arthrography (CTA) at 3 weeks and 6 months. RESULTS There were no significant differences in labral height and slope at 3 weeks and 6 months postoperatively in Group A. However, significant reductions in labral height and slope were evident between 3 weeks and 6 months postoperatively in Group B (P < 0.05). Group A yielded superior results to Group B with respect to labral height and slope at each time point (P < 0.05) in between-group analyses. The clinical outcomes were not significantly different between the two groups except for the patients' return to their premorbid sports activity level (P = 0.024). CONCLUSIONS The height and slope of the repaired capsulolabral structures in the early postoperative period after arthroscopic revision Bankart repair group were significantly lower than those of the primary Bankart repair group. Also the reduction of labral height and slope was significant in the revision Bankart repair group over time. Nonetheless, clinical outcomes did not differ significantly except return to premorbid sports activity level at final follow-up.
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Affiliation(s)
- Hyung-Min Lee
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon-Ryul Lim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won-Woo Lee
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Jae Kim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hwan Yoon
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Orthopaedic Surgery, Gang-Nam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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19
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Monk AP, Crua E, Gatenby GC, Walsh AJ, Stanley JC, Rosenfeldt MP, Twaddle BC, Walsh SJ. Clinical outcomes following open anterior shoulder stabilization for glenohumeral instability in the young collision athlete. J Shoulder Elbow Surg 2022; 31:1474-1478. [PMID: 35051538 DOI: 10.1016/j.jse.2021.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 12/07/2021] [Accepted: 12/12/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anterior glenohumeral instability occurs most commonly in those aged 15-29, with 72% of individuals younger than 22 years suffering recurrent episodes; collision athletes are at particular risk. In the setting of subcritical glenoid bone loss, arthroscopic Bankart repair is widely used despite concerns of recurrent dislocations when compared with open techniques. Furthermore, indications for bone-block procedures are evolving with the Latarjet procedure being favored amongst recent authors as a primary stabilization method in elite and contact athletes. OBJECTIVE To determine the efficacy of open modified Bankart stabilization in treating anterior glenohumeral instability in young collision athletes. METHODS This was a retrospective review of outcomes of consecutive patients aged 15-20 years who underwent unilateral or bilateral open stabilization for recurrent anterior glenohumeral instability over a 7-year period (2007-2015). The cohort was selected as recent literature suggests that this is the group with the highest redislocation rate and poorest outcomes. Outcome assessments included redislocation rate, return to sport, pain score, patient-related satisfaction scores, and the Western Ontario Shoulder Instability Index. RESULTS A total of 60 patients (55 male: 5 female) of mean age 18 years (range: 15-20 years) were available for follow-up at 7 years. All but 3 were competitive athletes with 18 competing regionally and 9 internationally; rugby union and rugby league represent the most common sports. Fifty-five of 60 (92%) have returned to their desired level of sport with 62% of athletes returning to their previous level of competition sport and 1 retuning at a higher level. The mean postoperative pain score was 2.5/10. The mean time to return to play was 14 months (range: 5-48 months). Eight of 60 shoulders reported redislocation (13%), 7 of these being traumatic dislocations after return to high-impact sporting activities. At 7 years of follow-up, 4 of 60 shoulders (7%) had undergone revision surgery. CONCLUSION Young collision athletes represent a challenging cohort of instability patients. This study of open modified Bankart in young collision sport athletes revealed excellent outcomes with 92% return to sport and a low revision rate. The results from this cohort rival those of arthroscopic repair. The open procedure described here in this 7-year series represents a robust, reliable technique that could be considered as an alternative to arthroscopic Bankart due to concern for recurrence, while avoiding potential morbidity and complication of bone-block procedures. There is still a role for the open modified Bankart procedure in treating traumatic anterior instability.
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Affiliation(s)
- A Paul Monk
- Unisports Orthopaedics, Auckland, New Zealand
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20
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Pasqualini I, Rossi LA, De Cicco FL, Tanoira I, Alonso Hidalgo I, Bongiovanni S, Giunta DH, Ranalletta M. The playing position significantly influences return to sports and recurrences after an arthroscopic Bankart repair in competitive rugby players. Shoulder Elbow 2022; 14:29-37. [PMID: 35845626 PMCID: PMC9284259 DOI: 10.1177/1758573221993089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/16/2021] [Accepted: 01/19/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The purpose of our study was to investigate the influence of the different rugby playing positions on return to sports, functional outcomes, and recurrences after an arthroscopic Bankart repair. METHODS A total of 88 rugby players were treated for anterior shoulder instability in our institution between 2010 and 2018. Functional outcomes, return to sports, recurrences, complications, and revisions rates were evaluated according to the playing position. RESULTS Overall, 73.8% of the patients returned to rugby and 60% returned at the same level as before the injury. The tight forwards and outside backs experienced a significant decrease in their competitive level after surgery, and showed the lowest functional outcomes. The tight forwards and outside backs showed a statistically significant increase in recurrence and revision rates, and an OR for recurrence of 12.8 and 9.6, respectively. DISCUSSION The playing position significantly influenced return to sports and recurrences after an arthroscopic Bankart repair in competitive rugby players. Specifically, the tight forwards and outside backs have returned to a lower level than they had before surgery, showed the lowest functional outcomes, and a significant increase in recurrences and revisions rates than the other groups.
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21
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Hoshika S, Matsuki K, Tokai M, Morioka T, Ueda Y, Hamada H, Takahashi N, Sugaya H. Pathology and surgical outcomes of unstable painful shoulders. JSES Int 2022; 6:349-354. [PMID: 35572430 PMCID: PMC9091796 DOI: 10.1016/j.jseint.2022.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Boileau et al have reported on the unstable, painful shoulder (UPS), which was defined as painful shoulders without any recognized anteroinferior subluxations or dislocations that were associated with roll-over lesions (ie, instability lesions) on imaging or at arthroscopy. However, they included various pathologies, probably due to the ambiguity in their definitions of UPS. We redefined UPS as follows: (1) shoulder pain during daily or sports activities, (2) traumatic onset, (3) no complaint of shoulder instability, and (4) soft-tissue or bony lesions, such as Bankart or humeral avulsion of glenohumeral ligament lesion, confirmed by arthroscopy. The purpose of this study was to retrospectively investigate pathologies of UPS based on our definitions. We also aimed to assess the outcomes after arthroscopic soft-tissue stabilization for UPS. Methods We reviewed patients who were retrospectively diagnosed as UPS based on our definition and underwent arthroscopic stabilization between January 2007 and September 2018. Patients' demographics, physical and radiographic findings, intraoperative findings, clinical outcomes (Rowe scores, Subjective Shoulder Value [SSV], and the visual analog scale [VAS] for pain), and return to play sport (RTPS) were investigated. Results This study included 91 shoulders in 91 patients with a mean age of 23 years (range, 15-51). The mean follow-up was 37 months (range, 24-156). Eighty-seven patients were involved in sports activities: collision/contact, 55 patients (60%); overhead, 26 patients (29%). The pain was reproduced during the anterior apprehension test in 86 shoulders (95%). Normal type (49%) predominated in glenoid morphology followed by fragment (bony Bankart) type (37%). Most fragment-type lesions were seen in collision/contact athletes. Intraoperative findings demonstrated that Bankart lesions were found in all patients and Hill-Sachs lesions only in 42%. Magnetic resonance arthrography in the abducted and externally rotated positions showed a Bankart lesion in 76 shoulders (84%). Rowe score, SSV, and pain VAS significantly improved postoperatively (P < .001 for each). Forty-two of 70 athletes (60 %) with > 2-year follow-up returned to the sport at a complete or near-preinjury level. Six (9%) athletes experienced reinjury. Conclusion All shoulders that were diagnosed as UPS with our definition had a Bankart lesion. There seemed to be two different types of pathologies: Bankart lesions in lax shoulders and bony Bankart lesions in collision/contact athletes. The pain experienced during the anterior apprehension test may be useful for the diagnosis of UPS. Arthroscopic soft-tissue stabilization yielded good clinical outcomes with a high RTPS rate, but the reinjury rate was relatively high.
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Affiliation(s)
- Shota Hoshika
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
| | - Keisuke Matsuki
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
| | - Morihito Tokai
- Tokyo Sports and Orthopaedic Clinic, Toshima, Tokyo, Japan
| | - Takeshi Morioka
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
| | - Yusuke Ueda
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
| | - Hiroshige Hamada
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
| | - Norimasa Takahashi
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
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22
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Successful Outcomes and Return to Sport After Arthroscopic Bankart Repair in National Collegiate Athletic Association and National Football League Football Players. Clin J Sport Med 2022; 32:e288-e292. [PMID: 34320568 DOI: 10.1097/jsm.0000000000000962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To characterize recurrent instability, return to sport (RTS), and patient-reported outcomes (PROs) after arthroscopic Bankart repair for acute traumatic anterior shoulder instability in National Collegiate Athletic Association (NCAA) and National Football League (NFL) football players. DESIGN Case series. SETTING Orthopaedic and sports medicine clinic. PARTICIPANTS National Collegiate Athletic Association and NFL football athletes with traumatic anterior shoulder instability who underwent arthroscopic shoulder stabilization at a single institution with at least 2-year follow-up. INTERVENTIONS OR ASSESSMENT OF RISK FACTORS OR INDEPENDENT VARIABLES Arthroscopic Bankart repair. MAIN OUTCOME MEASURES Recurrent instability, RTS, patient satisfaction, the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, and Rowe score. RESULTS Thirty-three players were included with a mean age of 23.8 years (range, 18-33 years) and a mean follow-up of 6.3 years (range, 4.1-9.3 years). One shoulder (3.0%) had a postoperative subluxation event, and 1 shoulder (3.0%) required revision surgery for issues other than instability; 93.3% of players were able to RTS at the same level or higher for at least 1 season. Mean satisfaction was 8.9 ± 2.3. Mean VAS was 1.0 ± 1.7, and mean ASES and Rowe scores were 90.7 ± 18.5 and 89.7 ± 15.2, respectively. CONCLUSION Arthroscopic Bankart repair is an effective surgical intervention for traumatic anterior shoulder instability in NCAA and NFL football players. At a mean 6-year follow-up, surgery restored stability in 97% of cases and 93.3% returned to their preinjury level of sport.
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23
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Rossi LA, Pasqualini I, Tanoira I, Ranalletta M. Factors That Influence the Return to Sport After Arthroscopic Bankart Repair for Glenohumeral Instability. Open Access J Sports Med 2022; 13:35-40. [PMID: 35401017 PMCID: PMC8985826 DOI: 10.2147/oajsm.s340699] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Abstract
Numerous studies have reported high rates of return to sports following arthroscopic Bankart repair (ABR) However, there is enormous controversy regarding the optimal management of these patients in the postoperative period. Controversy issues include rehabilitation, criteria for returning to sports, and the specific management of each athlete according to the sport they practice. Even though there are several rehabilitation protocols published in the literature, wide variability exists concerning the key elements of rehabilitation after an ABR. Regarding criteria for return to sports, there is a wide variation across the different published studies. The type of sports has been shown to affect an athlete's decision to return to sports. Nevertheless, most research is evaluated by classifications that cluster different sports into categories that may have other influences in return to sports when analyzed separately. Finally, in addition to physical readiness, the athlete's psychological state is crucial for returning to sports. However, the contribution of psychological readiness to an athlete's return to sports after shoulder instability surgery remains uncertain and unexplored.
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Affiliation(s)
- Luciano Andrés Rossi
- Hospital Italiano de Buenos Aires, Investigation Performed at the Shoulder Unit Department of Orthopedic Surgery, Buenos Aires, Argentina
| | - Ignacio Pasqualini
- Hospital Italiano de Buenos Aires, Investigation Performed at the Shoulder Unit Department of Orthopedic Surgery, Buenos Aires, Argentina
| | - Ignacio Tanoira
- Hospital Italiano de Buenos Aires, Investigation Performed at the Shoulder Unit Department of Orthopedic Surgery, Buenos Aires, Argentina
| | - Maximiliano Ranalletta
- Hospital Italiano de Buenos Aires, Investigation Performed at the Shoulder Unit Department of Orthopedic Surgery, Buenos Aires, Argentina
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Nakagawa S, Hirose T, Uchida R, Yokoi H, Ohori T, Sahara W, Mae T. A Glenoid Defect of 13.5% or Larger Is Not Always Critical in Male Competitive Rugby and American Football Players Undergoing Arthroscopic Bony Bankart Repair: Contribution of Resultant Large Bone Fragment. Arthroscopy 2022; 38:673-681. [PMID: 34389413 DOI: 10.1016/j.arthro.2021.07.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate bone union and postoperative recurrence after arthroscopic bony Bankart repair (ABBR) in male competitive rugby and American football players with a subcritical glenoid defect of ≥13.5% and to compare findings with those in players with a glenoid defect of <13.5%. METHODS Participants were male competitive rugby or American football players with a glenoid defect and bone fragment who underwent ABBR from July 2011 to December 2018 and were followed for a minimum of 2 years. We investigated the influence of glenoid defect and bone fragment size on bone union and postoperative recurrence after ABBR. RESULTS We included 45 rugby players and 35 American football players. A total of 38 shoulders were assigned to the small defect group (<13.5%) and 42 to the large defect group (≥13.5%). The complete bone union rate was 47.4% in the small defect group and 71.4% in the large defect group (P = .040), and postoperative recurrence was seen in 13 (34.2%) and 5 shoulders (11.9%), respectively (P = .030). In the small defect group, the bone fragment size was <7.5% in 30 shoulders and ≥7.5% in 8 shoulders; in comparison, the respective numbers were 12 and 30 shoulders in the large defect group, and large fragments (>7.5%) were significantly more common in this group (P < .001). The complete union rate was significantly higher in shoulders with a large fragment (≥7.5%) than in those with a small fragment (<7.5%; 78.9% versus 42.9%, respectively; P = .001). The recurrence rate was 33.3% in shoulders with a small fragment (<7.5%) and 10.5% in shoulders with a large fragment (≥7.5%; P = .017) and was significantly lower in shoulders with a complete union than in those without a complete union (6.3% versus 46.9%, respectively; P < .001). CONCLUSION The postoperative recurrence rate after ABBR was lower in male competitive rugby and American football players with a large glenoid defect (≥13.5%) than in those with a small glenoid defect (<13.5%) and might be associated with a higher rate of complete bone union of the resultant large bone fragment (≥7.5%). LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- Shigeto Nakagawa
- Department of Orthopaedic Sports Medicine, Yukioka Hospital, Osaka, Japan.
| | - Takehito Hirose
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Ryohei Uchida
- Department of Orthopaedic Sports Medicine, Kansai Rosai Hospital, Hyogo, Japan
| | - Hiroyuki Yokoi
- Department of Orthopaedic Sports Medicine, Yukioka Hospital, Osaka, Japan
| | - Tomoki Ohori
- Department of Orthopaedic Sports Medicine, Yukioka Hospital, Osaka, Japan
| | - Wataru Sahara
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan
| | - Tatsuo Mae
- Department of Sports Medicine Biomechanics, Osaka University, Graduate School of Medicine, Osaka, Japan
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25
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Inoue M, Tanaka S, Gotoh M, Mitsui Y, Moriyama H, Nakamura H, Ohzono H, Okawa T, Shiba N. Incidence of Re-Dislocation/Instability After Arthroscopic Bankart Repair: Analysis via Telephone Interviews. Kurume Med J 2021; 66:203-207. [PMID: 34690207 DOI: 10.2739/kurumemedj.ms664006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Current advances in arthroscopic surgery have led to good outcomes for arthroscopic Bankart repair (ABR) for recurrent anterior shoulder dislocation. However, recent studies have reported recurrence rates of 4%-19% after ABR. In our survey conducted from February 2002 to December 2010, the post-ABR re-dislocation rate was 8.8%. In 2011, we began performing the ABR with open Bristow (B) procedure or Remplissage (R) procedure in patients with large glenoid or humeral head bone defects and in patients who play collision sports. Therefore, the present study is the second series evaluating the incidence of re-dislocation and instability after recurrent anterior shoulder dislocation. METHOD Surgery was performed for 84 cases of shoulder instability from January 2011 to August 2017. After excluding 7 open surgeries, 6 reoperations, and 2 patients with multidirectional instability, telephone interviews were conducted with 69 patients. The average follow-up duration was 46.9 months (range, 13-92 months). RESULT ABR alone was performed 61 patients; the B procedure was added for 3 patients, and the R procedure was added for 5 patients. Telephone interviews were conducted with 61 patients. There were no cases of re-dislocation or reoperation. Four patients who underwent only ABR experienced postoperative instability, but not to the extent that their daily lives were affected. CONCLUSION This study showed that the addition of R or B technique to ABR for recurrent anterior shoulder dislocation resulted in a 0% re-dislocation rate.
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Affiliation(s)
| | - Suguru Tanaka
- Department of Orthopedics, Kurume University Hospital
| | - Masafumi Gotoh
- Department of Orthopedics, Kurume University Medical Center
| | | | | | | | - Hiroki Ohzono
- Department of Orthopedics, Kurume University Hospital
| | - Takahiro Okawa
- Department of Orthopedics, Kurume University Medical Center
| | - Naoto Shiba
- Department of Orthopedics, Kurume University Hospital
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Lamplot JD, Brusalis CM, Apostolakos JM, Langhans M, Hancock KJ, Pinnamaneni S, Kontaxis A, Warren RF, Rodeo SA, Greditzer HG, Taylor SA. Computed Tomography-Based Preoperative Planning Provides a Pathology and Morphology-Specific Approach to Glenohumeral Instability With Bone Loss. Arthroscopy 2021; 37:1757-1766.e2. [PMID: 33515735 DOI: 10.1016/j.arthro.2021.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To use computed tomography (CT) to determine a reproducible method of coracoid measurement to compare the ability of the classic Latarjet technique and the congruent arc modification (CAM) to restore native glenoid diameter and to develop a preoperative planning algorithm for glenoid restoration with a goal of achieving an on-track shoulder. METHODS Coracoid dimensions were measured on multiplanar reconstructed shoulder CT scans of patients aged 18 to 45 years obtained between December 1, 2019, and March 13, 2020. Patients were excluded if CT demonstrated osteophyte formation, glenoid dysplasia, coracoid fracture, or tumor. The proportion of glenoid diameter able to be restored using classic Latarjet technique and CAM were calculated. A treatment algorithm was proposed considering the amount of bone loss present and coracoid dimensions. RESULTS Coracoid dimensions of 117 consecutive patients were measured and varied considerably (length: 17.5-31.8 mm, width: 9.1-20.5 mm, thickness: 6.1-15.7 mm). While most patients had harvestable coracoid length ≥20 mm (male: 96.3% vs female: 94.4%, P = .65), only 27.8% of female patients had coracoid thickness ≥10 mm. When comparing Latarjet techniques, there was no difference in the proportion of patients in whom 30% glenoid diameter could be fully restored, but CAM was able to restore at least 35% in more male and female patients (98.8% vs 79.0% and 100% vs 61.1%, respectively, P = .00001). Intra- and inter-rater reliability was excellent ( intraclass correlation coefficient ≥0.950 for all dimensions). CONCLUSIONS We describe a reliable method of measuring coracoid dimensions for preoperative planning of glenoid restoration. The classic Latarjet technique reliably restores the glenoid anteroposterior diameter with bone loss of up to 30%. The majority of female patients have coracoid thickness <10 mm, which may increase the risk of graft fracture when using CAM. The decision to use the classic Latarjet technique or CAM considers each individual's glenoid and coracoid dimensions with a goal of achieving an on-track shoulder. CLINICAL RELEVANCE Our reliable method of coracoid measurement demonstrated the differing abilities of the classic Latarjet and CAM to restore the native glenoid diameter. An evidence-based algorithm using these measurements was developed to assist in preoperative planning for glenohumeral instability in the setting of bone loss, with a goal of achieving an on-track shoulder. Alternative techniques may be considered if an on-track shoulder cannot be achieved with Latarjet.
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Affiliation(s)
- Joseph D Lamplot
- Division of Sports Medicine, Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Christopher M Brusalis
- Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - John M Apostolakos
- Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Mark Langhans
- Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | | | | | - Andreas Kontaxis
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, U.S.A
| | - Russell F Warren
- Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Scott A Rodeo
- Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Harry G Greditzer
- Department of Musculoskeletal Radiology, Hospital for Special Surgery, New York, New York, U.S.A
| | - Samuel A Taylor
- Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A..
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27
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Tasaki A, Morita W, Nozaki T, Yonekura Y, Saito M, Phillips BB, Kitamura N. Arthroscopic Bankart Repair and Open Bristow Procedure in the Treatment of Anterior Shoulder Instability With Osseous Glenoid Lesions in Collision Athletes. Orthop J Sports Med 2021; 9:23259671211008274. [PMID: 34104661 PMCID: PMC8165538 DOI: 10.1177/23259671211008274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Traumatic anterior shoulder instability in collision sports athletes often involves osseous glenoid lesions, which make surgical treatment challenging. High redislocation rates have been seen in collision sports athletes treated using arthroscopic Bankart repair. Purpose: To investigate the effectiveness of a combined arthroscopic Bankart repair and open Bristow procedure for the treatment of traumatic anterior shoulder instability in collision sports athletes, with a focus on osseous glenoid lesions. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 149 shoulders in 141 competitive collision sports athletes (mean ± standard deviation age, 20.1 ± 4.1 years; 8 bilateral cases) who underwent a combined arthroscopic Bankart repair and open Bristow procedure with minimum 2 years of follow-up. Osseous Bankart lesions were arthroscopically reduced and fixed using a coracoid graft. Results: Clinical outcomes as indicated by mean Rowe score improved significantly from 50.0 preoperatively to 98.9 postoperatively (P < .001) at a median follow-up of 3.4 years (range, 2.5-7 years). There were 2 recurrent dislocations (1.3%), both of which had nonunion of the transferred coracoid. Osseous Bankart lesions were observed in 85 shoulders, and osseous glenoid lesions ≥10% of the diameter of the nonoperative side were found in 58 shoulders, including 24 off-track cases. Clinical outcomes were not significantly different between patients with a glenoid defect ≥10% and <10%. Nonunion of the transferred coracoid was observed in 16 shoulders (10.7%), which had inferior Rowe scores; however, we could not define any risk factors for nonunion, including patient characteristics or bone morphology. Postoperative computed tomography performed in 29 patients >1 year after surgery showed successful repair of the osseous glenoid lesions, with a restored glenoid articular surface in all cases. Significant pre- to postoperative increases were seen in glenoid diameter (mean, 13.1% [95% CI, 9.9%-16.3%]; P < .001) and area (mean, 10.6% [95% CI, 8.5%-12.7%]; P < .001). Conclusion: A combined arthroscopic Bankart repair and open Bristow procedure improved bone morphology and was a reliable surgical method for treating collision sports athletes with traumatic anterior shoulder instability involving osseous glenoid lesions.
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Affiliation(s)
- Atsushi Tasaki
- Department of Orthopedic Surgery, St Luke's International Hospital, Tokyo, Japan
| | - Wataru Morita
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Taiki Nozaki
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
| | - Yuki Yonekura
- Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
| | - Masayoshi Saito
- Department of Orthopedic Surgery, St Luke's International Hospital, Tokyo, Japan
| | - Barry B Phillips
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee; Campbell Clinic, Memphis, Tennessee, USA
| | - Nobuto Kitamura
- Department of Orthopedic Surgery, St Luke's International Hospital, Tokyo, Japan
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Vopat ML, Coda RG, Giusti NE, Baker J, Tarakemeh A, Schroeppel JP, Mullen S, Randall J, Provencher MT, Vopat BG. Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:23259671211006437. [PMID: 34104660 PMCID: PMC8155769 DOI: 10.1177/23259671211006437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The glenohumeral joint is one of the most frequently dislocated joints in the
body, particularly in young, active adults. Purpose: To conduct a systematic review and meta-analysis to evaluate and compare
outcomes between anterior versus posterior shoulder instability. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed using the PubMed, Cochrane Library, and
MEDLINE databases (from inception to September 2019) according to PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
guidelines. Studies were included if they were published in the English
language, contained outcomes after anterior or posterior shoulder
instability, had at least 1 year of follow-up, and included arthroscopic
soft tissue labral repair of either anterior or posterior instability.
Outcomes including return-to-sport (RTS) rate, postoperative instability
rate, and pre- and postoperative American Shoulder and Elbow Surgeons (ASES)
scores were recorded and analyzed. Results: Overall, 39 studies were included (2077 patients; 1716 male patients and 361
female patients). Patients with anterior instability had a mean age of 23.45
± 5.40 years (range, 11-72 years), while patients with posterior instability
had a mean age of 23.08 ± 8.41 years (range, 13-61 years). The percentage of
male patients with anterior instability was significantly higher than that
of female patients (odds ratio [OR], 1.36; 95% CI, 1.04-1.77;
P = .021). Compared with patients with posterior
instability, those with anterior instability were significantly more likely
to RTS (OR, 2.31; 95% CI, 1.76-3.04; P < .001), and they
were significantly more likely to have postoperative instability (OR, 1.53;
95% CI, 1.07-2.23; P = .018). Patients with anterior
instability also had significantly higher ASES scores than those with
posterior instability (difference in means, 6.74; 95% CI, 4.71-8.77;
P < .001). There were no significant differences
found in postoperative complications between the anterior group (11
complications; 1.8%) and the posterior group (3 complications; 1.6%) (OR,
1.12; 95% CI, 0.29-6.30; P = .999). Conclusion: Patients with anterior shoulder instability had higher RTS rates but were
more likely to have postoperative instability compared with posterior
instability patients. Overall, male patients were significantly more likely
to have anterior shoulder instability, while female patients were
significantly more likely to have posterior shoulder instability.
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Affiliation(s)
- Matthew L Vopat
- University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| | - Reed G Coda
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nick E Giusti
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jordan Baker
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Armin Tarakemeh
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Scott Mullen
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey Randall
- University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| | | | - Bryan G Vopat
- University of Kansas Medical Center, Kansas City, Kansas, USA
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Hoshika S, Sugaya H, Takahashi N, Matsuki K, Tokai M, Morioka T, Ueda Y, Hamada H, Takeuchi Y. Arthroscopic Soft Tissue Stabilization With Selective Augmentations for Traumatic Anterior Shoulder Instability in Competitive Collision Athletes. Am J Sports Med 2021; 49:1604-1611. [PMID: 33844602 DOI: 10.1177/03635465211003091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many surgeons prefer bony stabilization including Bristow or Latarjet procedures for shoulder instability in collision athletes, even though several potential complications have been reported. There has been a limited number of studies on the midterm outcomes of arthroscopic soft tissue stabilization for anterior shoulder instability in competitive collision athletes. PURPOSE To assess the outcomes of arthroscopic soft tissue stabilization in combination with selective augmentation procedures for collision athletes with traumatic anterior shoulder instability. STUDY DESIGN Case series; Level of evidence, 4. METHODS We retrospectively assessed rugby or American football players (<40 years old) who underwent arthroscopic Bankart or bony Bankart repair with selective augmentations (rotator interval closure and/or Hill-Sachs remplissage) for traumatic anterior shoulder instability between January 2012 and March 2017. Shoulders that required other bony procedures were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score and Subjective Shoulder Value sports score) were investigated. RESULTS This study included 113 shoulders in 100 patients with a mean age of 20 years (range, 15-36 years) at surgery. Rotator interval closure was performed on 36 shoulders in addition to Bankart repair, and rotator interval closure and Hill-Sachs remplissage were performed on 77 shoulders. The mean follow-up period was 44 months (range, 24-72 months). Of the 113 shoulders, 4 (3.5%) experienced postoperative dislocation, but there were no complications. A total of 93 athletes (93%) attained complete or near complete preinjury sports activity levels. The mean Rowe score significantly improved from 36 (range, 10-75) at presurgery to 96 (range, 35-100; P = .003) at postsurgery. The mean Subjective Shoulder Value sports score significantly improved after surgery, from a mean preoperative score of 22 (range, 0-50) to a postoperative score of 92 (range, 64-100; P = .002). CONCLUSION Our treatment strategy, where arthroscopic soft tissue stabilization was combined with selected augmentations, provided good clinical outcomes for competitive collision athletes in terms of low rates of recurrence and complication, a high rate of return to sports, and good shoulder function.
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Affiliation(s)
- Shota Hoshika
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | | | - Norimasa Takahashi
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | - Keisuke Matsuki
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | | | - Takeshi Morioka
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | - Yusuke Ueda
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | - Hiroshige Hamada
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | - Yasutaka Takeuchi
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
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30
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Bixby EC, Ahmad CS. Anterior Shoulder Instability in the Throwing Athlete. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Declève P, Van Cant J, Attar T, Urbain E, Marcel M, Borms D, Cools AM. The shoulder endurance test (SET): A reliability and validity and comparison study on healthy overhead athletes and sedentary adults. Phys Ther Sport 2020; 47:201-207. [PMID: 33321268 DOI: 10.1016/j.ptsp.2020.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/01/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The primary purpose was to examine the reliability of a new shoulder physical performance test -the Shoulder Endurance Test (SET)- in young healthy overhead athletes and sedentary adults and to provide preliminary reference values. The secondary objective was to determine whether there are differences on SET scores based on groups, sides and days. The third objective was to evaluate the relationship between the SET and shoulder rotational isometric strength in both groups. DESIGN Reliability and validity study. SETTING Laboratory setting. PARTICIPANTS A total sample of 92 participants volunteered to participate in this study (30 healthy overhead athletes - 62 sedentary adults). MAIN OUTCOME MEASURES We used a two-session measurement design separated by seven days to evaluate the reliability. We calculated intraclass correlation coefficients to determine relative reliability and used standard error of measurement and minimal detectable change to quantify absolute reliability. Systematic differences in SET scores between groups, days and sides were analysed with a two-way analysis of variance (ANOVA) for repeated measures. To check for systematic differences within groups between day 1 and day 2, a Wilcoxon Signed Rank Test was performed. Relationship between shoulder rotational isometric strength and the SET was determined using the Spearman Rank test (rs). RESULTS Relative reliability was high to very high in both groups (intraclass correlation coefficient [2,1] range = 0.78-0.93) and absolute reliability was clinically acceptable. The standard error of measurement varied from 10.7 s to 16.45 s. The minimal detectable change ranged from 29.6 s to 45.6 s. Weak correlations were found between the SET and isometric shoulder rotational strength (rs range = 0.309-0.431). RESULTS of the ANOVA for repeated measures showed a significant two-way interaction effect for day x groups (p = 0.020) and a significant main effect for side (p= < 0.001). Results of the Wilcoxon Signed Rank Test showed no systematic differences in group 1 between day 1 and day 2 for both sides (p = 0.79 dominant side; p = 0.66 non-dominant side). CONCLUSIONS The SET is a reliable clinically applicable shoulder physical performance test in young adult overhead athletes and sedentary adult.
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Affiliation(s)
- Ph Declève
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, B3, 9000 Gent, Belgium; Department of Physical Therapy, Institut Parnasse-ISEI, Avenue Mounier 84, 1200 Brussels, Belgium.
| | - J Van Cant
- Department of Physical Therapy, Institut Parnasse-ISEI, Avenue Mounier 84, 1200 Brussels, Belgium; Faculty of Motor Sciences, Université Libre de Bruxelles, Brussels, Belgium
| | - T Attar
- Department of Physical Therapy, Institut Parnasse-ISEI, Avenue Mounier 84, 1200 Brussels, Belgium
| | - E Urbain
- Department of Physical Therapy, Institut Parnasse-ISEI, Avenue Mounier 84, 1200 Brussels, Belgium
| | - M Marcel
- Department of Physical Therapy, Institut Parnasse-ISEI, Avenue Mounier 84, 1200 Brussels, Belgium
| | - D Borms
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, B3, 9000 Gent, Belgium
| | - Ann M Cools
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, B3, 9000 Gent, Belgium
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Rossi LA, Gorodischer T, Brandariz R, Tanoira I, Pasqualini I, Ranalletta M. High Rate of Return to Sports and Low Recurrences With the Latarjet Procedure in High-Risk Competitive Athletes With Glenohumeral Instability and a Glenoid Bone Loss <20. Arthrosc Sports Med Rehabil 2020; 2:e735-e742. [PMID: 33364611 PMCID: PMC7754520 DOI: 10.1016/j.asmr.2020.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/13/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose To analyze return to sports, functional outcomes, and complications following the Latarjet procedure in competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%. Methods All the included patients were operated between 2010 and 2016. The inclusion criteria were competitive athletes with anterior glenohumeral instability, a glenoid bone defect <20% who participated in contact sports, forced overhead sports, or had a previous failed Bankart repair and had a minimum 2 years’ follow-up. Return to sports, range of motion (ROM), the Rowe score, and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications and bone consolidation were also evaluated. Results A total of 65 athletes were included in the study. The mean follow-up was 53 months (±13), and the mean age was 23.9 years (range, 16-31 years). Overall, 94% were able to return to sports and 84% returned at the same level. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P < .001). No significant difference in shoulder ROM and functional scores was found between primary and revision cases. The total complication rate was 11% and the revision rate was 1.5% The recurrence rate was 4.6%. The bone block healed in 95% of the cases. Conclusions In high-risk competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%, the Latarjet procedure resulted in excellent functional outcomes, with most of the patients returning to sports and at the same level they had before injury with a low rate of recurrences Level of Evidence Therapeutic case series; Level of evidence, IV
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Affiliation(s)
- Luciano Andrés Rossi
- Address correspondence to Luciano Andrés Rossi, Peron 4190 (C1199ABB), Buenos Aires, Argentina.
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33
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Rossi LA, Tanoira I, Gorodischer T, Pasqualini I, Ranalletta M. High Variability in Functional Outcomes and Recurrences Between Contact Sports After Arthroscopic Bankart Repair: A Comparative Study of 351 Patients With a Minimum 3-Year Follow-Up. Arthrosc Sports Med Rehabil 2020; 2:e575-e581. [PMID: 33134997 PMCID: PMC7588624 DOI: 10.1016/j.asmr.2020.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/08/2020] [Indexed: 11/19/2022] Open
Abstract
Purpose To compare return to sports, functional outcomes, and complications of a consecutive series of contact athletes with anterior glenohumeral instability treated with isolated arthroscopic Bankart repair for isolated anterior instability. Methods Between January 2008 and December 2016, 351 competitive athletes who participated in contact or collision sports underwent isolated arthroscopic Bankart repair at our institution (rugby n = 105, soccer n = 90, martial arts n = 36 boxing n = 28, field hockey n = 30, handball n = 31, and basketball n = 31). Return to sports, the Rowe score, and the Athletic Shoulder Outcome Scoring System (ASOSS) score were used to assess functional outcomes. Complications also were evaluated. Results The mean follow-up period was 66.7 months (range, 36-148 months) and the mean age of the 351 patients was 21.3 years (range, 17-30 years).Overall, 309 patients (88%) were able to return to sports, and 284 (81%) returned at the same level as before the injury. The mean time to return to sports was 5.3 months. The rate of return to sports, the level achieved by the patients, and time to return to sports varied significantly between sports. The Rowe and ASOSS scores showed statistical improvement after operation (P < .001). The ASOSS score varied significantly between sports (P < .001). There were 40 recurrences (11.3%), 7 complications (2%) and 21 patients (6%) underwent revision surgery. There was a significant difference in the rate of recurrences and revisions between the different contact sports. Conclusions In athletes with glenohumeral instability who undergo isolated arthroscopic Bankart repair for isolated anterior instability, there is great variability in the rate of return to sport at the same level, in shoulder performance after returning to competition, and in the postoperative recurrence rates. Due to the high variability found in our study, results after arthroscopic Bankart repair in contact athletes should not be reported globally by including the different sports under the "collision or contact sports" label. Level of Evidence Retrospective Case Series; Level of evidence, 4.
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Affiliation(s)
- Luciano Andrés Rossi
- Address correspondence to Luciano Andrés Rossi, Ph.D., Peron 4190 (C1199ABB), Buenos Aires, Argentina.
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Chalmers PN, Hillyard B, Kawakami J, Christensen G, O'Neill D, Childress V, Tashjian RZ. Double-loaded suture anchors in the treatment of anteroinferior glenohumeral instability. JSES Int 2020; 4:587-591. [PMID: 32939491 PMCID: PMC7479039 DOI: 10.1016/j.jseint.2020.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Hypothesis The purpose of this study was to determine the clinical outcomes of arthroscopic labral repair for anteroinferior glenohumeral instability with the use of double-loaded suture anchors. Methods This study evaluated a series of consecutive patients treated after the senior author changed from single- to double-loaded suture anchors for the treatment of anteroinferior glenohumeral instability with a minimum follow-up period of 2 years. We collected the following outcomes at final follow-up: visual analog scale pain score, Simple Shoulder Test score, American Shoulder and Elbow Surgeons score, and instability recurrence data. Results A total of 41 consecutive patients underwent arthroscopic labral repair with double-loaded anchors, of whom 30 (71%) were able to be contacted at a minimum of 2 years postoperatively. These patients included 4 contact or collision athletes (13%). The patients had an average of 12 ± 13 prior dislocations over an average period of 56 ± 57 months preoperatively. Mean glenoid bone loss measured 16% ± 10%, and 67% (18 of 27 patients) had glenoid bone loss ≥ 13.5%. Intraoperatively, 3.2 ± 0.4 anchors were used. No posterior repairs or remplissage procedures were performed. At an average of 6.7 ± 2.7 years' follow-up, the visual analog scale pain score was 0.8 ± 1.4; Simple Shoulder Test score, 11 ± 2; and American Shoulder and Elbow Surgeons score, 90 ± 14. Patients with bone loss < 13.5% had a 0% redislocation rate and 11% subluxation rate, whereas those with bone loss ≥ 13.5% had a 6% reoperation rate, 22% redislocation rate, and 22% subluxation rate. Conclusion Arthroscopic labral repair with double-loaded anchors provides satisfactory clinical results at early to mid-term outcome assessment when glenoid bone loss is <13.5%.
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Affiliation(s)
- Peter N. Chalmers
- Corresponding author: Peter N. Chalmers, MD, Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84105, USA.
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35
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Fanning E, Maher N, Cools A, Falvey EC. Outcome Measures After Shoulder Stabilization in the Athletic Population: A Systematic Review of Clinical and Patient-Reported Metrics. Orthop J Sports Med 2020; 8:2325967120950040. [PMID: 32984424 PMCID: PMC7498977 DOI: 10.1177/2325967120950040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/07/2020] [Indexed: 01/02/2023] Open
Abstract
Background: Athletic endeavor can require the “athletic shoulder” to tolerate significant
load through supraphysiological range and often under considerable
repetition. Outcome measures are valuable when determining an athlete’s safe
return to sport. Few data are available to guide a clinician’s choice from
the variety of measures available. Purpose: To describe the use of quantifiable objective outcome measures and
patient-reported outcome tools after glenohumeral joint stabilization,
specifically in an athletic population. The secondary aim of our study was
to assess whether the method of measurement used was clearly described and
standardized to aid clinical interpretation. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic search of MEDLINE, Scopus, SPORTDiscus, and Web of Science
databases was performed in December 2018 based on the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. After
the application of selection criteria, a full review of identified papers,
and screening of reference lists, a total of 62 studies were included in the
review. All studies were independently appraised for quality, predefined
data fields were populated and cross-checked for accuracy, and results were
then summarized from these data fields. Results: Of the 62 included studies, 94% used a quantifiable objective clinical
outcome. A majority (85%) of the studies measured range of motion, 21%
recorded muscle strength, 5% measured electromyographic activity, 5%
examined shoulder kinematics, and 3% assessed joint proprioception after
surgery. However, only 18% of the studies clearly described a standardized
method of measuring the outcome. Nearly all (95%) of the studies used at
least 1 patient-reported outcome measure. The Rowe score was most commonly
used (35%). Conclusion: We must standardize and clearly describe the use of quantifiable objective
outcome measures to aid clinical interpretation. A concerted effort should
also be made to standardize the use of patient-reported outcome tools after
shoulder stabilization in the athletic population.
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Affiliation(s)
- Edel Fanning
- Sports Surgery Clinic, Sports Medicine, Dublin, Ireland.,University College Cork, Cork, Ireland
| | - Natasha Maher
- Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, West Yorkshire, UK
| | - Ann Cools
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Gent, Belgium
| | - Eanna C Falvey
- Sports Surgery Clinic, Sports Medicine, Dublin, Ireland.,University College Cork, Cork, Ireland
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36
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Yian EH, Weathers M, Knott JR, Sodl JF, Spencer HT. Predicting Failure After Primary Arthroscopic Bankart Repair: Analysis of a Statistical Model Using Anatomic Risk Factors. Arthroscopy 2020; 36:964-970. [PMID: 31926270 DOI: 10.1016/j.arthro.2019.11.109] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/31/2019] [Accepted: 11/16/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to establish and analyze a simplified scoring system based on anatomic imaging measurements to predict recurrent instability after primary arthroscopic shoulder capsulolabral repair. METHODS All patients undergoing primary arthroscopic anterior capsulolabral repair of the shoulder were reviewed. Patients were contacted and charts were reviewed for endpoint of recurrent instability and return to prior level of activity. Predictive variables for recurrent instability studied included age, sex, amount of glenoid bone loss, intact anterior articular arc (IAAA), glenohumeral tracking (off-track), contact sports and overhead sports participation. RESULTS 540 patients met inclusion criteria and follow-up data with magnetic resonance imaging data were available for 337 shoulders. Average follow-up was 6.2 years(range 3.4-9.3 years). Symptomatic recurrent instability occurred in 102 patients (30.3%) and 68% of contacted patients returned to pre-injury activities. In univariate analysis, age under 21 years, off-track lesions, IAAA <150°, and glenoid bone loss (GBL) of 10% or greater displayed an increased risk of recurrent instability. Multivariable analysis showed these factors remained significant: age <21 (odds ratio [ratio] 2.37), off-track glenoid (OR 2.86), IAAA <150 (OR 3.90), and GBL ≥10% (OR 7.47). A scoring system assigning 1 point each for age and off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10% yielded 79% sensitivity, 75% specificity, 58% positive predictive value, and 89% negative predictive value using a probability value of 20 percent for recurrent instability. CONCLUSION At mid-term follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series. Younger age, glenoid bone loss of 10% or more, IAAA <150° and off-track glenoid lesion conferred the greatest risk for postoperative instability. We propose a scoring system assigning 1 point for age, 1 point for off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10%. This schema demonstrated moderate accuracy for predicting recurrent instability when using a cutoff threshold score above 2 points for failure. LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
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Affiliation(s)
- Edward H Yian
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Anaheim, California, U.S.A.
| | - Michael Weathers
- Department of Orthopaedics, Northwest Permanente, Salem, Oregon, U.S.A
| | - Jonathan R Knott
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Anaheim, California, U.S.A
| | - Jeffrey F Sodl
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Anaheim, California, U.S.A
| | - Hillard T Spencer
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Anaheim, California, U.S.A
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37
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Trojan JD, Meyer LE, Edgar CM, Brown SM, Mulcahey MK. Epidemiology of Shoulder Instability Injuries in Collision Collegiate Sports From 2009 to 2014. Arthroscopy 2020; 36:36-43. [PMID: 31864594 DOI: 10.1016/j.arthro.2019.07.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 02/09/2023]
Abstract
PURPOSE To describe the types, mechanisms, and severity of shoulder instability injuries in collegiate collision athletes during the 2009-2010 through 2013-2014 academic years using the National Collegiate Athletic Association Injury Surveillance Program; to compare the injury incidence between men's collision sports and their women's non-collision counterparts, when possible; and to compare injury outcomes between Divisions I, II, and III. METHODS Data regarding men's football, wrestling, ice hockey, and lacrosse, as well as women's ice hockey and lacrosse, were obtained. Injuries requiring attention from a health care provider were reported. Incidence rates per 100,000 athlete-exposures (AEs) were calculated with 95% confidence intervals (CIs). Analysis of variance was used to compare time loss (TL), and χ2 analysis was used to compare surgery rates between divisions. RESULTS A total of 445 shoulder instability injuries occurred in 1,421,561 AEs from 2009-2010 to 2013-2014 (incidence rate, 31.30 injuries/100,000 AEs; 95% CI, 28.4-34.21 injuries/100,000 AEs). Subluxation accounted for 59.1% of injuries, with anterior subluxation (35.3%) being the most common injury. Dislocation resulted in the most TL per injury (17.58 days). Mean TL for all injuries was 8.17 days (standard deviation, 7.21 days). When non-time-loss injuries were excluded from analysis, players experienced a mean TL of 18.34 days (standard deviation, 8.44 days). Divisions I (4.77 days), II (20.52 days), and III (11.23 days) differed significantly in mean TL (P = .01). Of the injuries, 29.3% required surgery. The surgery rates for Divisions I (32.9%), II (38.1%), and III (19.4%) also differed significantly (P = .04). Men's ice hockey and lacrosse players sustained a 2.17-fold (95% CI, 1.04-4.50) higher incidence of shoulder instability than their female counterparts. CONCLUSIONS Anterior subluxation and dislocation accounted for 52.1% of all shoulder instability injuries. Injured athletes missed 8 days on average, and nearly 30% of injuries required surgery. Surgery rates and TL were significantly different between Divisions I, II, and III. Female athletes playing non-collision ice hockey and lacrosse experienced significantly lower shoulder instability rates than their male counterparts. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Jeffrey D Trojan
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Lucy E Meyer
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Cory M Edgar
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Storrs, Connecticut, U.S.A
| | - Symone M Brown
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A..
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Yamamoto N, Kawakami J, Hatta T, Itoi E. Effect of subcritical glenoid bone loss on activities of daily living in patients with anterior shoulder instability. Orthop Traumatol Surg Res 2019; 105:1467-1470. [PMID: 31624030 DOI: 10.1016/j.otsr.2019.08.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 07/21/2019] [Accepted: 08/21/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND It has been biomechanically demonstrated that 20% to 25% is a critical glenoid bone loss. Recently, there are several reports describing that a bone loss less than 20% to 25% needed to be treated because patients may have decreased quality of life without recurrent instability events. The purpose of this study was to clarify the presence of subcritical bone loss that would affect postoperative instability or quality of life. METHODS Subjects were 43 patients aged≤40years with less than 25% glenoid bone loss who had undergone arthroscopic Bankart repair. These patients were assessed at a mean follow-up of 32months. The Western Ontario Shoulder Instability (WOSI) and Rowe scores were used for the clinical evaluation. Patients were divided in 3 groups based on the percentage of bone loss: group 1: <8%; group 2: 8% to 17%; and group 3: >17%. RESULTS The recurrence rate was 7% (3/43 shoulders). A weak negative correlation was seen between bone loss and sports/recreation/work domain of the WOSI score (r=-0.304, p=0.0191). The WOSI for group 3 was significantly lower than that for group 1 and 2 (p=0.0009). The male WOSI scores were significantly lower than the female ones (p=0.0471). The WOSI scores of the contact athletes were significantly lower than those of non-contact athletes (p=0.0275). All the patients in Group 3 were males and participated in contact sports. CONCLUSION Glenoid bone loss between 17% and 25% is considered to be a "subcritical bone loss" in our series, especially in male patients who are involved in sports or high-level activities. LEVEL OF EVIDENCE III, retrospective study.
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Affiliation(s)
- Nobuyuki Yamamoto
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Jun Kawakami
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Taku Hatta
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan.
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Bone union of the transferred coracoid graft is the key factor affecting the extent of postoperative graft changes and the clinical results following the modified Bankart and Bristow procedure: a computed tomography scan study. J Orthop Surg Res 2019; 14:84. [PMID: 30898131 PMCID: PMC6429825 DOI: 10.1186/s13018-019-1129-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/12/2019] [Indexed: 11/23/2022] Open
Abstract
Background The extent of postoperative changes in the coracoid process grafted during the modified Bankart and Bristow procedure remains unclear. The purpose of the present study was to quantify the postoperative changes in bone surface area as assessed on computed tomography, as well as to clarify the impact of such changes on the clinical results. Methods Twenty-three shoulders of 21 subjects who underwent the modified Bankart and Bristow procedure were retrospectively analyzed. Computed tomography images were obtained immediately after surgery and at the final follow-up. The changes in bone surface area of the grafted coracoid process were measured on computed tomography slices in the proximity of the screw bore. Clinical outcomes were evaluated in terms of the Rowe, Walch-Duplay, and simple shoulder test scores. Results Bone area increased in 15 shoulders (65.2%) and decreased in eight shoulders (34.8%). Bone area increased by 51.3% in shoulders with bone union in the superior part of the coracoid process graft, with no significant differences between the superior and inferior sides of the graft regarding the rate of change in bone surface area (41.4% vs. 68.9% increase). However, in shoulders with bone union in the inferior part of the coracoid process graft, the rate of change in bone area differed significantly between the superior and inferior sides of the graft, exhibiting a 42.3% decrease on the superior side and 39.8% increase on the inferior side. In shoulders with no bone union, bone area decreased by 29.5% (17.4% vs. 39.3% decrease on the superior and inferior side, respectively), whereas the Rowe and Walch-Duplay scores were significantly lower than those noted in shoulders with bone union. Conclusions Postoperative bone formation and bone resorption in the coracoid process grafted during the modified Bankart and Bristow procedure depend on whether and where bone union occurs. Graft non-union is associated with inferior clinical results.
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Hatta T, Yamamoto N, Shinagawa K, Kawakami J, Itoi E. Surgical decision making based on the on-track/off-track concept for anterior shoulder instability: a case-control study. JSES OPEN ACCESS 2019; 3:25-28. [PMID: 30976732 PMCID: PMC6443644 DOI: 10.1016/j.jses.2018.10.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The purpose of this study was to assess the clinical outcomes of patients with anterior shoulder instability who underwent surgical treatment according to the on-track/off-track concept. Methods We retrospectively analyzed patients who underwent surgical treatment according to the glenoid track concept with a minimum of 2 years’ follow-up. By use of preoperative 3-dimensional computed tomography images, surgical options were selected: arthroscopic Bankart repair (ABR) for patients with on-track lesions and the Latarjet procedure or ABR with the remplissage procedure for patients with off-track lesions. The recurrence rate was assessed at 2-year follow-up after surgery. Results Among 92 patients enrolled in this study, 81 had on-track lesions and underwent ABR. Of the 11 patients with off-track lesions, 1 underwent ABR with the remplissage procedure and 10 underwent the Latarjet procedure. Recurrences occurred in 4 patients treated by ABR (5%), whereas no recurrences were observed in off-track cases treated by the remplissage or Latarjet procedure. Conclusion Clinical application of the on-track/off-track concept for determining surgical options in preoperative planning seems to be useful to prevent recurrent instability after surgery.
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Affiliation(s)
- Taku Hatta
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Nobuyuki Yamamoto
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Kiyotsugu Shinagawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Jun Kawakami
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
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Arthroscopic anterior shoulder stabilisation in overhead sport athletes: 5-year follow-up. Ir J Med Sci 2019; 188:1233-1237. [DOI: 10.1007/s11845-019-01986-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 02/06/2019] [Indexed: 02/01/2023]
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Ro K, Kim MS, Kim JD, Rhee YG. Arthroscopic Findings and Clinical Outcomes in Patients 40 Years of Age and Older With Recurrent Shoulder Dislocation. Arthroscopy 2019; 35:314-322. [PMID: 30611590 DOI: 10.1016/j.arthro.2018.08.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 08/12/2018] [Accepted: 08/12/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE The present study investigates the intra-articular findings and clinical outcomes after arthroscopic surgery in patients after age 40 with chronic anterior shoulder instability. METHODS Fifty patients older than 40 years who underwent arthroscopic stabilization for recurrent anterior shoulder dislocation were analyzed. RESULTS The mean age at the time of surgery was 44.8 years (range, 40-72 years), and the mean duration of follow-up was 45 months (range, 28-150 months). The mean visual analog scale score for pain with motion significantly improved from 4.1 preoperatively to 1.7 at the last follow-up (P < .001). The range of motion in the affected shoulder revealed limitations of 9.4° in forward flexion and 17.8° in external rotation compared with the unaffected shoulder. Both the Constant and Rowe scores significantly improved (P < .001 and P < .001, respectively). Recurrence, which includes dislocation and subluxation, occurred in 14% postoperatively. Anteroinferior labral lesion was seen in 92% of patients. Associated lesions included superior labrum anterior to posterior lesion (22%), midsubstance capsular tear (10%), and Hill-Sachs lesion (92%). Rotator cuff tears were found in 18%-partial-thickness tear in 10% and full-thickness tear, which was repaired with suture anchor, in 8%. Among the intra-articular lesions, there was no significant relation with recurrent instability or functional outcome as a single factor. CONCLUSIONS In patients with chronic anterior shoulder instability who were older than 40 years, the clinical results after arthroscopic surgery showed statistically significant improvement with good muscle strength recovery. The quality of labral lesion, size of the Hill-Sachs lesion, and glenoid defect showed positive correlation with the number of preoperative dislocation. The intra-articular pathologies were varied, however no single articular lesion had significant impact on the recurrence rate. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Kyunghan Ro
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Myung Seo Kim
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Jong Dae Kim
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Yong Girl Rhee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea.
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Hartzler R. Editorial Commentary: Middle-Age Does Not Confer Immunity From Recurrent Instability After Arthroscopic Bankart Repair. Arthroscopy 2019; 35:323-324. [PMID: 30712612 DOI: 10.1016/j.arthro.2018.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/23/2018] [Indexed: 02/02/2023]
Abstract
Recurrent anterior shoulder instability remains a challenge to treat with arthroscopy, as the rate of postoperative instability remains high in certain patient populations. Indications for performing an "anatomic" arthroscopic reconstruction (isolated Bankart repair) are narrowing as surgeons identify risk factors for failure with this approach. In particular, the presence of certain bone loss patterns that occur with high numbers of instability events should prompt consideration for nonanatomic reconstruction, such as Latarjet or Hill-Sachs remplissage, to reduce the rate of postoperative recurrent instability.
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Domos P, Ascione F, Wallace AL. Arthroscopic Bankart repair with remplissage for non-engaging Hill-Sachs lesion in professional collision athletes. Shoulder Elbow 2019; 11:17-25. [PMID: 30719094 PMCID: PMC6348582 DOI: 10.1177/1758573217728414] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/20/2017] [Accepted: 07/24/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The present study aimed to determine whether arthroscopic remplissage with Bankart repair is an effective treatment for improving outcomes for collision athletes with Bankart and non-engaging Hill-Sachs lesions. METHODS Twenty collision athletes underwent arthroscopic Bankart repair with posterior capsulotenodesis (B&R group) and were evaluated retrospectively, using pre- and postoperative WOSI (Western Ontario Shoulder Instability), EQ-5D (EuroQOL five dimensions), EQ-VAS (EuroQol-visual analogue scale) scores and Subjective Shoulder Value (SSV). The recurrence and re-operation rates were compared to a matched group with isolated arthroscopic Bankart repair (B group). RESULTS The mean age was 25 years with an mean follow-up of 26 months. All mean scores improved with SSV of 90%. There was a mean deficit in external rotation at the side of 10°. One patient was treated with hydrodilatation for frozen shoulder. One patient had residual posterior discomfort but no apprehension in the B&R group compared to 5% persistent apprehension in the B group. In comparison, the recurrence and re-operation rates were 5% and 30% (p = 0.015), 5% and 35% (p = 0.005) in the B&R and B groups, respectively. CONCLUSIONS This combined technique demonstrated good outcomes, with lower recurrence rates in high-risk collision athletes. The slight restriction in external rotation does not significantly affect any clinical outcomes and return to play.
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Affiliation(s)
- Peter Domos
- Department of Trauma and Orthopaedics, Northern General Hospital, Sheffield, UK,Peter Domos, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK.
| | - Francesco Ascione
- Department of Orthopedics, Seconda Università degli Studi di Napoli, Naples, Italy
| | - Andrew L. Wallace
- Shoulder Unit, Hospital of St John and St Elizabeth and Fortius Clinic, London, UK
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Kasik CS, Rosen MR, Saper MG, Zondervan RL. High rate of return to sport in adolescent athletes following anterior shoulder stabilisation: a systematic review. J ISAKOS 2018; 4:33-40. [PMID: 31044093 DOI: 10.1136/jisakos-2018-000224] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Traumatic anterior shoulder instability remains common for the adolescent athletes. Aim or objective To perform a systematic review on the outcomes and return to sport (RTS) following Bankart repair in adolescent athletes. Evidence review A systematic review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines was conducted of studies reporting outcomes following open and/or arthroscopic Bankart repair using modern suture anchors following traumatic anterior shoulder dislocations in adolescent patients (ages 10-19 years). Quality assessment was evaluated with ROBINS-I and MINORS instruments. The outcomes analysed included RTS, timetable to unrestricted activity, recurrent instability and revision surgery. Findings This systematic review identified 11 studies comprising 461 adolescent athletes with a mean age of 15.7 years (range, 11-19 years) and an average follow-up of 48.8 months (range, 22-85.2 months). A total of 392 patients (400 shoulders) underwent arthroscopic Bankart repair, while the remaining 69 patients (69 shoulders) underwent an open procedure. The average MINORS score was 9.6 for non-comparative studies and 17 for comparative studies. ROBINS-I revealed six studies to have a moderate risk of bias, while the remaining five studies presented serious risk of bias. There was an overall 81.5% rate of RTS to preinjury levels of athletic competition at an average of 5.3 months following Bankart repair for traumatic anterior shoulder instability. The overall total mean incidence of recurrent instability was 18.5%, while the mean incidence of revision surgery was 12.1%. Contact athletes had a 31.1% and 13% rate of recurrence and revision surgery, respectively. In comparison, collision athletes were shown to have a 10.4% and 1.4% incidence of recurrent instability and revision surgery, respectively. Conclusions and relevance Adolescent athletes who undergo Bankart repair for traumatic anterior shoulder instability have an 81.5% rate of RTS to preinjury levels of play at an average of 5 months following surgery. The overall total mean incidence of recurrent instability in the adolescent population is 18.5%, while the mean incidence of revision surgery is 12.1%. The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery. Level of evidence Level IV.
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Affiliation(s)
- Connor S Kasik
- Department of Orthopaedic Surgery, McLaren Greater Lansing, Lansing, Michigan, USA
| | - Michael R Rosen
- Department of Orthopaedic Surgery, McLaren Greater Lansing, Lansing, Michigan, USA
| | - Michael G Saper
- Department of Orthopedics and Sports Medicine, Seattle Children's, Seattle, Washington, USA
| | - Robert L Zondervan
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
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Alkaduhimi H, Saarig A, van der Linde JA, Willigenburg NW, van Deurzen DFP, van den Bekerom MPJ. An assessment of quality of randomized controlled trials in shoulder instability surgery using a modification of the clear CLEAR-NPT score. Shoulder Elbow 2018; 10:238-249. [PMID: 30214489 PMCID: PMC6134533 DOI: 10.1177/1758573218754370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 11/19/2017] [Accepted: 12/27/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The present study aimed to evaluate the methodological quality and determine the quality of reporting of randomized controlled trials (RCTs) that assess surgical treatment for shoulder instability. METHODS A Cochrane, Pubmed, EMBASE and Trip database search was performed, including the relevant literature, regarding RCTs that report on shoulder instability published between January 1994 and January 2017. Methodological quality was assessed with a modification of the Checklist to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). Points were assigned based on 18 items regarding patient characteristics, randomization, care provider characteristics, surgical details and blinding, with a total score ranging from 0 points to 18 points. Missing items were verified with the corresponding authors of the studies. Quality of reporting corresponds to the total scores including the items that were additionally provided by the authors. RESULTS We included 22 studies. Of these, nine corresponding authors provided additional information. The average methodological quality was 16.9 points (11 studies) and the average quality of reporting was 9.5 points (22 studies). Items scoring worst included information regarding the surgeon's experience, the patients' level of activity, comorbidities, analyzing according to 'intention-to-treat' principles, and blinding of care providers, participants and assessors. CONCLUSIONS RCTs reporting on shoulder instability surgery are well performed but poorly reported.
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Affiliation(s)
- Hassanin Alkaduhimi
- Hassanin Alkaduhimi, Oosterpark 9, 1091 AC
Amsterdam, The Netherlands. E-mail:
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Traumatic Instability: Treatment Options and Considerations for Recurrent Posttraumatic Instability. Sports Med Arthrosc Rev 2018; 26:102-112. [PMID: 30059444 DOI: 10.1097/jsa.0000000000000204] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Recurrent traumatic glenohumeral instability is a complex problem with multiple variables to consider, but patient demographics, activities, as well as clinical and radiographic findings provide significant information to help choose the best treatment option. Although nonoperative treatment is a viable option for primary glenohumeral instability and in-season instability, recurrent instability exhibits anatomic factors which render nonsurgical treatment limited in scope. A proper patient history, clinical examination, and standard and advanced imaging are necessary in the assessment of patients with recurrent traumatic instability. Age, activity, hypermobility, tissue quality, glenoid and humeral head bone stock, and any prior surgical treatment are factors that must be considered for surgical planning. Open and arthroscopic Bankart repairs are good surgical options when bone loss is not an issue but increasing glenoid or humeral osseous deficiency in this setting frequently warrants additional procedures which address bony insufficiency. Controversy remains concerning the threshold value for glenoid bony deficiency and combined, bipolar defects, but this critical number may be less than previously suspected. Despite this controversy, successful surgical treatment of recurrent glenohumeral instability is possible when properly assessed and the correct surgery applied.
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Jeon YS, Jeong HY, Lee DK, Rhee YG. Borderline Glenoid Bone Defect in Anterior Shoulder Instability: Latarjet Procedure Versus Bankart Repair. Am J Sports Med 2018; 46:2170-2176. [PMID: 29879363 DOI: 10.1177/0363546518776978] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal procedure for anterior shoulder instability with a borderline (15%-20%) bone defect on the anterior rim of the glenoid is still controversial. PURPOSE To compare the clinical outcome and recurrence rate between the arthroscopic Bankart repair and Latarjet procedure among patients with recurrent anterior shoulder instability and a borderline glenoid bone defect. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The authors retrospectively reviewed cases of arthroscopic Bankart repair and the Latarjet procedure for recurrent anterior shoulder instability with a borderline (15%-20%) glenoid bone defect. Enrollment comprised 149 patients (Bankart group, n = 118; Latarjet group, n = 31). The mean follow-up and age at operation were 28.9 ± 7.3 months (range, 24-73 months) and 26 ± 5 years (range, 16-46 years), respectively. RESULTS Rowe and UCLA (University of California, Los Angeles) shoulder scores significantly improved from 42.0 ± 14.3 and 22.9 ± 3.2 preoperatively to 90.9 ± 15.4 and 32.5 ± 3.3 postoperatively in the Bankart group ( P < .001) and from 41.0 ± 17.9 and 22.3 ± 3.4 to 91.1 ± 16.1 and 32.3 ± 3.4 in the Latarjet group ( P < .001), respectively. There were no significant between-group differences in Rowe ( P = .920) or UCLA ( P = .715) scores at the final follow-up. Mean postoperative loss of motion during forward flexion, external rotation in abduction, and internal rotation to the posterior was 3.0° ± 6.2°, 11.6° ± 10.2°, and 0.6 spinal segment in the Bankart group and 3.7° ± 9.8°, 10.3° ± 12.8°, and 0.9 spinal segment in the Latarjet group, respectively. These differences were not significant. However, the loss of external rotation at the side was significantly greater in the Bankart group (13.3° ± 12.9°) than in the Latarjet group (7.3° ± 18.1°, P = .034). The overall recurrence rate was significantly higher in the Bankart group (22.9%) than in the Latarjet group (6.5%), ( P = .040). CONCLUSION The Latarjet procedure and arthroscopic Bankart repair both provided satisfactory clinical outcome scores and pain relief for anterior shoulder instability with a borderline glenoid bone defect. However, the Latarjet procedure resulted in significantly lower recurrences and less external rotation limitation than the arthroscopic Bankart repair. Therefore, the Latarjet procedure could be a more reliable surgical option in anterior recurrent instability with a borderline glenoid bone defect.
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Affiliation(s)
- Yoon Sang Jeon
- Department of Orthopedic Surgery, College of Medicine, Inha University Hospital, Incheon, Republic of Korea
| | - Ho Yeon Jeong
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Dong Ki Lee
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Yong Girl Rhee
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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Rahu M, Kartus JT, Põldoja E, Pedak K, Kolts I, Kask K. Do Articular-Sided Partial-Thickness Rotator Cuff Tears After a First-Time Traumatic Anterior Shoulder Dislocation in Young Athletes Influence the Outcome of Surgical Stabilization? Orthop J Sports Med 2018; 6:2325967118781311. [PMID: 30090831 PMCID: PMC6077916 DOI: 10.1177/2325967118781311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Because of the high risk for redislocations after a first-time traumatic anterior shoulder dislocation with conservative treatment, recent publications have recommended early arthroscopic intervention, especially for young athletes. Concomitant rotator cuff tendon damage may occur when the shoulder dislocates; however, its presence and influence on clinical results have not been well described in this patient category. Hypothesis: In opposition to current opinion, a substantial number of articular-sided partial-thickness rotator cuff tears (APTRCTs) would be found at surgery after a first-time traumatic anterior shoulder dislocation in young athletes. However, the impact of these injuries on 2-year postoperative results would be negligible. Study Design: Cohort study; Level of evidence, 3. Methods: Sixteen male patients (mean age, 21 years [range, 16-25 years]) with a first-time traumatic anterior shoulder dislocation without bony Bankart lesions were included in this study. The indications for surgical treatment were age less than 25 years and being active in collision or contact sports at a competitive level. Arthroscopic surgery was performed at a mean 7.8 days (range, 2-14 days) after injury. Rowe and American Shoulder and Elbow Surgeons (ASES) scores as well as range of motion were evaluated at a minimum 2 years after an arthroscopic Bankart procedure, and a comparison of the clinical results between patients with and without APTRCTs was conducted. Results: An anterior-inferior capsulolabral injury was found in all patients. There were no bony Bankart lesions. An APTRCT was found in 9 of the 16 patients. At 2 years after surgical treatment, there were no significant differences between the patients with and without APTRCTs in terms of the Rowe score (90.0 and 87.1, respectively; P = .69) and ASES score (94.6 and 90.4, respectively; P = .67). Conclusion: APTRCTs were found in the superior part of the shoulder joint after a first-time traumatic anterior shoulder dislocation in a majority of young male athletes treated with surgical stabilization. There were no significant differences found between patients with and without APTRCTs in terms of the Rowe and ASES scores at 2 years after surgical treatment.
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Affiliation(s)
- Madis Rahu
- Department of Anatomy, University of Tartu, Tartu, Estonia.,Sports Medicine and Rehabilitation Clinic, Tartu University Hospital, Tartu, Estonia
| | - Jüri-Toomas Kartus
- Department of Orthopaedics, NU Hospital Group, Trollhättan/Uddevalla, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elle Põldoja
- Department of Anatomy, University of Tartu, Tartu, Estonia
| | - Kirsti Pedak
- School of Natural Sciences and Health, Tallinn University, Tallinn, Estonia
| | - Ivo Kolts
- Department of Anatomy, University of Tartu, Tartu, Estonia
| | - Kristo Kask
- Orthopaedic Centre, Surgery Clinic, North Estonia Medical Centre, Tallinn, Estonia
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