All-Suture Anchor vs. Knotless Suture Anchor for the Treatment of Anterior Shoulder Instability-A Prospective Cohort Study.

All-suture or soft-anchors (SA) represent a new generation of suture anchor technology with a completely suture-based system. This study's objective was to assess Juggerknot® SA, for arthroscopic Bankart repair in recurrent shoulder instability (RSI), and to compare it to a commonly performed knotless anchor (KA) technique (Pushlock®). In a prospective cohort study, 30 consecutive patients scheduled for reconstruction of the capsulolabral complex without substantial glenoid bone loss were included and operated on using the SA technique. A historical control group was operated on using the KA technique for the same indication. Clinical examinations were performed preoperatively and 12 and 24 months postoperatively. RSI and WOSI at 24 months were the co-primary endpoints, evaluated with logistic and linear regression. A total of 5 out of 30 (16.7%) patients suffered from RSI in the SA group, one out of 31 (3.2%) in the KA group (adjusted odds ratio = 10.12, 95% CI: 0.89-115.35), and 13.3% in the SA group and 3.2% in the KAgroup had a revision. The median WOSI in the SA group was lower than in the KA group (81% vs. 95%) (adjusted regression coefficient = 10.12, 95% CI: 0.89-115.35). Arthroscopic capsulolabral repair for RSI using either the SA or KA technique led to satisfying clinical outcomes. However, there is a tendency for higher RSI and lower WOSI following the SA technique.

Mid- to long-term results of postoperative immobilization in internal vs. external rotation after arthroscopic anterior shoulder stabilization.

BACKGROUND: There is still a disagreement on the postoperative rehabilitation concerning position of immobilization of the shoulder after arthroscopic anterior shoulder stabilization and its influence on the clinical outcome. The aim of this study was to evaluate the clinical results and the recurrence rate after arthroscopic anteroinferior shoulder stabilization and postoperative immobilization in internal rotation vs. external rotation. METHODS: Twenty-five patients (22 male and 3 female, mean age 28.5 years) were included in this prospective nonrandomized cohort study. In group I (11 male, 2 female, mean age 28 years), the postoperative functional immobilization was carried out in internal rotation of 60°, and in group II (11 male, 1 female, mean age 30 years), 15° of external rotation of the arm for 4 weeks in both groups. The clinical follow-up was performed at 2, 4, and 6 weeks as well as at 3, 6, and 12 months postoperatively including assessment of range of motion and functional shoulder scores (Subjective Shoulder Value, Constant score, Rowe score, Walch Duplay score, Melbourne Instability Shoulder Score). Furthermore, shoulder instability was evaluated using the apprehension, relocation, and surprise tests. Mid-term follow-up data were additionally assessed after a minimum of 4 years. RESULTS: Twenty patients (19 male and 1 female) with an average age of 28 years were followed up for 62 (53-72) months after arthroscopic stabilization. The comparison of both groups showed almost equal results regarding the range of motion without any significant differences (P > .05). The evaluation of the shoulder function scores also showed no significant differences with an average Subjective Shoulder Value of 95% vs. 91%, Constant score of 89 vs. 88 points, Rowe score of 96 vs. 94 points, Walch Duplay score of 86 vs. 89 points, Melbourne Instability Shoulder Score of 96 points, and Western Ontario Shoulder Instability Index of 88% vs. 84% (P > .05). There was no recurrent dislocation in both groups. CONCLUSION: The type of immobilization after arthroscopic shoulder stabilization does not influence the clinical results after a mid- to long-term follow-up.

Analysis of complication after open coracoid transfer as a revision surgery for failed soft tissue stabilization in recurrent anterior shoulder instability.

BACKGROUND: The coracoid transfer represents a treatment option for patients with recurrent shoulder instability. Only a few studies exist about the complication rate of the coracoid transfer as a revision surgery following failed soft tissue stabilization. The purpose of this study was to analyze the results and complication rate after coracoid transfer as a revision surgery. METHODS: In this study 38 patients (4 females, 34 males, mean age 27 years) were included of whom 29 patients were available for follow-up after a mean of 27 months. Previous shoulder stabilization procedures were predominantly arthroscopic (n = 25). Complications were divided according to their timely appearance into early (< 3 months) and late (> 3 months) postoperatively as well as need for revision. Clinical scores [Constant Score (CS), Rowe Score (RS), Walch-Duplay-Score (WDS), WOSI and Subjective-Shoulder-Value (SSV)] were evaluated preoperatively and at final follow-up. RESULTS: In this patient cohort, the overall complication rate was 27.6%, all of them occurred > 3 months postoperatively. In seven of eight cases (24.1%) a repeat surgical procedure was conducted. Recurrent instability occurred in three patients (10.3%) of which two received a revision surgery (n = 1 iliac-crest bone graft, n = 1 labral repair). Due to persistent pain five patients underwent an arthroscopic implant removal. The complication rate was with 40% higher in patients with two or more previous surgeries (n = 4 out of 10 patients) compared to patients with one previous surgery (21%, n = 4 out of 19 patients). The scores increased significantly comparing pre- to postoperative [CS 74-90 points, RS 27-91 points, WDS 16-89 points, WOSI 40-76% and SSV 41-82% (p < 0.05)]. CONCLUSION: The open coracoid transfer as a revision surgery after failed soft tissue stabilization leads to satisfying clinical results. However, the complication rate is high though comparable to data in the literature when used as a primary surgery. The indication for a coracoid transfer should be judged carefully and possible alternatives should be considered.

Influence of Bony Defects on Preoperative Shoulder Function in Recurrent Anteroinferior Shoulder Instability.

BACKGROUND: Recurrent anteroinferior shoulder dislocations are often associated with bony glenoid and humeral defects. The influence of those bony lesions on the postoperative outcomes after arthroscopic shoulder stabilization procedures has been the subject of many studies. Little is known about the influence of those lesions on preoperative function. PURPOSE: To evaluate the influence of glenoid and humeral bony defects on preoperative shoulder function in recurrent anteroinferior shoulder instability. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Included in the study were 90 patients (70 men, 20 women; mean age, 27.1 years; 24 patients with prior failed stabilization) with posttraumatic recurrent anteroinferior shoulder instability who underwent preoperative computed tomography (CT) of both shoulders. The glenoid index was used to measure glenoid defect on a 3-dimensional CT. Humeral head defect was measured on a 2-dimensional CT with evaluation of the Hill-Sachs quotient, product, sum, and difference. Preoperative evaluation also included the Rowe score, Constant score, Walch-Duplay score, Melbourne Instability Shoulder Score (MISS), Western Ontario Shoulder Instability Index (WOSI), and Subjective Shoulder Value (SSV). RESULTS: There was a weak but significant correlation of the Hill-Sachs quotient and the glenoid index with the Rowe score (P = .03, r = -0.22 and P = .03, r = 0.23, respectively). Furthermore, the Hill-Sachs product significantly correlated with the WOSI (P = .02); in particular, the physical symptoms subscore showed a significant correlation (P = .04). The glenoid index showed a significant correlation with the SSV (P < .01). No significant correlation was found between the Walch-Duplay score, Constant score, or MISS and bony defects. CONCLUSION: The results of this study show that objective and subjective scoring systems correlate significantly with the clinical condition of patients with recurrent shoulder instability and associated bony defects. It is recommended that clinicians use the Rowe score, WOSI, and SSV for the clinical evaluation of patients with recurrent anteroinferior shoulder instability and associated bony defects. These evaluation systems may provide an early clinical indication of bony defects. Furthermore, very poor results on these evaluations could underline the necessity of a CT scan for the diagnosis of bony defects in recurrent shoulder instability and might be helpful for decision making concerning the indication of a CT.

Defect Characteristics of Reverse Hill-Sachs Lesions.

BACKGROUND: Little scientific evidence regarding reverse Hill-Sachs lesions (RHSLs) in posterior shoulder instability exists. Recently, standardized measurement methods of the size and localization were introduced, and the biomechanical effect of the extent and position of the defects on the risk of re-engagement was determined. PURPOSE: To analyze the characteristics and patterns of RHSLs in a large case series using standardized measurements and to interpret the results based on the newly available biomechanical findings. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In this multicenter study, 102 cases of RHSLs in 99 patients were collected from 7 different shoulder centers between 2004 and 2013. Patient- as well as injury-specific information was gathered, and defect characteristics in terms of the size, localization, and depth index were determined on computed tomography or magnetic resonance imaging scans by means of standardized measurements. Additionally, the position (gamma angle) of the posterior defect margin as a predictor of re-engagement was analyzed. RESULTS: Three types of an RHSL were distinguished based on the pathogenesis and chronicity of the lesion: dislocation (D), locked dislocation (LD), and chronic locked dislocation (CLD). While the localization of the defects did not vary significantly between the subgroups (P = .072), their mean size differed signficantly (D: 32.6° ± 11.7°, LD: 49.4° ± 17.2°, CLD: 64.1° ± 20.7°; P < .001). The mean gamma angle as a predictor of re-engagement was similarly significantly different between groups (D: 83.8° ± 14.5°, LD: 96.5° ± 17.9°, CLD: 108.7° ± 18.4°; P < .001). The orientation of the posterior defect margin was consistently quite parallel to the humeral shaft axis, with a mean difference of 0.3° ± 8.1°. CONCLUSION: The distinction between the 3 different RHSL types based on the pathogenesis and chronicity of the defect helps identify defects prone to re-engagement. The gamma angle as a measurement of the position of the posterior defect margin and therefore a predictor of re-engagement varies significantly between the defect types.