Aims

Recurrent dislocation is both a cause and consequence of glenoid bone loss, and the extent of the bony defect is an indicator guiding operative intervention. Literature suggests that loss greater than 25% requires glenoid reconstruction. Measuring bone loss is controversial; studies use different methods to determine this, with no clear evidence of reproducibility. A systematic review was performed to identify existing CT-based methods of quantifying glenoid bone loss and establish their reliability and reproducibility

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available. Cite this article: Bone Joint J 2024;106-B(10):1100–1110

Glenoid and humeral head bone defects have long been recognized as major determinants in recurrent shoulder instability as well as main predictors of outcomes after surgical stabilization. However, a universally accepted method to quantify them is not available yet. The purpose of the present study is to describe a new CT method to quantify bipolar bone defects volume on a virtually generated 3D model and to evaluate its reproducibility. A cross-sectional observational study has been conducted. Forty CT scans of both shoulders were randomly selected from a series of exams previously acquired on patients affected by anterior shoulder instability. Inclusion criterion was unilateral anterior shoulder instability with at least one episode of dislocation. Exclusion criteria were: bilateral shoulder instability; posterior or multidirectional instability, previous fractures and/or surgery to both shoulders; congenital or acquired inflammatory, neurological, or degenerative diseases. For all patients, CT exams of both shoulders were acquired at the same time following a standardized imaging protocol. The CT data sets were analysed on a standard desktop PC using the software 3D Slicer. Computer-based reconstruction of the Hill-Sachs and glenoid bone defect were performed through Boolean subtraction of the affected side from the contralateral one, resulting in a virtually generated bone fragment accurately fitting the defect. The volume of the bone fragments was then calculated. All measurements were conducted by two fellowship-trained orthopaedic shoulder surgeons. Each measurement was performed twice by one observer to assess intra-observer reliability. Inter and intra-observer reliability were calculated. Intraclass Correlation Coefficients (ICC) were calculated using a two-way random effect model and evaluation of absolute agreement. Confidence intervals (CI) were calculated at 95% confidence level for reliability coefficients. Reliability values range from 0 (no agreement) to 1 (maximum agreement). The study included 34 males and 6 females. Mean age (+ SD) of patients was 36.7 + 10.10 years (range: 25 – 73 years). A bipolar bone defect was observed in all cases. Reliability of humeral head bone fragment measurements showed excellent intra-observer agreement (ICC: 0.92, CI 95%: 0.85 – 0.96) and very good interobserver agreement (ICC: 0.89, CI 95%: 0.80 – 0.94). Similarly, glenoid bone loss measurement resulted in excellent intra-observer reliability (ICC: 0.92, CI 95%: 0.85 – 0.96) and very good inter-observer agreement (ICC: 0.84, CI 95%:0.72 – 0.91). In conclusion, matching affected and intact contralateral humeral head and glenoid by reconstruction on a computer-based virtual model allows identification of bipolar bone defects and enables quantitative determination of bone loss

Purpose: The hand-to-forehead test is a new subjective and objective test for anterior shoulder instability. This test is performed preoperatively under general anaesthesia and involves a quantifiable patient-controlled apprehension test and an objective quantitative test of anterior stability. Material and methods: Between January 1998 and April 2000, 135 patients (97 men and 38 women), mean age 25 years, age range 16–40 years, candidates for surgery for anterior instability of the shoulder (115 Latarget, 14 Bankart, 6 capsular shift) were tested. A control group of 300 candidates free of any shoulder disorder for other surgery were also tested. Results: the Apprehension test was positive in 95 of the operated patients and negative in 40. Mean angle was 160° (90–180°). The test was always negative in patients with an underlying hyperlaxity (18 patients). The test was positive in 20 controls and negative in 270. Test sensitivity was 72%, specificity 92.5%, positive predictive value 42%, (prevalence 1.5%) and negative predictive value 86%. Reproducibility was 80%. The objective test was positive in 125 of the operated patients and negative in 10. The value was 2++ in 55% of the cases. In the control group, the objective test was positive in 28 and negative in 272. The sensitivity of the objective test was 95%, specificity 90%, positive predictive value 55% and negative predictive value 95%. Reproducibility was 92%. Discussion: The purpose of the hand-to-forehead test is to express the instability as perceived by the patient and to exteriorise anterior laxity without reproducing true anterior displacement. Excepting cases with underlying hyperlaxity, this test does not appear to be inflenced by different injuries subsequent to recurrent anterior dislocation. (no significant difference between glenoid bone lesions, Broca lesions or Malgaigne notches). Conclusion: This new test provides a reliable objective assessment of anterior instability of the shoulder using a quantifiable combination of classical apprehension and laxity tests. It is a supplementary diagnostic tool for difficult cases and a useful aid for pre- and postoperative evaluation of these patients

This meta-analysis supports the conclusion that in patients with recurrent traumatic anterior shoulder instability, an open repair has a more favorable outcome with respect to recurrence and return to activity when compared to arthroscopic repair. More evidence from randomized clinical trials is required to either refute or substantiate this conclusion. The purpose of this study was to evaluate the outcomes between arthroscopic and open repair for recurrent traumatic anterior shoulder instability. The search involved clinical studies of all languages in the Medline database up to October 31, 2001. The following key words were used:. anterior shoulder instability;. Bankart lesion;. traumatic recurrent anterior shoulder instability; and. arthroscopic and open Bankart repair. All abstracts were reviewed and articles were included if there was a direct comparison between arthroscopic and open repair for traumatic recurrent anterior shoulder instability. These articles were manually assessed and cross-referenced for additional abstracts. The final group of articles were independently critically appraised and data on recurrent instability and return to activity (RTA) was extracted. Recurrent instability was defined as patient report of one or more subluxations and/or dislocations. RTA was not consistently defined in these articles and was based upon the available information. 584,. 161,. 59 and. 44. From these searches, sixteen articles were determined eligible for the meta-analysis including two foreign and two unpublished manuscripts. Ten studies were included in the final analysis: one RCT, two pseudo-experimental designs, four prospective cohorts, and three retrospective studies. Pooled Mantel-Haenszel Odds Ratio for recurrent instability and RTA were 2.22 (p=0.002, 95%CI 1.36,3.65) and 2.85 (p=0.004, 95%CI 1.40,5.78) respectively, in favor of the open repair. Based upon this meta-analysis open repair has a more favorable outcome with respect to recurrence and RTA

Aim: To describe the technique and the mid term results of anterior shoulder instability arthroscopic reconstruction. Patients-methods: Between March and December 2000 29 patients-28 males with ages ranging between 19–29 years (mean age 23 y.) and 1 female 24 years old-underwent arthroroscopic stabilization of anterior shoulder instability. During the procedure the anterior-inferior part of the labrum was reattached to the glenoid using bioabsorbable and metallic suture anchors. In selected patients in which capsule plication after anchors’ insertion was insufficient additional capsular shrikange or/and rotators’ interval closure was also performed. Results: Postoperatively patient evaluation took place using Rowe-Zarins scale. According to this score 22 patients (75,9%) had excellent or very good outcome. Three (3) patients (10,35%) were lost during follow up while 1 (3,45%) died. From the remaining 25 patients 2 had recurrence of the instability (6.9%) and in 1 patient (3,45%) a stiff shoulder was noticed and arthroscopically resolved. Finally a disengaged metallic suture anchor was noticed incidentally during routine radiographic examination in one patient (3,45%).The anchor was successfully removed under arthroscopic visualization without compromising the final outcome. Conclusions: Arthroscopic reconstruction of anterior shoulder instability when precisely performed after correct patient selection is an effective technique achieving results comparable to those of traditional open procedures

Previously, we conducted a multi-center, double-blinded randomized controlled trial comparing arthroscopic Bankart repair with and without remplissage. The end point for the randomized controlled trial was two years post-operative, providing support for the benefits of remplissage in the short term in reducing recurrent instability. The aim of this study was to compare the medium term (3 to 9 years) outcomes of patients previously randomized to have undergone isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) for the management of recurrent anterior glenohumeral instability. The rate of recurrent instability and instances of re-operation were examined. The original study was a double-blinded, randomized clinical trial with two 1:1 parallel groups with recruitment undertaken between 2011 and 2017. For this medium-term study, participants were reached for a telephone follow-up in 2020 and asked a series of standardized questions regarding ensuing instances of subluxation, dislocation or reoperation that had occurred on their shoulder for which they were randomized. Descriptive statistics were generated for all variables. “Failure” was defined as occurrence of a dislocation. “Recurrent instability” was defined as the participant reporting a dislocation or two or more occurences of subluxation greater than one year post-operative. All analyses were undertaken based on intention-to-treat whereby their data was analyzed based on the group to which they were originally allocated. One-hundred and eight participants were randomized of which 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to final follow-up was 49.3 for the NO REMP group and 53.8 for the REMP group. The rates of re-dislocation or failure were 8% (4/52) in the REMP group at an average of 23.8 months post-operative versus 22% (11/50) in the NO REMP at an average of 16.5 months post-operative. The rates of recurrent instability were 10% (5/52) in the REMP group at an average of 24 months post-operative versus 30% (15/50) in the NO REMP group at an average of 19.5 months post-operative. Survival curves were significantly different favouring REMP in both scenarios. Arthroscopic Bankart repair combined with remplissage is an effective procedure in the treatment of patients with an engaging Hill-Sachs lesion and minimal glenoid bone loss (<15%). Patients can expect favourable rates of recurrent instability when compared with isolated Bankart repair at medium term follw-up

Purpose: Performing a labral repair alone in patients with recurrent anterior instability and a large glenoid defect has led to poor outcomes. We present a technique involving the use of iliac crest allograft inserted into the glenoid defect in athletes with recurrent anterior shoulder instability and large bony defects of the glenoid (> 25% of glenoid diameter) We hypothesized that restoring a near-normal glenoid structure would prevent further dislocations and that osseous union would be achieved. Method: All athletes with recurrent anterior shoulder instability and a large glenoid defect who underwent open anterior shoulder stabilization and glenoid reconstruction with iliac crest allograft were prospectively followed over a three year period. Pre-operatively, a detailed history and physical exam was obtained along with radiographs, a CT scan, and magnetic resonance imaging of the affected shoulder. All patients also complete the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) evaluation forms pre – and post-operatively. A CT scan was again obtained 6 months post-operatively to assess osseous union of the graft, and the patient again when through a physical exam in addition to completing the SST, ASES, and Western Ontario Shoulder Instability Index (WOSI) forms. Results: Nine patients (all male) were followed for an average of 16 months (4 – 36 months) and had a mean age of 24.4 years. All patients exhibited a negative apprehension/ relocation test and full shoulder strength at final follow-up. Eight of nine patients had achieved osseous union at six months (88.9%). ASES scores improved from 64.3 to 96.7, and SST scores improved from 66.7 to 100. Average post-operative WOSI scores were 94%. Conclusion: The use of iliac crest allograft provides a safe and clinically useful alternative compared to previously described procedures for recurrent shoulder instability in the face of glenoid deficiency

Introduction The standard surgical practice for athletes with recurrent anterior shoulder instability who play contact or collision sports is to perform either the Bankart repair or Bristow procedure. The purpose of this study was to investigate the outcome of a combined Bankart and Bristow procedure for recurrent anterior shoulder instability in high contact and collision athletes. Methods Ninety-one patients underwent 100 combined Bankart and Bristow procedures for anterior shoulder instability (nine bilateral cases). Combined procedures were indicated in athletes participating in contact and collision sports. We were able to follow-up 71% of cases (71 shoulders in 65 patients) at an average of 6.5 years after surgery (range 2.1 to 12.3 years). The average age at the time of surgery was 23 years (range 15 to 47 years). There were 63 males and only two females. All patients were participating in competitive level sport at the time of injury of which 76.1% was rugby. A Rowe rating was calculated for each patient. Results Forty-four percent were graded excellent, 18% good, 27% fair and 11% poor. Overall 66% of athletes returned to their pre-injury level of sport or better, whilst 25% return to a lower level of their sport. Nine percent did not return to sport after surgery. This cohort included 37 professional or semi-professional players of whom 73% were able to return to their pre-morbid or a higher level of sport. Only six percent have experienced further dislocations since surgery. A further 12% have experienced shoulder subluxation and another 19% report feelings of insecurity. Four percent have required an additional procedure. Eighty-nine reported no or only mild limitation of function or discomfort and 87% were either very satisfied or satisfied with their outcome. Conclusions The combined open Bankart repair and Bristow procedures gives good results in athletes who participate in contact and collision sports. It has proved to be a robust procedure in the long term, allowing almost 75% of professional and semi-professional athletes to return to the same level or higher of sporting participation

Purpose of the study: The purpose of this retrospective clinical and radiographic study was to analyse the long-term results obtained after Patte’s triple locking procedure for the treatment of anterior instability of the shoulder joint. Material and methods: A questionnaire was sent to 574 patients who underwent the procedure performed by the same senior operator from 1986 to 2006. Variables studied wer the Walch-Duplay score (with pain score), patient satisfaction, postoperative complications and radiographic aspect. Results: One hundred fifty patients (26%) responded and sent three radiographs. There were 107 men and 43 women, mean age 28.6±8.7 years (range 16–57). Mean follow-up was 14.6 years (range 2.8–22.6). One hundred seventeen patients (78%) were reviewed with follow-up greater than 10 years. Two patients (1.3%) experienced recurrent anterior instability; no revision was required. The Walch-Duplay scores were excellent or good in 146 patients (97.3%); 53% of patients were pain free; 34% had episodic pain, 9% moderate to mild pain and 4% severe pain. Resumption of sports activity was noted by 85% of patients. Overall, 79% of patients were very satisfied, 18% satisfied, and 3% not satisfied. Postoperative complications (2%) were one case each of infection, transient paresis of the musculocutaeous nerve, and superficial venous thrombosis. There were radiographic signs of an anomaly of the coracoids block in 13 patients (8%); non-union (n=3), lysis (n=4) fracture (n=2), migration (n=1), fracture of the ceramic washer (n=3). The block or washer overhang was noted in 19 patients (12.7%). Centred osteoarthritis was noted in 31% of patients (25% Samilson 1, 4% Samilson 2, 2% Samilson 3). There were two factors associated with long-term degenerative disease: age > 40 at surgery (p=0.02 and block overhang (p< 0.01). Discussion: Patte’s triple locking procedure is an open procedure for the treatment of anterior shoulder instability. The technique is very minute and specific postoperative rehabilitation is needed. In these conditions, the operation is effective, providing good control of shoulder stability and allowing resumption of sports activities with a low complication rate. This study shows that long-term degenerative disease can be decreased if the patient undergoes surgery before the age of 40 years and if the coracoids block does not overhang

Purpose: To present the technique and the results of simultaneous arthroscopic reconstruction of Bankart and SLAP lesions in patients with anterior shoulder instability. Method: We performed shoulder arthroscopy in 95 patients aged 16–38 years (mean age:24,8) suffering anterior shoulder instability. Preoperative evaluation included clinical assessment, x-rays, MRI-arthrogram and examination under anaesthesia in comparison to the healthy shoulder. SLAP lesion was fixed using metallic suture anchors (FASTAK 2,4mm x 11,7 mm-Arthrex).The anchor was inserted in a 45° direction relative to the glenoid level. Bankart lesion was reconstructed using 2–3 bioabsorbable suture anchors (Panalok-Mitek J& J).The arthroscope was inserted through standard posterior, anterosuperior and anteroinferior portals while a posterolateral portal (portal of Whilrnington) was created for SLAP lesion repair. Patients’ average follow-up was 22 months (range, 18–30 months) and the results were evaluated using the ASES score. Results: SLAP lesion was found in 13 patients: 6 pat.-type II (46%), 3 pat.-type I (23%), 2 pat.-type IV (15%), 1pat.-type III (7,6%) and 1 pat with a complex lesion. Of these patients 10 had also co-existed Bankart lesion. In 2 patients Hill-Sachs lesion was found while degenerative rotator cuff changes existed in 3 patients. While performing clinical evaluation anterior instability signs and symptoms were apparent with the patients complaining also for discomfort and crepitus during overhead activities. MRI preoperative sensitivity for SLAP lesion diagnosis was 59% while specificity and Positive predictive value were 90% and 76% respectively. Shoulder function and the overall ASES score improved from 44 pre-op. to 96 post-op. Conclusion: Combined Bankart and SLAP lesions are uncommon in non-throwing patients with anterior instability. Arthroscopic suture anchors fixation ensures early and reliable rehabilitation. MRI arthrography study by a skeletal radiologist predicts to a high rate diagnosis

Purpose: Although arthroscopic Bankart repair is yet an established procedure in the treatment of traumatic anterior shoulder instability, it is still not known whether it reproduces the good results of the open repair procedure. Aim of this investigation was to compare the functional and subjective outcome between open and arthroscopic Bankart repair. Material and methods: A retrospective cross sectional study design on the comparison of open and arthoscopic Bankart treatments between 1995 and 2004 was implemented at the Dresden Orthopedic Surgery Department. In this period a total of 223 patients underwent surgery due to anterior shoulder instability, among which 212 patients had posttraumatic instability. A diagnostic arthroscopy was performed in all patients, but only 40 patients with intact capsulolabral complex and without capsular laxity were treated arthroscopically, the remaining 183 patients underwent an open Bankart procedure. A total of 186 patients with posttraumatic anterior instability could be clinically re-examined within 1 to 5 years after initial surgery, among which 147 patients underwent an open and 39 patients an arthroscopic Bankart procedure. The median age of this sample was 27 years (interquartile range 21 – 37 years) at initial surgery, 21% of these patients were female. Results: After open surgery 11 of 147 patients (8%) and 6 of 39 (15%) after arthroscopic surgery reported one or more re-dislocation after initial treatment, which occurred after a mean dislocation free time of 62 versus 40 months, respectively (95% confidence intervals 59 – 65 versus 36 – 44 months). Both a univariate analysis (Logrank test p=0.012) and a multivariate Cox regression analysis (Likelihood Ratio p=0.023) confirmed a statistically significant difference in the time between initial surgery to first reluxation. 4 of the 11 re-dislocations after open and 1 of 6 after arthroscopic surgery occurred after a new accident. That makes a re-dislocation rate without new adequate trauma of 5% after open and 13% after arthroscopic treatment. ROM showed no difference between open and arthroscopic Bankart procedure for abduction and a mild difference for external rotation. 21 of 115 (18%) patients had an external rotation lag of 20° or more after open surgery versus 1 of 34 (3%) after arthroscopic treatment (Fisher p=0,027). The Rowe score demonstrated “good” or “excellent” functional results in 102 of 117 (87%) patients versus 28 of 35 (80%) patients after open versus arthroscopic treatment (Fisher p=0,285). Conclusion: In this sample arthroscopic Bankart repair demonstrated more frequently and significantly earlier re-dislocation after initial surgery than did the open treatment alternative. External rotation lags of at least 20° occured more frequently after the open procedure

Aim: The aim of this study was to validate the SF12 questionnaire for use with patients with anterior glenohumeral instability. This was done with a view to replacing the longer parent questionnaire, the SF36 if a comparative level of validity was found with this patient group. Method: Patients attending the a shoulder clinic with at least one previous, documented episode of anterior glenohumeral joint dislocation were asked to complete the SF12, Oxford Instability, Oxford General Shoulder and SF36 questionnaires recording their level of shoulder function and general health status. Twenty subjects agreed to participate in the study. The results of the four questionnaires were scored according to the instructions issued by their authors, zeroed and converted into percentages to allow them all to be compared on the same scale then they were tabulated for comparison. The score on the questionnaires for each patient and the difference between the scores was calculated and plotted. The mean and standard deviation of the differences was then also plotted to assess the spread of the results (Bland and Altman’s method). Results: The mean age of the subjects was 33.5 years (range 16 to 75 years). Three subjects were female and seventeen male. Conclusion: The study suggests that the SF12 is suitable to be used as a replacement for the SF36. It shows a similar correlation with the ‘gold standard’ shoulder specific Oxford Instability score and displays a good correlation with the SF36 compared to the other measures

The Latarjet procedure is a successful primary and revision option for anterior shoulder instability; however recent reports have highlighted varying complication rates. Our aim was to prospectively study clinical, functional and radiological outcomes of patients undergoing this procedure. 50 consecutive patients underwent a Latarjet coracoid transfer between 2006 and 2012. Mean age was 27 years (17–63), 48 were male. Pre-/post-operative imaging, Oxford Shoulder Instability Score (OISS), American Shoulder & Elbow Surgeons score (ASES), Subjective Shoulder Value score (SSV) and clinical evaluation were documented. Mean follow up was 32 months (6–74). There were no dislocations or revision procedures. Subluxation occurred in one patient only. 95% of shoulders were subjectively graded “excellent” or “good;” 5% “fair;” and none as “poor”. The mean pre-op ASES was 58(50–66) and 95(92–98) post-operatively (p< 0.001). The mean pre-operative OISS was 19(18–22) and 43(41–45) post-operatively (p<0.001). The mean SSV increased from 46% to 89% (p < 0.001). 98% of patients considered their surgery to be “successful” and 95% would recommend the procedure to a friend. 82% returned to sport at their previous level. There were no infective or metalwork-related complications. Five experienced transient neurological symptoms all of which resolved within three months. These results suggest that the Latarjet procedure is safe and reliable with low complication rates

The Latarjet procedure is a successful primary and revision option for anterior shoulder instability; however recent reports have highlighted varying complication rates. Our aim was to prospectively study clinical, functional and radiological outcomes of patients undergoing this procedure. 50 consecutive patients underwent a Latarjet coracoid transfer between 2006 and 2012. Mean age was 27 years (17–63), 48 were male. Pre-/post-operative imaging, Oxford Shoulder Instability Score (OISS), American Shoulder & Elbow Surgeons score (ASES), Subjective Shoulder Value score (SSV) and clinical evaluation were documented. Mean follow up was 32 months (6–74). There were no dislocations or revision procedures. Subluxation occurred in one patient only. 95% of shoulders were subjectively graded “excellent” or “good;” 5% “fair;” and none as “poor”. The mean pre-op ASES was 58(50–66) and 95(92–98) post-operatively(p<0.001). The mean pre-operative OISS was 19(18–22) and 43(41–45) post-operatively(p<0.001). The mean SSV increased from 46% to 89%(p < 0.001). 98% of patients considered their surgery to be “successful” and 95% would recommend the procedure to a friend. 82% returned to sport at their previous level. There were no infective or metalwork-related complications. 5 experienced transient neurological symptoms all of which resolved within 3 months. These results suggest that the Latarjet procedure is safe and reliable with low complication rates

Although soft tissue capsulolabral repairs are the mainstay of treatment for recurrent anterior shoulder instability, bone defects are becoming more commonly recognized as additional problems for these patients. Humeral Head defects have been commonly ignored, however, there are a group of patients with failed procedures who have this as their main pathology. The purpose of this paper is to present a review of patients with large Humeral Head impression defects with a large structural irradiated Allograft. From April 1995 to January 2001, eighteen patients with recurrent anterior shoulder instability with Large Humeral Head Defects (> 25%) were treated with irradiated humeral allografts. Patients underwent physical and radiographic examination, subjective assessments including VAS scores for pain, instability, and satisfaction and completed a Constant and WOSI scores to determine clinical result. Radiograhic evaluation included standard radiographs and either MR or CT assessment. Eighteen Patients with an average age of 31.5 (18–52) were reviewed at an average time of fifty months (24–96) following their surgical procedure. There were fourteen male and four female patients each having had an average of 2.1 (1–8) prior operative procedures. All patients had resolution of their instability with no documented recurrences. All patients had severe apprehension preop and this resolved completely in fifteen. Average loss of external rotation was forty degrees preop and improved to ten degrees postop. Two patients had partial collapse of the graft with symptoms of pain in External Rotation requiring screw removal. There were no other complications. Patients improved on WOSI from 1882 to 381 and had an avearage Constant score of eighty-seven postop. Subjectively all patients would have the procedure again and pain improved from 72.5 to 22.5. There are certain situations where large humeral head defects contribute to the failure of instability repairs and ongoing instability. Allograft reconstruction with matched irradiated grafts is an excellent alternative for eliminating instability. Funding: Smith and Nephew

Purpose: This study was conducted to analyse the importance of the Malgaigne notch and its position on standard x-rays taken in internal rotation or on arthroscan in patients treated for anterior instability of the shoulder. Our purpose was to search for criteria perdictive of outcome of arthroscopic stabilisation of the shoulder joint using the Bankart method. Material and methods: Fifty-four patients were reviewed to determine the postoperative Duplay score. Mean follow-up was 68 months (32–100). Mean age at surgery was 29 years. We divided the patients into three populations as a function of preoperative symptoms: population A two dislocations or more, population B one dislocation then episodes of subluxation, population C no dislocation but pain. We divided this population according to the Duplay score. Group 1 patients had a fair or poor outcome, Group 2 patients had a good or excellent outcome. We reviewed 54 radiograms using patterns of increasing size (mm by mm) to assess the radius of the humeral head and the depth of the notch. We evaluate the reproducibility of this method by comparing the readings of ten senior orthopaedic surgeons. There were no false positives or false negatives. Variance of the measures taken by the ten surgeons was 0.67 at 1.31 mm, a small variance. We compared the ratio between the radius of the humeral head and the depth of the notch in the different groups. Results: The Malgaigne notch was significantly deeper in population A (19%) than in population B (14%) or population C (14.3%). This suggests that the size of the notch has an effect on symptomatology of shoulder instability. The notch was also significantly deeper in group 1 patients (fair or poor outcome) (21%) than in group 2 (good or excellent outcome) (16%) (p=0.05). Discussion: Beyond a threshold set at 15%, there were 54% fair or poor results. The position of the notch in height was significantly different in population A compared with populations B and C (p=0.01). It appears to be higher in case of true recurrent dislocation. We did not demonstrate any statistical link between the position of the notch on the CT scan and surgical outcome. This study demonstrates the importance of information on the internal rotation images in choosing the proper type of surgery for shoulder instability

Purpose. This prospective, expertise-based randomized clinical trial compares arthroscopic to open shoulder stabilization by measuring the disease-specific quality of life outcome in patients with traumatic unidirectional anterior shoulder instability, and determining the incidence of recurrent instability at 2-years post-operatively. Method. One hundred and ninety-six patients were randomly allocated to arthroscopic (n=98) or open (n=98) repair using an expertise-based approach with a surgeon specializing in one type of surgery. Randomization was performed using computer-generation, variable block sizes and concealed envelopes. Outcomes were measured at baseline, 3 and 6 months, 1 and 2 years post-operatively. These outcomes included the Western Ontario Shoulder Instability (WOSI) Index quality of life outcome and the American Shoulder and Elbow Society (ASES) functional outcome. Both outcomes were measured on a visual analog scale from 0 to 100, where a higher score represents better quality of life or function. Recurrent instability was categorized as traumatic/atraumatic, and as a subluxation/dislocation. Analyses included ANOVA of repeated measures and independent t-tests. Bonferroni adjustments for pairwise contrasts were made for multiple comparisons. Chi-squared analyses were performed on recurrence. Statistical significance was reported at p < 0.05. Results. There were no statistically significant differences at baseline with respect to gender, involved dominant shoulders, age, WOSI or ASES scores. At 2-years post-operatively, 19 patients in the Open group and 14 patients in the Arthroscopic group were lost to follow-up. A comparison of the baseline characteristics of these lost to follow-up patients showed no statistically significant differences in WOSI and ASES scores, age, involved dominant shoulder, gender and presence of Hill Sachs lesions between the groups. Of the patients that completed 2-year follow-up, there was no difference in mean WOSI score between the two groups: Open = 85 (SD = 20; 95% CI = 81 89), Arthroscopic = 82 (SD = 20; 95% CI = 77 86), p = 0.31. The ASES score for the Open group at 2-years was 91 (SD = 13; 95% CI = 88 94) and 88 (SD = 16; 95% CI = 85 92) for the Arthroscopic group, p = 0.17. Recurrence rates at 2-years were statistically different with 11% in the Open (9/80) and 23% in the Arthroscopic (20/87) groups, p = 0.05. Conclusion. At 2-years post-operative follow-up, there was no difference in disease-specific quality of life between Open and Arthroscopic repair. Open repair had a significantly lower risk of recurrence

Aim: The common anatomic pathology responsible for the recurrent dislocation of the shoulder is in younger patients a trauma causes the Bankart lesion. Contrary to that, the common cause for recurrent instability in older patients, which is far more rare, is the massive tear of the rotator cuff tendons. During that the shoulder loose the of the posterior-upper stabilizing element (posterior mechanism according to Neer), and present a secondary anterior-inferior recurrent instability. This paper presents the results of the operative treatment for the above-mentioned rare and complex lesion.

Material – Method: Seven (7) patients, three (3) male and four (4) female with a mean age of 71 years developed recurrent shoulder instability as a result of trauma or preceding infection, which destroyed the rotator cuff. The initial injury was associated with dislocation in 2 cases and without dislocation in 3. The other 2 had a prior infection of the glenohumeral joint, which was treated conservatively. The patients who suffered injury were initially treated with a sling for 2 to 4 weeks. All cases presented with instability, pain and weakness, and in 2 cases the subluxation was obvious in every attempt to raise the arm. The radiological findings consisted of subacromial space narrowing, sclerosis and spur formation of the inferior part of the acromion and diffuse osteoporosis. All of the patients had tears in at least two tendons of the rotator cuff. The cases were treated operatively with a combination of the Boytchev anterior stabilization procedure (osteotomy of the coracoid process, transfer of the conjoined tendon under the subscapularis tendon and repositioning of the coracoid process) with an attempt to close the rotator cuff tear. A complete closure was achieved in 3 cases (in one the long head of the biceps was used), and a partial closure in 2. In the remaining 2 cases the closure of the tear was impossible. All of the patients postoperatively underwent an early mobilization regime.

Results: The mean follow-up was 30 months. Stabilization of the shoulder was achieved in 6 cases. Constant score varied from 50 to 85. One patient had a recurrent of the subluxation. All of the patients presented marked improvement in pain and in muscle strength. Two (2) of them developed almost full range of motion and satisfactory muscle strength. Four (4) patients presented decreased range of motion and muscle strength 50% of the unaffected arm, while one patient developed inability to raise his arm above 70 degrees. Five cases out of seven showed a satisfactory response to daily life activities.

Conclusions: The combination of recurrent anterior instability with massive rotator cuff tears presents great difficulty in treatment especially in the cases where an infection had preceded. A complete closure of the rotator cuff tear is usually very difficult to achieve, while the treatment of the instability alone leads to dubious results as far as pain and range of motion is concerned. For the management of the above complex lesion the existing literature is rather poor, and the combination of the Boytchev procedure with an repair of the rotator cuff tear, yielded satisfactory results mainly in regard to pain control, and secondly in achieving a good postoperative range of motion.

Aim: The common cause for recurrent instability in older patients, is the massive tear of the rotator cuff tendons. This paper presents the results of the operative treatment for the above-mentioned rare and complex lesion. Method: Seven (7) patients, three (3) male and four (4) female with a mean age of 71 years developed recurrent shoulder instability as a result of trauma or preceding infection, which destroyed the rotator cuff. All cases presented with instability, pain and weakness, and in 2 cases the subluxation was obvious in every attempt to raise the arm. All of the patients had tears in at least two tendons of the rotator cuff. The cases were treated operatively with a combination of the Boytchev anterior stabilization procedure with an attempt to close the rotator cuff tear. A complete closure was achieved in 3 cases, and a partial closure in 2. In the remaining 2 cases the closure of the tear was impossible. All of the patients postoperatively underwent an early mobilization regime. Results: The mean follow-up was 30 months. Stabilization of the shoulder was achieved in 6 cases. Constant score varied from 50 to 85. One patient had a recurrent of the subluxation. All of the patients presented marked improvement in pain and in muscle strength. Two (2) of them developed almost full range of motion and satisfactory muscle strength. Four (4) patients presented decreased range of motion and muscle strength 50% of the unaffected arm, while one patient developed inability to raise his arm above 70 degrees. Conclusions: The combination of recurrent anterior instability with massive rotator cuff tears presents great difþculty in treatment especially in the cases where an infection had preceded. A complete closure of the rotator cuff tear is usually very difþcult to achieve.