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

Aims. The open Latarjet procedure is a widely used treatment for recurrent anterior instability of the shoulder. Although satisfactory outcomes are reported, factors which influence a patient’s experience are poorly quantified. The aim of this study was to evaluate the effect of a range of demographic factors and measures of the severity of instability on patient-reported outcome measures in patients who underwent an open Latarjet procedure at a minimum follow-up of two years. Methods. A total of 350 patients with anterior instability of the shoulder who underwent an open Latarjet procedure between 2005 and 2018 were reviewed prospectively, with the collection of demographic and psychosocial data, preoperative CT, and complications during follow-up of two years. The primary outcome measure was the Western Ontario Shoulder Instability Index (WOSI), assessed preoperatively, at two years postoperatively, and at mid-term follow-up at a mean of 50.6 months (SD 24.8) postoperatively. The secondary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. The influence of the demographic details of the patients, measurements of the severity of instability, and the complications of surgery were assessed in a multivariate analysis. Results. The mean age of the patients was 25.5 years (22 to 32) and 27 (7.7%) were female. The median time to surgery after injury was 19 months (interquartile range (IQR) 13 to 39). Seven patients developed clinically significant complications requiring further intervention within two years of surgery. The median percentage WOSI deficiency was 8.0% (IQR 4 to 20) and median QuickDASH was 3.0 (IQR 0 to 9) at mid-term assessment. A minority of patients reported a poorer experience, and 22 (6.3%) had a > 50% deficiency in WOSI score. Multivariate analysis revealed that consumption of ≥ 20 units of alcohol/week, a pre-existing affective disorder or epilepsy, medicolegal litigation, increasing time to surgery, and residing in a more socioeconomically deprived area were independently predictive of a poorer WOSI score. Conclusion. Although most patients treated by an open Latarjet procedure have excellent outcomes at mid-term follow-up, a minority have poorer outcomes, which are mainly predictable from pre-existing demographic factors, rather than measures of the severity of instability. Cite this article: Bone Joint J 2023;105-B(4):389–399

Aims. This study aimed to quantify the shoulder kinematics during an apprehension-relocation test in patients with anterior shoulder instability (ASI) and glenoid bone loss using the radiostereometric analysis (RSA) method. Kinematics were compared with the patient’s contralateral healthy shoulder. Methods. A total of 20 patients with ASI and > 10% glenoid bone loss and a healthy contralateral shoulder were included. RSA imaging of the patient’s shoulders was performed during a repeated apprehension-relocation test. Bone volume models were generated from CT scans, marked with anatomical coordinate systems, and aligned with the digitally reconstructed bone projections on the RSA images. The glenohumeral joint (GHJ) kinematics were evaluated in the anteroposterior and superoinferior direction of: the humeral head centre location relative to the glenoid centre; and the humeral head contact point location on the glenoid. Results. During the apprehension test, the centre of the humeral head was 1.0 mm (95% CI 0.0 to 2.0) more inferior on the glenoid for the ASI shoulder compared with the healthy shoulder. Furthermore, the contact point of the ASI shoulder was 1.4 mm (95% CI 0.3 to 2.5) more anterior and 2.0 mm (95% CI 0.8 to 3.1) more inferior on the glenoid compared with the healthy shoulder. The contact point of the ASI shoulder was 1.2 mm (95% CI 0.2 to 2.6) more anterior during the apprehension test compared to the relocation test. Conclusion. The humeral head centre was located more inferior, and the GHJ contact point was located both more anterior and inferior during the apprehension test for the ASI shoulders than the healthy shoulders. Furthermore, the contact point displacement between the apprehension and relocation test revealed increased joint laxity for the ASI shoulder than the healthy shoulders. These results contribute to existing knowledge that ASI shoulders with glenoid bone loss may also suffer from inferior shoulder instability. Cite this article: Bone Joint J 2024;106-B(10):1133–1140

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

Aims. The aims of this study were to validate the minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) thresholds for Western Ontario Shoulder Instability Index (WOSI), Rowe score, American Shoulder and Elbow Surgeons (ASES), and visual analogue scale (VAS) scores following arthroscopic Bankart repair, and to identify preoperative threshold values of these scores that could predict the achievement of MCID and PASS. Methods. A retrospective review was conducted on 131 consecutive patients with anterior shoulder instability who underwent arthroscopic Bankart repair between January 2020 and January 2023. Inclusion criteria required at least one episode of shoulder instability and a minimum follow-up period of 12 months. Preoperative and one-year postoperative scores were assessed. MCID and PASS were estimated using distribution-based and anchor-based methods, respectively. Receiver operating characteristic curve analysis determined preoperative patient-reported outcome measure thresholds predictive of achieving MCID and PASS. Results. MCID thresholds were determined as 169.6, 6.8, 7.2, and 1.1 for WOSI, Rowe, ASES, and VAS, respectively. PASS thresholds were calculated as ≤ 480, ≥ 80, ≥ 87, and ≤ 1 for WOSI, Rowe, ASES, and VAS, respectively. Preoperative thresholds of ≥ 760 (WOSI) and ≤ 50 (Rowe) predicted achieving MCID for WOSI score (p < 0.001). Preoperative thresholds of ≤ 60 (ASES) and ≥ 2 (VAS) predicted achieving MCID for VAS score (p < 0.001). A preoperative threshold of ≥ 40 (Rowe) predicted achieving PASS for Rowe score (p = 0.005). Preoperative thresholds of ≥ 50 (ASES; p = 0.002) and ≤ 2 (VAS; p < 0.001) predicted achieving PASS for the ASES score. Preoperative thresholds of ≥ 43 (ASES; p = 0.046) and ≤ 4 (VAS; p = 0.024) predicted achieving PASS for the VAS. Conclusion. This study defined MCID and PASS values for WOSI, Rowe, ASES, and VAS scores in patients undergoing arthroscopic Bankart repair. Higher preoperative functional scores may reduce the likelihood of achieving MCID but increase the likelihood of achieving the PASS. These findings provide valuable guidance for surgeons to counsel patients realistically regarding their expectations. Cite this article: Bone Joint J 2024;106-B(10):1118–1124

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

We prospectively evaluated 61 patients treated arthroscopically for anterior instability of the shoulder at a mean follow-up of 44.5 months (24 to 100) using the Rowe scale. Those with post-operative dislocation or subluxation were considered to be failures. Logistic regression analysis was used to identify patients at increased risk of recurrence in order to develop a suitable selection system. The mean Rowe score improved from 45 pre-operatively to 86 at follow-up (p < 0.001). At least one episode of post-operative instability occurred in 11 patients (18%), although their stability improved (p = 0.018), and only three required revision. Subjectively, eight patients were dissatisfied. Age younger than 28 years, ligamentous laxity, the presence of a fracture of the glenoid rim involving more than 15% of the articular surface, and post-operative participation in contact or overhead sports were associated with a higher risk of recurrence, and scored 1, 1, 5 and 1 point, respectively. Those patients with a total score of two or more points had a relative risk of recurrence of 43% and should be treated by open surgery

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

We reviewed the outcome of arthroscopic stabilisation of anterior glenohumeral instability in young adults using the transglenoid suture technique. A questionnaire was sent to 455 consecutive patients who had undergone this procedure between 1992 and 2000. Of these, 312 patients (68.5%) with 313 affected shoulders and a mean age of 20 years (18 to 28) responded. Outcome was determined by the number of re-dislocations or, in patients who had not re-dislocated, by the disease-specific quality of life as measured by the Western Ontario Shoulder Instability index. During a mean follow-up of 6.4 years (1 to 14), 177 patients (56%) sustained a re-dislocation, including 70 who required a further operation. In 136 patients (44%) who reported neither re-dislocation nor re-operation, the index scores were good (median 90.4%; 28.9% to 100%). No significant peri- or pre-operative predictors of re-dislocation or re-operation were found. We found a high rate of re-dislocation after transglenoid suture repair in young, physically active patients

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

Aims. Patients with recurrent anterior dislocation of the shoulder commonly have an anterior osseous defect of the glenoid. Once the defect reaches a critical size, stability may be restored by bone grafting. The critical size of this defect under non-physiological loading conditions has previously been identified as 20% of the length of the glenoid. As the stability of the shoulder is load-dependent, with higher joint forces leading to a loss of stability, the aim of this study was to determine the critical size of an osseous defect that leads to further anterior instability of the shoulder under physiological loading despite a Bankart repair. Patients and Methods. Two finite element (FE) models were used to determine the risk of dislocation of the shoulder during 30 activities of daily living (ADLs) for the intact glenoid and after creating anterior osseous defects of increasing magnitudes. A Bankart repair was simulated for each size of defect, and the shoulder was tested under loading conditions that replicate in vivo forces during these ADLs. The critical size of a defect was defined as the smallest osseous defect that leads to dislocation. Results. The FE models showed a high risk of dislocation during ADLs after a Bankart repair for anterior defects corresponding to 16% of the length of the glenoid. Conclusion. This computational study suggests that bone grafting should be undertaken for an anterior osseous defect in the glenoid of more than 16% of its length rather than a solely soft-tissue procedure, in order to optimize stability by restoring the concavity of the glenoid

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

In the Trillat procedure for recurrent anterior instability of the shoulder the coracoid process is osteotomised and tilted downward to act as a bone block, and a screw is used to fix it and the Bankart lesion to the anterior scapular neck. We reviewed 52 cases after a mean follow-up of 69 months. Results in 73% of shoulders were excellent, 10% were good, 7% fair and 10% poor. Dislocation recurred in 4%, but a positive apprehension sign was present in 10 other shoulders. Some degenerative changes were seen in 62% of shoulders, a complication known to be associated with bone-block procedures. The most important reason for loss of lateral rotation was iatrogenic impingement of the coracoid. This frequent and potentially serious complication can also cause posterior subluxation of the humeral head and osteoarthritis

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