Shoulder Injuries…And Elves!

As we reach the end of another year, many of our children’s minds in the United States are caught up wondering and worrying about Santa’s helpers: the elves. Elves are very elusive—always watching the behavior of children, but from a child’s perspective, are somehow never seen or discovered. Their elusiveness doesn’t stop the minds of children’s curiosity. Children will continue to seek them out, maybe even setting “elf traps,” but most children respect the power and influence elves have on influencing their potential Christmas morning. A reminder from parents “the elves are watching” is often enough to cause immediate change in behavior for the better.

 

Just as elves are both respected and yet elusive to children looking forward to Christmas morning, the perfect surgery to treat shoulder instability is also sought after yet remains elusive for shoulder surgeons across the globe. For most surgeons, the perfect shoulder instability surgery would be an arthroscopic approach that minimizes soft tissue injury and scarring, preserves the subscapularis, restores both glenoid and humeral head bone and cartilage loss, restores labral suction-seal function and perfectly balances capsular soft tissue tension to create a stable shoulder with full strength and range of motion with minimal risk to neurologic and vascular structures. The end result of this intervention would of course minimize risk of recurrent instability and risk of degenerative joint disease. When viewed in that light, Orthopaedic Surgeons’ ability to find the perfect surgery seems as likely as children stumbling onto one of Santa’s elves.

 

Yet in our desire to improve patient outcomes and strive for the ideal, we continue to toil, experiment and record the results of our research efforts. In Arthroscopy and associated publications this year, several studies helped to push our understanding closer to the ideal and recognize the limits of our current approach to treating shoulder instability.

 

First things first, Till and colleagues informed us using machine learning algorithms looking at 200 patients with a mean follow up of 11 years that 41% of patients who underwent surgery obtained a “perfect outcome,” and 61% obtained an “optimal observed outcome.” 1 This was defined as decreased postoperative pain, no recurrent instability or revision surgery, no osteoarthritis and minimal restricted range of motion. Looked at another way, the population studied from the Mayo Clinic and Olmstead Medical Center that underwent surgery only had optimal outcomes 61% of the time. What about the other 39% of patients? How do they and we as Orthopaedic Surgeons do better? Perhaps we can alter our surgical techniques. Plancher et al. presented their data looking at five year outcomes in patients that underwent a standard arthroscopic Bankart repair but with the addition of two bioabsorbable plication sutures used in “areas of redundancy” of the anterior capsule as well as rotator interval closure with PDS suture in patients with hyperlaxity.2 In their study, population largely based out of New York and Connecticut, 38 of 64 patients participated in collision/contact sports with a traumatic re-injury rate of 12% at nine years average follow up. While not leading to perfect outcomes, paying attention to capsular tensioning with additional plication stitches seems like a reasonable less-invasive surgical technique to help reduce recurrent instability rates. In addition to plicating capsular tissue, plenty of data in the last few years (52 articles published in 2022 alone) have supported the addition of remplissage to arthroscopic Bankart surgery to address humeral-sided bone loss and as a way to reduce risk of failure or recurrent instability following surgery in the primary setting.3-5 MacDonald and colleagues presented their data at the 2022 AANA Annual Meeting of a double blinded randomized control trial in a patient population that was at high risk for recurrent dislocation (>15% glenoid bone loss plus any size of Hill-Sach’s lesion), and found significantly lower risks of recurrent instability and dislocation when remplissage was added to Bankart repair.6 Not only is remplissage effective in reducing recurrent instability, it appears the addition of remplissage reduces apprehension, does not limit external rotation,and leads to improved return to sport compared to isolated arthroscopic Bankart surgery.7,8 As noted though, the return to sport rate is not quite as high in throwing athletes, a group that remains the most challenging to determine appropriate surgical correction for instability.8,9 Nonetheless, remplissage should be considered a powerful tool for use in primary arthroscopic surgery as a means of dealing with most Hill Sach’s lesions.9 

 

What about glenoid bone loss affecting shoulder instability? Open Latarjet surgery is an excellent option in high-risk patients with anterior glenoid bone loss when the goal is to limit chance of recurrent instability and to return to high-demand activities.10,11 But Latarjet comes with its own risks and issues.  While recurrent instability rates and revision surgery remains relatively low for Latarjet, Schmidt and colleagues noted a 30-day higher risk of revision surgery in open Latarjet compared to Bankart surgery, and up to a 26% risk of graft resorption, degenerative joint changes and persistent shoulder pain was reported by Jackson et al. in their systematic review published this year.12,13 Using iliac crest bone graft placed in an arthroscopic manner (aka “arthroscopic Eden-Hybinette”) has sustained increased interest over the last decade, but presents the same concern with Latarjet when using screw fixation in regards to graft remodeling and prominent hardware. Two different studies from China were published this year looking at outcomes of arthroscopic Eden-Hybinette. Li and colleagues from Foshan Hospital compared patients who underwent arthroscopic iliac crest bone grafting who were fixed with two screws verses a cohort fixed with two suture buttons and found less graft resorption and hardware irritation in the suture button fixation group.14 Wu et al. from Jiao Tong University in Shanghai compared a cohort of arthroscopic iliac crest bone grafting fixated with suture buttons combined with labral repair to a cohort treated with arthroscopic Bankart and remplissage in patients with bipolar bone defects and anterior glenoid bone loss measuring 16-18%, finding similar functional outcomes with low recurrence rates between the two cohorts.15 As more data is published in support of an arthroscopic bone grafting approach with suture button fixation, the next important steps in research are to evaluate outcomes for arthroscopic glenoid bone grafting utilizing suture-button or non-screw fixation combined with labral repair and remplissage surgery in comparison to a traditional open Latarjet surgery, specifically looking at functional outcomes, return to sport, recurrent instability rate, persistent pain, degenerative joint changes and complications.

 

While it is as likely that children will actually encounter one of Santa’s elves this winter as shoulder surgeons will have concluded upon the perfect surgery for shoulder instability by year’s end, the quest and curiosity must continue as we all embark on a new year dedicated to improving our patients’ lives and outcomes through the surgical interventions we offer. In the meantime, we will continue to enjoy “the search” for that which continues to remain elusive but inspires our efforts and imaginations.

 

References

  1. Till, S.E., Lu, Y., Reinholz, A.K., et al. Artificial Intelligence Can Define and Predict the "Optimal Observed Outcome" After Anterior Shoulder Instability Surgery: An Analysis of 200 Patients With 11-Year Mean Follow-Up. Arthrosc Sports Med Rehabil 2023;5:100773.
  2. Plancher, K.D., Briggs, K.K., Zuccaro, P., Tucker, E.E., Petterson, S.C. Arthroscopic Labral Reconstruction with a Modified Inferior Capsular Shift Allows Return to Sport and Excellent Outcomes in Contact and Non-Contact Athletes With Anterior Shoulder Instability at Minimum 5-Year Follow-up. Arthroscopy 2023.
  3. Hurley, E.T., Toale, J.P., Davey, M.S., et al. Remplissage for Anterior Shoulder Instability with Hill-Sachs Lesions: A Systematic Review and Meta-Analysis. J Shoulder Elbow Surg 2020;29:2487-94.
  4. Camus, D., Domos, P., Berard, E., Toulemonde, J., Mansat, P., Bonnevialle, N. Isolated Arthroscopic Bankart Repair vs. Bankart Repair with "Remplissage" for Anterior Ahoulder Instability with Engaging Hill-Sachs Lesion: A Meta-Analysis. Orthop Traumatol Surg Res 2018;104:803-9.
  5. Yang, J.S., Mehran, N., Mazzocca, A.D., Pearl, M.L., Chen, V.W., Arciero, R.A. Remplissage Versus Modified Latarjet for Off-Track Hill-Sachs Lesions With Subcritical Glenoid Bone Loss. Am J Sports Med 2018;46:1885-91.
  6. MacDonald, P., McRae, S., Lapner, P., et al. Paper 71: Remplissage Reduces the Risk of Postoperative Recurrent Instability Versus Bankart Repair Alone: Medium-Term Results from a Randomized Controlled Rrial. Orthop J Sports Med 2022;10.
  7. Yu, W., Kim, H., Seo, J.H., Jeon, I.H., Koh, K.H. Remplissage in Addition to Arthroscopic Bankart Repair for Shoulder Instability With On-Track Hill-Sachs Lesions Reduces Residual Apprehension Without External Rotation Limitation. Arthroscopy 2023;39:692-702.
  8. Gouveia, K., Harbour, E., Athwal, G.S., Khan, M. Return to Sport After Arthroscopic Bankart Repair With Remplissage: A Systematic Review. Arthroscopy 2023;39:1046-59 e3.
  9. Kelly, A.M., Kelly, J.D. Editorial Commentary: Shoulder Remplissage Is a Beneficial Addition to Bankart or Glenoid Bone Loss Treatment: Stay on Track and Use Wisely. Arthroscopy 2023;39:703-5.
  10. Hurley, E.T., Danilkowicz, R.M., Paul, A.V., et al. Majority of Studies Show Similar Rates of Return to Play After Arthroscopic Bankart Repair or Latarjet Procedure: A Systematic Review. Arthroscopy 2023.
  11. Hurley, E.T., Moore, T.K., Kilkenny, C., et al. Young Collision Athletes Have High Rate of Return to Play and Good Clinical Outcomes Following Open Latarjet Procedure. Arthroscopy 2023.
  12. Jackson, G.R., Brusalis, C.M., Schundler, S.F., et al. Isolated Primary Latarjet Procedures for Anterior Shoulder Instability Results in High Rates of Graft Resorption and Glenohumeral Degenerative Changes With Low Rates of Failure at a Minimum 2-Year Follow-Up: A Systematic Review. Arthroscopy 2023.
  13. Schmidt, R.C., O'Neill, C.N., Gowd, A.K., et al. Significant Increase in Early Reoperation After Latarjet-Bristow Procedure Versus Arthroscopic Bankart Repair for Anterior Shoulder Instability: A Propensity Score Matched Analysis. Arthroscopy 2023.
  14. Li, L., Lu, M., Zhao, L., et al. All-Arthroscopic Glenoid Bone Augmentation Using Iliac Crest Autograft Procedure for Recurrent Anterior Shoulder Instability: Button Fixation Is a Feasible and Satisfactory Alternative to Screw Fixation. Arthroscopy 2023.
  15. Wu, D., Zhou, Z., Song, W., et al. Arthroscopic Autologous Iliac Crest Grafting Results in Similar Outcomes and Low Recurrence Compared to Remplissage Plus Bankart Repair for Anterior Shoulder Instability With Bipolar Bone Defects. Arthroscopy 2023;39:1600-7.
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