Long-term recurrence rate in anterior shoulder instability after Bankart repair based on the on- and off-track concept

BACKGROUND Since its first proposal, the concept of on- and off-track lesions in anterior shoulder instability has gained clinical relevance as a tool to predict the failure rate of arthroscopic Bankart repair. Current literature only reports either short-term follow-up or long-term results of small sample sizes. The aim of this study was to provide a long-term evaluation of recurrent instability following arthroscopic Bankart repair in a large cohort using the on-track vs. off-track concept as a predictor for failure. METHODS We retrospectively analyzed 271 patients who underwent primary arthroscopic Bankart repair for anterior shoulder instability between 1998 and 2007. All patients with a minimum follow-up of 78 months and a preoperative computed tomographic (CT) or magnetic resonance imaging (MRI) scan were included into the study. Preoperative CT and/or MRI scans were used to determine the glenoid track and width of Hill-Sachs lesion. Recurrence of instability was defined as presence of instability symptoms (dislocation, subluxation, and/or apprehension) or revision surgery (stabilization procedure) and was assessed as the primary outcome parameter. RESULTS The glenoid track of 163 shoulders was assessed (female n = 51, male n = 112) with a mean follow-up of 124 months (99.4-145.6, standard deviation = 2.5) and a mean age of 24 years (20-34.). An off-track Hill-Sachs lesion was found in 77 cases (47%), and in 86 cases (53 %) it was on-track. The rate of recurrent instability in the off-track group was 74% (n = 57) compared with 27% (n = 23) in the on-track group (P < .001). The overall rate of revision surgery due to instability was 29% (n = 48) after a mean time of 50.9 months (±42.8) following Bankart repair. The rate of revision surgery in the off-track group was 48% (n = 37) after a mean of 53.5 months (±42.0) vs. 13% (n = 11) after 42.3 months (±46.3) in the on-track group (P < .001). CONCLUSION This study shows that the on- and off-track concept helps to distinguish patients for whom an isolated arthroscopic Bankart repair yields long-term benefits. Because of the high rate of recurrent instability in the off-track group, an off-track lesion should be treated surgically in such a way that the off-track lesion is converted into an on-track lesion

Incidence, radiographic predictors and clinical outcome for acromial stress reaction and acromial fractures in reverse total shoulder arthroplasty

INTRODUCTION Acromial and scapular spine fractures (ASF) are known complications following implantation of Reverse Total Shoulder Arthroplasty (RTSA). The entity of acromial stress reaction (ASR) without fracture has recently been described. The purpose of this study was to analyze the incidence, radiographic predictors, treatment options, healing rate and clinical outcome of ASF and ASR compared to a control group. METHODS A total of 854 primary RTSAs were implanted between 2005 and 2018 in a single shoulder unit of a tertiary referral hospital and retrospectively reviewed for the incidence of ASF and ASR. ASR was defined as pain at the acromion or scapular spine after fracture exclusion on CT scans. The ASF group was matched to a control group. Preoperative and postoperative radiographs were analyzed for radiographic predictors of ASF or ASR. The impact of ASF and ASR, operative versus non-operative treatment and fracture union on clinical outcome (Constant-Murley Score, Subjective Shoulder Value and range of motion) with minimum follow-up of 2 years was analyzed. RESULTS A total of 46 ASF (5.4 %) in 44 patients and 44 ASR (5.2%) in 43 patients were detected at a mean of 16 ± 24 months and 20±23 months postoperative, respectively. Predictive radiographic factors were an increased critical shoulder angle (CSA) and lateralization shoulder angle (LSA). The overall union rate was 55% (22/40) but significantly higher following operative treatment (9/11, 82%) compared to non-operative treatment (13/29, 45%). Patients with ASF/ASR demonstrated inferior clinical outcome (CS 44 ± 21 and 48 ± 18; SSV 52 ± 25 and 57 ± 27) compared to the control group (CS 66 ± 14; SSV: 82 ± 22) independent of bony union or treatment at mean of 59 ± 33 months (ASF) and 61 ± 38 months (ASR). CONCLUSION ASF and ASR are frequent complications following RTSA implantation with similar poor clinical outcome measures. The healing rate was shown to be much higher with a surgical approach. Nevertheless, fracture consolidation does not result in better clinical outcomes compared with nonunion

Effect of Abduction Brace Wearing Compliance on the Results of Arthroscopic Rotator Cuff Repair

Background: The benefit of protective bracing after rotator cuff reconstruction has been debated for many years, although immobilization compliance has never been assessed objectively to date. In a previous study, compliance with the wearing of an abduction brace was measured for the first time with use of temperature-sensitive sensors. The purpose of the present follow-up study was to assess the effect of immobilization compliance on tendon-healing after rotator cuff repair. Methods: The clinical and radiographic outcomes for 46 consecutive patients with objectively assessed abduction brace wearing compliance after arthroscopic repair of a superior rotator cuff tear were prospectively analyzed. Rotator cuff integrity was examined with ultrasound. Clinical outcomes were assessed with the relative Constant-Murley score (RCS), the Subjective Shoulder Value (SSV), and pain and patient satisfaction ratings. Receiver operating characteristic (ROC) curves were used to determine the optimal cutoff value of abduction brace compliance for discriminating between shoulders that will and will not have a retear and the association of compliance with the failure of rotator cuff repair. Results: After a mean duration of follow-up of 20 ± 9 months, the odds ratio for having a rotator cuff repair failure was 13-fold higher for patients with a compliance rate of <60% (p = 0.037). The retear rate was 3% (1 of 35 patients) in the high-compliance cohort (≥60% compliance) and 27% (3 of 11) in the low-compliance cohort (<60% compliance) (p = 0.037). No differences in RCS, SSV, pain, or postoperative patient satisfaction were observed between patients with ≥60% compliance and those with <60% compliance. Conclusions: Patients with a compliance rate of <60% had a 13-fold increase in the risk of rotator cuff retear. The 2 patients with the lowest compliance rates (11% and 22%) both had retears. Due to the small sample size, no final conclusions can be drawn regarding the influence of immobilization compliance on tendon-healing after rotator cuff repair. These findings justify a prospective trial with a larger cohort to confirm or disprove the value of compliance with abduction bracing. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence