Rockwood Adults CH34

1128

SECTION TWO • Upper Extremity

Annotated References Reference

Annotation

The authors concluded that this biomechanical study provided evidence to aid in surgical decision-making by examining the effects of bipolar bone loss and consideration of remplissage in cases of “off-track” Hill– Sachs lesions in glenoids with subcritical (15%) anterior bone loss. This was a prospective study on 247 primary anterior dislocations of the shoulder followed for 10 years in a multicenter study. At the 10-year follow-up evaluation, 52% had no additional dislocation. Recurrent dislocation necessitating operative treatment occurred in 23% of the shoulders. Radiographs that demonstrated an evident Hill–Sachs lesion was associated with a significantly worse prognosis with regard to recurrence than was no evident lesion ( P < 0.04). At 10-year follow- up, 11% had mild and 9% had moderate or severe arthropathy after dislocation. This was a prospective multicenter study that included 257 shoulders in 255 patients (age, 12–40 years) with a first-time anterior shoulder dislocation. After 25 years, radiographic imaging was performed in 223 shoulders (97%). Only 44% of shoulders were normal radiographically at 25 years after a primary shoulder dislocation. Arthropathy was mild in 29%, moderate in 9%, and severe in 17% of the shoulders. Of the shoulders without a recurrence, 18% had moderate/severe arthropathy. Other factors that correlated with moderate/severe arthropathy were age > 25 years at primary dislocation and primary dislocation caused by high-energy sports activity. Shoulders that had not recurred had less arthropathy than shoulders classified as recurrent or stabilized over time. Sixty-two surgically stabilized shoulders had less arthropathy than those that became stable over time. The authors concluded that age at primary dislocation, recurrence, high-energy sports, and alcohol abuse were factors associated with the development of arthropathy. There are many studies on the management of anterior shoulder instability in the adult patient population. However, a paucity of literature exists regarding shoulder dislocations in skeletally immature patients. The presence of open proximal humeral physis changes the management of these patients with primary shoulder dislocations. A comprehensive literature review of recent literature shows a relatively low rate of recurrent instability after the primary dislocation compared with older literature. The authors recommended conservative management in this subset of patients after primary dislocation. Surgery should only be indicated after a prolonged trial of therapy or with recurrence of instability. The objective of this study was to evaluate the effects of subcritical bone loss (below the 20%–25% range) on outcomes and redislocation rates after an isolated arthroscopic Bankart repair for anterior shoulder instability. The authors reported results of 73 shoulders that underwent isolated anterior arthroscopic labral repair at a single military institution. The cohort was divided into quartiles based on bone loss. Quartile 1 had a mean bone loss of 2.8%, quartile 2 had 10.4%, quartile 3 had 16.1%, and quartile 4 had 24.5%. The mean WOSI score and SANE scores worsened as bone loss increased in each quartile. The WOSI score increased to rates consistent with a poor clinical outcome between quartiles 2 and 3 (bone loss, 13.5%). There was an overall failure rate of 12.3%. The percentage of glenoid bone loss was significantly higher among those repairs that failed versus those that remained stable (24.7% vs. 12.8%, P < 0.01). There was a significant increase in failure ( P < 0.05) between quartiles 1, 2, and 3 (7.3%) compared with quartile 4 (27.8%). The authors concluded that bone loss above 13.5% led to a clinically significant decrease in WOSI scores consistent with an unacceptable outcome even if patients did not sustain a recurrence of their shoulder instability.

Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients: a ten-year prospective study. J Bone Joint Surg Am . 1996;78(11):1677–1684.

Hovelius L, Saeboe M. Neer Award 2008: arthropathy after primary anterior shoulder dislocation—223 shoulders prospectively followed up for twenty-five years. J Shoulder Elbow Surg . 2009;18(3):339–347.

Li X, Ma R, Nielsen NM, et al. Management of shoulder instability in the skeletally immature patient. J Am Acad Orthop Surg . 2013;21(9): 529–537.

Shaha JS, Cook JB, Song DJ, et al. Redefining “critical” bone loss in shoulder instability: functional outcomes worsen with “subcritical” bone loss. Am J Sports Med . 2015;43(7):1719–1725.