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Onlay Dynamic Anterior Stabilization With Biceps Transfer for the Treatment of Anterior Glenohumeral Instability Produces Good Clinical Outcomes and Successful Healing at a Minimum 1 Year of Follow-Up
Address correspondence to Clara de Campos Azevedo, M.D., Ph.D., Serviço de Ortopedia e Traumatologia, Hospital dos SAMS de Lisboa, Rua Cidade de Gabela, 1. 1849-017 Lisboa, Portugal.
Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Hospital dos SAMS de Lisboa, Lisbon, PortugalShoulder and Elbow Unit, Orthopaedic and Musculoskeletal Centre, Cuf Tejo Hospital, Lisbon, Portugal
Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Hospital dos SAMS de Lisboa, Lisbon, PortugalShoulder and Elbow Unit, Orthopaedic and Musculoskeletal Centre, Cuf Tejo Hospital, Lisbon, Portugal
To report the results of the onlay dynamic anterior stabilization (DAS) using the long head of biceps (LHB) and the double double-pulley technique for the treatment of anterior glenohumeral instability (AGI) with ≤20% glenoid bone loss (GBL).
Methods
From September 2018 to December 2021, patients with AGI and ≤20% GBL were enrolled in a prospective study on DAS and followed for a minimum of 1 year. The primary outcomes were Western Ontario Shoulder Instability Index, Rowe score, range of motion, and strength. The secondary outcomes were ability to return to play (RTP), RTP at same level, lack of recurrence of instability, successful LHB healing, and lack of complications. Magnetic resonance imaging was used to measure GBL, Hill–Sachs interval, glenoid track, and assess LHB integrity.
Results
Eighteen consecutive patients underwent DAS. Fifteen patients had a minimum follow-up of 12 months (mean, 23.93 ± 13.67 months). In total, 12 were male and 3 female patients; 73.3% practiced recreational sports; mean age at surgery was 23.40 ± 6.53 years; mean number of dislocation episodes were 10.13 ± 8.42; mean GBL was 8.21 ± 7.39% (range, 0-20.24%); mean Hill–Sachs interval was 15.00 ± 2.96 mm; and mean glenoid track was 18.87 ± 2.57mm. The mean improvement in the Western Ontario Shoulder Instability Index and Rowe score (959.27 ± 386.70 and 74.00 ± 22.22 points) was significant (P < .001 and P < .001) and more than 6 times greater than the minimum clinically important difference. The mean improvement in active elevation, abduction, and external and internal rotation (23.00 ± 27.76°, 33.33 ± 43.78°, 8.33 ± 13.58°, and 0.73 ± 1.28 points) was significant (P = .006, P = .011, P = .032, and P = .044). RTP rate was 93.33%. RTP at same level was 60.00%. One patient with hyperlaxity had a redislocation (6.7% recurrence). No complications were reported. Each magnetic resonance imaging scan showed successful LHB healing to the anterior glenoid.
Conclusions
At a minimum of 1-year follow-up, DAS produces significant and clinically important improvements in shoulder function, successful LHB healing, and is safe for the treatment of AGI with ≤20% GBL without severe hyperlaxity.
Level of Evidence
IV, therapeutic case series.
The optimal surgical treatment for anterior glenohumeral instability with limited (0%-13.5%) to subcritical (13.5%-25%) glenoid bone loss (GBL) is controversial.
Most complications are related to malpositioned hardware and grafts. For GBL of 10% to 20%, isolated Bankart repair has shown a 2-times greater risk of redislocation compared with the Latarjet procedure.
Risk factors for recurrence after arthroscopic instability repair-the importance of glenoid bone loss >15%, patient age, and duration of symptoms: A matched cohort analysis.
Arthroscopic Subscapularis augmentation of bankart repair in chronic anterior shoulder instability with bone loss less than 25% and capsular deficiency: Clinical multicenter study.
Dynamic anterior stabilization (DAS) with the long head of the biceps tendon (LHB) is a new arthroscopic soft-tissue procedure for the treatment of anterior glenohumeral instability.
Theoretically, the transposition of the LHB to the anterior glenoid through the subscapularis tendon increases anterior glenohumeral stability by producing a hammock and a sling effect, much like the Latarjet.
The hammock effect is produced by the downward force exerted by the LHB on the subscapularis muscle during the first degrees of glenohumeral abduction and external rotation (ER). The sling effect is produced by the LHB blocking the anterior translation of the humeral head during increased degrees of glenohumeral abduction and ER. Furthermore, recent biomechanical cadaveric studies have shown that DAS avoids the risk of loss of ER,
What is the critical value of glenoid bone loss at which soft tissue Bankart repair does not restore glenohumeral translation, restricts range of motion, and leads to abnormal humeral head position?.
A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair.
In instability models with 10% and 20% of anterior GBL, the relative anterior glenohumeral translation was significantly lower after DAS than after isolated Bankart repair,
Dynamic anterior stabilization using transosseous bone tunnel technique with the adjustable loop length cortical button incorporating high-strength suture augmentation for recurrent shoulder instability.
Garcia JC, Mendes RB, Muzy PC, de Paiva Raffaelli M, Dumans e Mello MB. Dynamic anterior stabilization of the shoulder with adjustable-loop device. [published online December 21, 2022]. Arthros Tech. https://doi.org/10.1016/j.eats.2022.08.055.
Arthroscopic biceps transfer to the glenoid with Bankart repair grants satisfactory 2-year results for recurrent anteroinferior glenohumeral instability in subcritical bone loss.
have reported the results of different arthroscopic methods of transposing and fixing the LHB tendon to the anterior glenoid rim but there is a lack of clinical studies reporting either the short- or medium-term results of DAS.
The purpose of the current study was to report the results of the onlay DAS using the LHB and the double double-pulley (DDP) technique for the treatment of anterior glenohumeral instability with ≤20% GBL. We hypothesized that DAS would produce good clinical results and successful healing of the transposed LHB and would be safe for the treatment of anterior glenohumeral instability.
Methods
Between September 2018 and December 2021, a unicentric single-arm prospective study on the all-arthroscopic all-suture anchor DAS using the LHB and the DDP technique was conducted. Patients who had anterior glenohumeral instability, with 1 or more episodes of anterior dislocation, limited (<13.5%) to subcritical (<25%) GBL, shoulder pain, and anterior apprehension refractory to conservative treatment, were invited to participate. The exclusion criteria were ipsilateral acute proximal humerus fractures or rotator cuff tears.
Surgical Technique
Patients in the study population were the first in whom DAS was performed by the authors. The surgical technique was previously described in detail.
All procedures were performed by the same surgical team (C.I.d.C.A. and A.C.L.P.G.A.) with 15 and 4 years of practice since training, respectively. Each patient underwent arthroscopic surgery under general anesthesia, in the beach-chair position, using a mechanical arm positioner with the shoulder placed at 70° of elevation and 10° of abduction, and in neutral rotation. Three arthroscopic portals were used: the posterior portal was established in the soft spot, aiming the 4-mm and 30° arthroscope at the coracoid process; the anterior portal was established from outside-in under direct vision using an 18-gauge needle directed to the middle third of the subscapularis tendon, lateral to the conjoint tendon, and a working cannula (5 × 85 mm) with an outflow connection was placed through it; and the presence and classification of a concomitant SLAP tear
was confirmed at this point, using a probe placed through the anterior portal. The shoulder was placed at increased degrees of abduction and ER, and the presence of an engaging or nonengaging Hill–Sachs lesion was confirmed. The anterolateral portal was established from outside in, distal to the anterolateral aspect of the acromion, using the needle directed laterally to the transverse humeral ligament, parallel and slightly distal to the superior border of the subscapularis. A 3.5- × 135-mm radiofrequency ablator probe was introduced through the anterolateral portal and was used to cut the transverse humeral ligament laterally to the LHB tendon, until the LHB tendon was completely released from the bicipital groove. The subscapularis tendon split was performed using the switching stick and the radiofrequency ablator. The radiofrequency ablator was used either through the anterior portal after placing the switching stick through the posterior portal to mark the level of the split at the middle third and using the anterolateral portal as a viewing portal with the arthroscope through it, or through the anterolateral portal after placing the switching stick through the anterior portal.
After debridement using a 4- × 125-mm automated shaver, two 1.8- or 1.9-mm all-suture double-loaded anchors were implanted on the anteroinferior glenoid rim, through the subscapularis split, one at the 4-o’clock and the other at the 5-o’clock position (right shoulder) approximately 5 mm apart (Fig 1). All limbs of the sutures from the glenoid anchors were passed through the LHB tendon with the suture passer according to the following sequence: first, 2 different limbs of the sutures from the superior glenoid anchor were passed distal to the bicipital anchor on the labrum and a surgeon’s knot and 2 half-stitches are tied to be used as the first double-pulley knot; second, approximately 5 mm distal to this knot, 2 different limbs of the sutures from the inferior glenoid anchor were passed, and the second double pulley knot was tied (Figs 2 and 3). Using the ablator, the LHB was tenotomized distally to the bicipital anchor on the superior labrum and proximally to the first double-pulley knot. The opposing limbs of the different sutures from the glenoid anchors were pulled while the 2 double-pulley knots were used to push the tenotomized LHB through the subscapularis tendon split. The suture limbs were tied once the LHB reached the anteroinferior glenoid rim (Fig 4). One 1.3- or 1.8-mm all-suture single-loaded anchor was implanted between the 4- and 5-o’clock positions, adjacent to the superior half of the transposed LHB tendon on the glenoid rim, and a simple knot was tied to plicate the remaining anterior labrum or capsular tissue onto the glenoid rim (Fig 5).
Fig 1Arthroscopic image of the right shoulder of patient 8. Posterior portal view showing the two 1.9 all-suture double-loaded anchors whose 8 suture limbs will be used in the double double-pulley technique; (A) one anchor at the 4- o’clock and (B) the other anchor at the 5-o’clock position, implanted on the anteroinferior glenoid rim, adjacent to the glenoid bone loss (GBL) area. (G, glenoid; H, humeral head.)
Fig 2Arthroscopic image of the right shoulder of patient 10. Posterior portal view showing the 8 suture limbs (black arrow) that were passed through the subscapularis tendon (Sc) split and the long head of the biceps (LHB) after implantation of the 2 all-suture double-loaded anchors on the glenoid (G), and the most distal double pulley knot (Dpk). (H, humeral head; Ss, supraspinatus tendon.)
Fig 3Arthroscopic image of the right shoulder of patient 13. Posterior portal view showing the 2 double double-pulley knots (A and B) tied over the long head of the biceps (LHB), and the opposing limbs of the sutures (C, D, E, and F). (H, humeral head.)
Fig 4Representation of the arthroscopic posterior portal view of the double double-pulley technique. (A) The subscapularis tendon split (dashed ellipse) is viewed from the posterior portal while the long head of the biceps (LHB) tendon is still in situ; the dashed lines represent the contour of the subscapularis muscle lying anterior to the scapula. (B) Two 1.9-mm all-suture double-loaded anchors were implanted on the anteroinferior glenoid rim, and the 8 suture limbs were passed through the subscapularis tendon split and the LHB tendon. The 2 knots of the double double-pulley were tied on top of the LHB, which is now ready to be tenotomized at the level of the anchor of the LHB (dashed line). (C) The remaining 4 opposing suture limbs were pulled and the LHB tendon reached the anteroinferior glenoid rim after passing through the subscapularis tendon split. The dashed line represents the final course of the LHB tendon through and anteriorly to the subscapularis tendon. The opposing 4 suture limbs will each be used to obtain an additional 2 knots to reinforce the fixation of the LHB to the glenoid rim
Fig 5Arthroscopic image of the right shoulder of patient 8. Posterior portal view showing the remaining capsular tissue plicated onto the anterior glenoid rim, after implanting one 1.8-mm all-suture single-loaded anchor adjacent to the superior half of the transposed long head of the biceps (LHB) tendon on the glenoid rim. (G, glenoid; H, humeral head.)
For the first 3 weeks, patients wore a sling and were instructed to remove it several times a day to perform passive shoulder and elbow exercises. Shoulder exercises were limited to elevation from 0° to 90°, and external–internal rotation exercises with the arm at the side from internal rotation (IR) to the neutral position. From weeks 3 to 6, shoulder and elbow exercises progressed from passive to active assisted exercises and the use of the sling was subsequently diminished. Until 6 weeks, active resistant elbow exercises were not allowed. From weeks 6 to 8, active resistant elbow exercises progressed from 1 kg to 2 kg. After week 8, active resistant elbow exercises progressed according to pain tolerance. Active shoulder abduction in external rotation was avoided until 3 months. After 6 months, a full return to the previous level of sports activity was progressively allowed.
Outcome Measurements
The patients were assessed preoperatively and at 1, 3, 6, 12, 24, 36, and 48 months postoperative by 2 experienced shoulder surgeons (C.I.d.C.A. and A.C.L.P.G.A.). The primary and secondary end points of the study were the 12-month and the last follow-up, respectively. The primary outcome measures were the Western Ontario Shoulder Instability Index (WOSI),
The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI).
shoulder active elevation, abduction, ER, IR, and abduction strength. The secondary outcomes were the ability to return to play (RTP), RTP at the same level, the lack of recurrence of anterior instability, the successful healing and lack of complications of the LHB, and the operative time.
Each patient underwent magnetic resonance imaging (MRI) of the shoulder preoperatively and at a minimum follow-up of 6 months postoperatively in a 1.5-T closed-type scanner (MAGNETOM; Siemens Healthineers, Cary, NC) using a dedicated shoulder radiofrequency coil. The MRI scans were assessed preoperatively to measure the estimated GBL, Hill–Sachs interval, and glenoid track and postoperatively to assess the integrity of the transposed LHB. Integrity of the LHB was defined as the absence of discontinuity between the tendon and the anterior glenoid rim in the coronal, sagittal, and axial planes. The measurements and assessments were performed by an experienced shoulder surgeon (C.I.d.C.A.) using the Horos software (version 3.3.6, Horos Project, Brooklyn, NY). The estimated GBL was measured according to the glenoid width method using the best-fit circle on the oblique sagittal proton density–weighted sequences, on the slice with the largest glenoid surface area (Fig 6). A straight line was drawn connecting supraglenoid tubercle to the most inferior point on glenoid traversing center of the best-fit circle defined by edges of inferior glenoid and the same equation according to the arthroscopic bare spot technique was used
Walter WR, Samim M, LaPolla FWZ, Gyftopoulos S. Imaging quantification of glenoid bone loss in patients with glenohumeral instability: A systematic review. [published online March 5, 2019]. AJR Am J Roentgenol. https://doi.org/10.2214/AJR.18.20504.
: ([R – r] / [2R]) × 100% = percentage of estimated GBL, where R = estimated native glenoid radius, r = deficient glenoid radius, (R – r) = glenoid defect, and 2R = estimated intact native glenoid diameter. The glenoid track was calculated using the formula: ([{2R} × 0.83]) – [R – r]). The length of the Hill–Sachs lesion (HSL) was measured on the T2-weighted axial sequence. A Hill–Sachs interval lower than the glenoid track characterized an on-track lesion, whereas a Hill–Sachs interval greater than the glenoid track characterized an off-track lesion.
Fig 6Preoperative magnetic resonance images of patient 8 showing the measurements used for the calculation of the glenoid and humeral bone loss. (A) Measurement of the estimated glenoid bone loss according to the glenoid width method using the best-fit circle on the oblique sagittal proton density–weighted sequence. (B) Measurement of the Hill–Sachs lesion on the T2-weighted axial sequence. (R, estimated native glenoid radius; r, deficient glenoid radius.)
The learning curve of the procedure was measured using the operative time, which was recorded for each surgery and measured from the first skin incision to the completion of closure of all incisions. The recurrence of anterior instability and the presence or absence of complications concerning the LHB, and of any neurologic complaints, were assessed at each clinical follow-up appointment. A clinical neurologic examination of the shoulder, arm, elbow, forearm, wrist, and hand was performed. The presence of either pain or apprehension in the anterior apprehension test at either the primary or secondary end points of the study, or the occurrence of a recurrent episode of anterior glenohumeral dislocation after DAS were considered a recurrence of anterior instability. The presence of either a Popeye deformity or of pain in the biceps muscle were considered a complication of the LHB.
The minimum clinically important difference (MCID), defined as the smallest change in the outcome measurement that signifies an important improvement in a symptom after arthroscopic repair of anterior shoulder instability, for the WOSI and Rowe score (151.9 and 9.7, respectively),
Minimal clinically important differences in Rowe and Western Ontario Shoulder Instability Index scores after arthroscopic repair of anterior shoulder instability.
Minimal clinically important differences and correlating factors for the Rowe score and the American Shoulder and Elbow Surgeons score after arthroscopic stabilization surgery for anterior shoulder instability.
was used to determine whether the mean improvement in the clinical results at each end point of the study was either good or poor. The clinical result was defined as “good” or “poor” when the mean improvement in the WOSI or Rowe score was greater or lower than the MCID, respectively, at both end points. The procedure was considered safe if the postoperative MRI showed successful healing of the LHB, and the clinical assessment confirmed a lack of postoperative complications of the LHB.
This study was approved by the institutional review board and ethics committee of Centro Hospitalar de Lisboa Ocidental, approval number: 08112018HSFX2, “Comissão de Ética para a Saúde do CHLO”; the study was registered a priori (September 2018) and is publicly accessible at the site of the U.S. National Library of Medicine, ClinicalTrials.gov (ClinicalTrials.gov ID: NCT03693716, https://clinicaltrials.gov/). Each patient signed an informed consent form.
Statistical Analysis
For the a priori power analysis, G∗Power 3.1 was used.
The chosen variable was the WOSI score, and the 2-tailed paired-samples t test was used for the sample size calculation. The study was designed to achieve a power of 85% at a significance level of P < .05, with a beta = 0.15 and alpha = 0.05. The mean improvement and standard deviation in the WOSI score 1 year after arthroscopic Bankart repair for recurrent anterior instability in the study by Park et al
Minimal clinically important differences in Rowe and Western Ontario Shoulder Instability Index scores after arthroscopic repair of anterior shoulder instability.
(299.4 ± 303.7) were used, and a Cohen d effect size of 0.986 was computed. The number of subjects required to show a difference between groups was n = 12.
Parametric tests were used to compare the primary outcomes from preoperatively to postoperatively (2-tailed paired-samples t test), and to compare the categorical variables (Fisher exact or χ2 test). A nonparametric test was used to compare the primary and secondary outcomes, as well as the mean operative time between the first and last group of patients (Mann–Whitney U test). To determine the magnitude of the difference found, the Hedges g effect size of the mean changes in primary outcomes from preoperatively to postoperatively in the study population was calculated.
the outcome measures used to compare the subgroups were limited to primary and secondary outcomes. The subgroups defined a priori included patients who had <10% or ≥10% of GBL, were able or unable to RTP, and who did or did not RTP at the same level. No analyses accounting for missing data were performed; decreases in the number of participants throughout the study reflect those who were excluded because of missing data. SPSS Statistics 28 software (IBM Corp., Armonk, NY) was used for statistical analyses. Statistical significance was set at P < .05.
Results
Eighteen consecutive patients met the inclusion criteria and underwent DAS. Three patients had less than 12 months of follow-up at the time of the latest outcome analysis; therefore, they did not reach the primary end point of the study and were excluded from the primary and secondary outcome analyses. However, they were included in preoperative and intraoperative analyses, as shown in Table 1. The remaining 15 patients (mean follow-up, 23.93 months ± 13.67 months; range, 12.16-48.49 months) reached the primary and secondary end points and were included in the primary and secondary outcome analyses.
Table 1Demographic, Clinical, and Imaging Characteristics of the Study Population
Baseline Characteristics (Preoperative or Intraoperative)
Patients Who Underwent DAS (Total N = 18)
Patients With 12 Months of Minimum FU (Total N = 15)
Age at first episode, y
20.39 ± 5.50
19.73 ± 5.65
Age at surgery, y
26.00 ± 9.20
23.40 ± 6.53
Right-sided lesion
14 (78.78)
13 (86.67)
Dominant-sided lesion
14 (78.78)
13 (86,67)
Male
15 (83.33)
12 (80.00)
Beighton score, points
0.94 ± 2.58
1.13 ± 2.80
Overhead or noncontact type of sports
5 (27.78)
5 (33.33)
Contact type of sports
13 (72.22)
10 (66.67)
Recreational level of sports
14 (77.78)
11 (73.33)
Competitive level of sports
4 (22.22)
4 (26.67)
No. of shoulder dislocation episodes
13.08 ± 11.85
10.13 ± 8.42
History of previous surgery for anterior instability
1 (5.56)
0
SLAP type 1 or 2 lesions
7 (38.89)
5 (33.33)
Repair of the SLAP lesion
1 (5.56)
10 (6.67)
HSL visible on the preoperative MRI
16 (88.89)
13 (86.67)
Hill–Sachs interval, mm
15.53 ± 3.05
15.00 ± 2.96
Estimated anterior GBL
8.43 ± 6.92
8.21 ± 7.39
Glenoid track, mm
19.20 ± 2.45
18.87 ± 2.57
Estimated anterior GBL ≥10%
11 (61.11)
9 (60,00)
On-track lesion
17 (93.75)
14 (93.33)
HSL engaged intraoperative before DAS
9 (50)
7 (46.15)
Additional capsulolabral plicature
11 (61.11)
10 (66.67)
LHB fixed using two 1.9-mm anchors (S&N)
11 (61.11)
10 (66.66)
LHB fixed using two 1.8-mm anchors (CONMED)
7 (38.89)
5 (33.33)
Operative time, min
98.23 ± 19.64
97.73 ± 21.39
NOTE. Data are presented as mean ± SD or absolute value and percentage in parentheses. CONMED, Y-Knot Flex 1.8-mm all-suture anchor double loaded with suture; DAS, dynamic anterior stabilization; FU, follow-up; GBL, glenoid bone loss; HSL, Hill–Sachs lesion; LHB, long head of the biceps tendon; No, number; SD, standard deviation; SLAP, superior labrum anterior to posterior; S&N, Smith & Nephew SUTUREFIX 1.9-mm all-suture anchor double-loaded with suture; WOSI, Western Ontario Shoulder Instability Index.
As shown in Tables 2 and 3, the mean improvement in the WOSI and Rowe score was significant and more than 6 and 7 times greater than the MCID for anterior shoulder instability for the WOSI, and for the Rowe, respectively,
Minimal clinically important differences in Rowe and Western Ontario Shoulder Instability Index scores after arthroscopic repair of anterior shoulder instability.
Minimal clinically important differences and correlating factors for the Rowe score and the American Shoulder and Elbow Surgeons score after arthroscopic stabilization surgery for anterior shoulder instability.
with large effect sizes at each end point. Individually, each patient met the MCID for the WOSI and the Rowe score at final follow-up. The mean improvement in the range of motion (ROM) was significant as well, whereas the mean improvement in strength was not significant from preoperative to 12 months only.
Table 2Mean Changes in the Clinical Outcomes From Preoperatively to 12 Months (n = 15)
Measured as the greatest vertebral body that the patient’s thumb could reach without pain: lateral thigh = 0, buttock = 1, sacrum = 2, lumbar = 3, T12 = 4, and T7 = 5.
NOTE. Data are presented as mean ± SD. P values were calculated using the 2-tailed paired-samples t-test.
Abd, abduction; Deg, degrees; ER, external rotation; IR, internal rotation; SD, standard deviation; labrum anterior to posterior; WOSI, Western Ontario Shoulder Instability Index.
∗ Significance level set at P < .05.
† Measured as the greatest vertebral body that the patient’s thumb could reach without pain: lateral thigh = 0, buttock = 1, sacrum = 2, lumbar = 3, T12 = 4, and T7 = 5.
Measured as the highest vertebral body that the patient’s thumb could reach without pain: lateral thigh = 0, buttock = 1, sacrum = 2, lumbar = 3, T12 = 4, and T7 = 5.
NOTE. Data are presented as mean ± SD. P values were calculated using the 2-tailed paired-samples t-test.
Abd, abduction; deg, degrees; ER, external rotation; IR, internal rotation; SD, standard deviation; WOSI, Western Ontario Shoulder Instability Index.
∗ Significance level set at P < .05.
† Measured as the highest vertebral body that the patient’s thumb could reach without pain: lateral thigh = 0, buttock = 1, sacrum = 2, lumbar = 3, T12 = 4, and T7 = 5.
No LHB complications, neurologic or other, were reported during the follow-up period. Patient 11 had an atraumatic recurrent episode of anterior glenohumeral dislocation at 8 months and had a positive apprehension sign at 12 months’ postoperatively. Patients 11 and 12 had severe hyperlaxity, each with a Beighton score
of 8 points, whereas the remaining sample of 13 patients had an average Beighton score of 0.08 ± 0.27 points (range, 0-1). No recurrent episodes of anterior glenohumeral dislocation or apprehension were reported either in patient 12 or in the remaining 13 patients who did not have severe hyperlaxity. Therefore, the recurrence rate of anterior instability in the overall group was 6.7%. The postoperative MRI of each patient showed that the transposed LHB had successfully healed to the glenoid bone (Fig 7) at a mean follow-up period of 9.36 ± 5.66 months (range, 6.02-25.35 months).
Fig 7Magnetic resonance images of patient 8 at 13.35 months postoperatively showing the successfully healed transposed long head of the biceps tendon. Course of the long head of the biceps tendon (white arrows) through the subscapularis tendon on the (A) axial and (B) coronal proton-density slices
The average operative time of the 18 cases did not significantly differ between the first (mean, 96.22 minutes ± 22.23; range, 71-132 minutes) and last 9 cases (mean, 100.33 minutes ± 17.78; range, 70-130 minutes) (U = 35.5, P = .658). As shown in Table 4, 8 patients reached the 24 months of follow-up and had a significant mean improvement in the WOSI and Rowe score. At final follow-up, the RTP rate was 93.33% and RTP at the same level was 60.00%. Among the patients who practiced competitive sports, the RTP rate was 100%. There were no significant differences in the primary and secondary outcomes either between the group of patients who were able and unable to RTP, or between the group who did and did not RTP at the same level.
Table 4Shoulder Clinical Scores of the Study Population Grouped According to Minimum Follow-up of 24 and 48 Months
Patients With 24 Months of Minimum FU (Total n = 8)
P Value
Patients With 48 Months of Minimum FU (Total n = 3)
As shown in Table 5, there were no significant differences in the primary and secondary outcomes between the group of patients with GBL <10% (mean GBL, 0%) and ≥10% (mean GBL, 13.68 % ± 3.35%; range, 10.20%-20.24 %).
Table 5Demographics and Clinical Scores of the Study Population Grouped According to Estimated Anterior GBL (n = 15)
Measured as the highest vertebral body that the patient’s thumb could reach without pain: lateral thigh = 0, buttock = 1, sacrum = 2, lumbar = 3, T12 = 4, and T7 = 5.
1.33 ± 1.86
0.33 ± 0.50
.254
Abd strength improvement
2.39 ± 3.45
0.33 ± 0.50
.724
NOTE. Data are presented as mean ± SD or absolute value and percentage in parentheses unless otherwise specified; P values were calculated using the Mann–Whitney U test and Fisher exact or χ2 test for the ordinal or continuous and categorical variables, respectively.
Abd, abduction; ER, external rotation; FU, follow-up; GBL, glenoid bone loss; HSL, Hill–Sachs lesion; intraop, intraoperatively; IR, internal rotation; pts, points; postop, postoperative; preop, preoperative; SD, standard deviation; RTP, return to play; WOSI, Western Ontario Shoulder Instability Index.
∗ Measured as the highest vertebral body that the patient’s thumb could reach without pain: lateral thigh = 0, buttock = 1, sacrum = 2, lumbar = 3, T12 = 4, and T7 = 5.
The most important findings of the study were that the all-arthroscopic all-suture anchor DAS using the LHB and the DDP technique produced good clinical outcomes at 12, 24, and 48 months of follow-up in patients with GBL of 0% to 20%. In addition, the LHB healed to the anterior glenoid in each patient. The mean improvement in the WOSI and Rowe score was significant and more than 6 times greater than the MCID for anterior shoulder instability. There were no recurrences of anterior instability in the subgroup of patients without severe hyperlaxity; there were no restrictions in ROM and no complications, either of the LHB or neurologic, in the overall group; and the LHB successfully healed in each patient, meaning that the all-arthroscopic all-suture anchor DAS using the LHB is a safe procedure for GBL of 0% to 20% in patients without severe hyperlaxity.
The sample size is sufficiently large, and the study is adequately powered to show significant differences between preoperative and postoperative outcome scores. The large effect sizes reported in the study show the magnitude of the improvement from preoperative to postoperative. The significant improvement in the average ROM, with no restriction in ER or IR, confirms the results reported in the biomechanical study by Mehl et al,
Arthroscopic biceps transfer to the glenoid with Bankart repair grants satisfactory 2-year results for recurrent anteroinferior glenohumeral instability in subcritical bone loss.
Therefore, this may be a suitable option to treat patients who wish to return to the practice of overhead sports or activities highly dependent on shoulder ROM. The results of the current study are promising in comparison with arthroscopic Bankart repair augmented with Hill–Sachs remplissage, which may result in an overall RTP rate of 78% and a recurrence rate of instability of 7.5%,
and with the between-glenohumeral-ligaments-and-subscapularis-tendon technique that may result in a recurrence rate of 50% when used in patients with GBL >15%.
In the current study, the presence of either pain or apprehension in the anterior apprehension test, even in the absence of a recurrent episode of anterior dislocation, was considered a recurrence of anterior instability. Therefore, the threshold for what was considered a recurrence after DAS was lowered. This is in line with what has been advocated by several authors for the assessment of the success of anterior instability surgery, and who have found that in young active populations a clinically significant decrease in WOSI scores is consistent with an unacceptable outcome even in patients who did not sustain a recurrence of anterior dislocation,
Arthroscopic biceps transfer to the glenoid with Bankart repair grants satisfactory 2-year results for recurrent anteroinferior glenohumeral instability in subcritical bone loss.
of the 22 patients who underwent DAS, 3 had a recurrent episode of dislocation (13.6%) at a mean follow-up of 3.2 ± 0.7 years (range, 1.2-4.2 years); these failures occurred early in their learning curve. In the current study, only one recurrent dislocation episode was reported, which was an atraumatic dislocation in 1 patient who had severe hyperlaxity. No postoperative anterior apprehension or redislocation episodes were reported in the patients without severe hyperlaxity.
In the current study, the relatively long mean operative time did not significantly differ between the first and last cases, showing that DAS using the DDP is a technically demanding procedure that requires a long operative time to be successfully accomplished. Nevertheless, the average operative time reported in the current study is in line with that reported in studies on other types of complex arthroscopic procedures for the treatment of anterior glenohumeral instability with limited to subcritical glenoid bone loss. In the systematic review conducted by Ekhtiari et al.,
it was found that the early groups of patients who underwent arthroscopic Latarjet had a mean operative time of 138.7 minutes (range, 103-183 minutes) versus the late groups, which had a mean operative time of 108.8 minutes (range, 76-139 minutes). The lack of complications despite the long operative time seems to corroborate that DAS, although complex, is a safe procedure.
The results of the study seem to suggest that DAS does not cause LHB complications from 12 months to 48 months postoperatively. The type of postoperative rehabilitation protocol that was used, which protected the LHB from being loaded until 2 months postoperative, may have favored the LHB healing and may have helped avoid these complications. In the study by Collin et al,
Arthroscopic biceps transfer to the glenoid with Bankart repair grants satisfactory 2-year results for recurrent anteroinferior glenohumeral instability in subcritical bone loss.
The preoperative MRI measurements underestimated the severity of the bipolar lesions. Sixteen patients had a HSL and, of these, only one had an off-track lesion. However, during arthroscopy, it was found that the HSL engaged in 50% of the patients; therefore, one half of the patients had an intraoperatively confirmed off-track lesion. The ideal method of measuring bipolar lesions and the glenoid track is a matter of controversy, and there is no consensus in the literature regarding either the imaging modality or measuring method.
Walter WR, Samim M, LaPolla FWZ, Gyftopoulos S. Imaging quantification of glenoid bone loss in patients with glenohumeral instability: A systematic review. [published online March 5, 2019]. AJR Am J Roentgenol. https://doi.org/10.2214/AJR.18.20504.
What is the most reliable method of measuring glenoid bone loss in anterior glenohumeral instability? A cadaveric study comparing different measurement techniques for glenoid bone loss.
With the exception of the Hill–Sachs interval, CT and MRI show no significant differences in the diagnostic value of the HSL measurement regardless of the measurement technique.
This finding has been attributed to the improved identification of the rotator cuff and the resulting greater measurement precision with MRI, which means that decreased lengths of HSL can be found using MRI. This may result in MRI showing a decreased proportion of off-track lesions compared with CT. Nevertheless, it has been suggested that MRI may be more appropriate than CT for measuring GBL or HSLs because of the avoidance of radiation exposure and the equivalent diagnostic validity of most measuring methods.
With the exception of the Hill–Sachs interval, CT and MRI show no significant differences in the diagnostic value of the HSL measurement regardless of the measurement technique.
In the current study, none of the HSLs engaged after DAS, showing that DAS can be used to successfully manage bipolar lesions. The arthroscopic instrumentation used for DAS did not require specific arthroscopic guides or bulky instrumentation sets, whereas arthroscopic bony or coracoid transfer procedures usually do. Therefore, DAS adds another option to the armamentarium of the orthopaedic surgeon for the treatment of preoperatively apparent on-track bipolar lesions that intraoperatively are found to be engaging. Preoperative MRI may underestimate the presence of SLAP tears as well.
In the current study, in patients with concomitant SLAP type I to II lesions, DAS proved to be a “fill two needs with one deed” treatment option, simultaneously addressing the SLAP lesion and the anterior glenohumeral instability in an “all in one procedure.”
The study shows that DAS is a safe procedure because there was no recurrence of anterior instability in the patients who did not have severe hyperlaxity, there were no complications of the LHB, which successfully healed in each patient, and no neurologic complications were reported during the follow-up period. Several variables may have come into play in accomplishing these outcomes. First, the type of fixation of the LHB used, which relied on an onlay method of fixation on the cortical surface of the glenoid, similar to that used by Milenin and Toussaint,
while avoiding the creation of large bone tunnels that can increase the risk of glenoid fracture. Furthermore, in the onlay method of fixation, the transposed LHB mimics the original labrum, which may have been advantageous in the chronic cases with labral insufficiency in which an additional Bankart repair was impossible. Indeed, Nicholson et al.
Biomechanical analysis of anterior stability after 15% glenoid bone loss: comparison of Bankart repair, dynamic anterior stabilization, dynamic anterior stabilization with Bankart repair, and Latarjet.
recently showed, in a cadaveric model with 15% GBL, that the isolated inlay DAS is less efficient in restoring anterior stability than DAS with a Bankart repair, highlighting the need for the Bankart repair when an inlay DAS is used. Second, DAS avoids traction to the musculocutaneous nerve because the LHB is transposed instead of the conjoint tendon; therefore, there is decreased risk of injury to the musculocutaneous nerve in comparison with the coracoid transfer procedures. In the case report by DeFroda et al,
an open DAS technique was used in a case of recurrent dislocation and musculocutaneous palsy, in which a revision of the previously performed Bankart repair to either the Latarjet or Bristow procedures was relatively contraindicated because of the increased risk of injury to the musculocutaneous nerve,
and no neurologic complications were reported after DAS. Furthermore, DAS that uses all-suture anchors to fix the LHB to the glenoid may avoid the risk of hardware- or implant-related postoperative complications. Finally, DAS may avoid the risk of scapular dyskinesis and respective potential nefarious long-term consequences, because the LHB tendon is transposed instead of the coracoid. The Latarjet procedure has been shown to permanently disturb the physiological scapular kinesis because the pectoralis minor is detached, and the vector and the working length of the coracobrachialis and the short head of the biceps are changed.
Therefore, DAS may be a new alternative that avoids short and long-term complications of extending the Bankart repair, Hill–Sachs remplissage, or bone block procedures beyond their ideal indications.
Limitations
The study has some limitations. First, the power analysis and sample size calculation were limited to the overall group and did not include the subgroup analyses. Therefore, the focus of the discussion was placed on the overall group, and the conclusions drawn from the results of the subgroup analyses were interpreted with caution. Second, only 8 patients (53.3%) of the current series had a minimum follow-up of 24 months. Therefore, the discussion focused on the improvement of the primary outcomes, and on determining the safety of this procedure regarding the successful healing and lack of complications of the LHB, for which the 12 months of minimum follow-up was sufficient. Last, the study lacks a comparative group to support the discussion about DAS versus other surgical techniques.
Conclusions
At a minimum of 1-year follow-up, DAS produces significant and clinically important improvements in shoulder function, successful LHB healing, and is safe for the treatment of anterior glenohumeral instability with ≤20% GBL without severe hyperlaxity.
Risk factors for recurrence after arthroscopic instability repair-the importance of glenoid bone loss >15%, patient age, and duration of symptoms: A matched cohort analysis.
Arthroscopic Subscapularis augmentation of bankart repair in chronic anterior shoulder instability with bone loss less than 25% and capsular deficiency: Clinical multicenter study.
What is the critical value of glenoid bone loss at which soft tissue Bankart repair does not restore glenohumeral translation, restricts range of motion, and leads to abnormal humeral head position?.
A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair.
Dynamic anterior stabilization using transosseous bone tunnel technique with the adjustable loop length cortical button incorporating high-strength suture augmentation for recurrent shoulder instability.
Garcia JC, Mendes RB, Muzy PC, de Paiva Raffaelli M, Dumans e Mello MB. Dynamic anterior stabilization of the shoulder with adjustable-loop device. [published online December 21, 2022]. Arthros Tech. https://doi.org/10.1016/j.eats.2022.08.055.
Arthroscopic biceps transfer to the glenoid with Bankart repair grants satisfactory 2-year results for recurrent anteroinferior glenohumeral instability in subcritical bone loss.
The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI).
Walter WR, Samim M, LaPolla FWZ, Gyftopoulos S. Imaging quantification of glenoid bone loss in patients with glenohumeral instability: A systematic review. [published online March 5, 2019]. AJR Am J Roentgenol. https://doi.org/10.2214/AJR.18.20504.
Minimal clinically important differences in Rowe and Western Ontario Shoulder Instability Index scores after arthroscopic repair of anterior shoulder instability.
Minimal clinically important differences and correlating factors for the Rowe score and the American Shoulder and Elbow Surgeons score after arthroscopic stabilization surgery for anterior shoulder instability.
What is the most reliable method of measuring glenoid bone loss in anterior glenohumeral instability? A cadaveric study comparing different measurement techniques for glenoid bone loss.
With the exception of the Hill–Sachs interval, CT and MRI show no significant differences in the diagnostic value of the HSL measurement regardless of the measurement technique.
Biomechanical analysis of anterior stability after 15% glenoid bone loss: comparison of Bankart repair, dynamic anterior stabilization, dynamic anterior stabilization with Bankart repair, and Latarjet.
The authors report the following potential conflicts of interest or sources of funding: A.C.A. reports consultant for CONMED. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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