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Purpose of ReviewThe purpose of this review is to outline the natural history and best clinical practices for nonoperative management of anterior shoulder instability.Recent FindingsRecent studies continue to demonstrate a role for nonoperative treatment in the successful long-term management of anterior glenohumeral instability. The success of different positions of shoulder immobilization is reviewed as well.SummaryThere are specific patients who may be best treated with nonoperative means after anterior glenohumeral instability. There are also patients who are not good nonoperative candidates based on a number of factors that are outlined in this review. There continues to be no definitive literature regarding the return to play of in-season athletes. Successful management requires a thorough understanding of the epidemiology, pathoanatomy, history, physical examination, diagnostic imaging modalities, and natural history of operative and nonoperative treatment.

Purpose This systematic review and meta-analysis aimed to (1) determine the proportion of patients who underwent anterior shoulder instability surgery and did not return to sports for psychological reasons and (2) estimate differences in psychological readiness scores between patients who did and did not return to sports. Methods The EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE and Cochrane Library databases were searched for relevant studies. The data synthesis included the proportion of patients who did not return to sports for psychological reasons and the mean differences in the psychological readiness of athletes who returned and those who did not return to sports. Non-binomial data were analysed using the inverse-variance approach and expressed as the mean difference with 95% confidence intervals. Results The search yielded 700 records, of which 13 (1093 patients) were included. Fourteen psychological factors were identified as potential causes for not returning to sports. The rates of return to sports at any level or to the preinjury level were 79.3% and 61.9%, respectively. A total of 55.9% of the patients cited psychological factors as the primary reason for not returning to sports. The pooled estimate showed that patients who returned to sports had a significantly higher Shoulder Instability-Return to Sport After Injury score ( P  < 0.00001) than those who did not, with a mean difference of 30.24 (95% CI 24.95–35.53; I 2  = 0%; n.s.). Conclusions Psychological factors have a substantial impact on the rate of return to sports after anterior shoulder instability surgery. Patients who returned to sports had significantly higher psychological readiness than those who did not return to sports. Based on these results, healthcare professionals should include psychological and functional measurements when assessing athletes’ readiness to return to sports. Level of evidence Level IV.

Introduction Arthroscopic revision anterior shoulder instability repair has been proposed, and early clinical results have been promising. However, long-term results after this procedure and the probable risk factors for failure have not been sufficiently discussed in the literature. Materials and methods Thirty-eight patients who were diagnosed with recurrent anteroinferior shoulder instability after failed Bankart repair, treated with ACRR between September 1998 and November 2003 and able to be contacted were included. Of these patients, 2 were excluded from the study due to the use of SureTak anchors for fixation, and 5 other patients refused to participate in the study due to lack of interest (3 patients) or lack of time (2 patients). The remaining shoulders were clinically examined at a minimum of ten years after surgery via the ASES, Constant, AAOS, Rowe, Dawson and VAS scores for pain and stability. Degenerative arthropathy was assessed with the modified Samilson-Prieto score. Results All 31 remaining shoulders were evaluated at a mean time of 11.86 years (142.4 months) after surgery. Six patients (19.35%) reported redisolcation after the revision procedure, 4 of whom were affected by a new significant shoulder trauma. The ROWE and Constant scores improved significantly. Moderate to severe dislocation arthropathy was observed in 19.4% of patients. Five patients (16.2%) were not satisfied with the procedure. Conclusion Long-term follow-up after ACRR shows predictable results, with a high degree of patient satisfaction, good to excellent patient-reported outcome scores and minimal radiological degenerative changes. However, with an average recurrence rate of 19.3% after 11.86 years, the redislocation rate appears high. With careful patient selection, recurrence rates can be significantly reduced.

Purpose of ReviewArthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability.Recent FindingsImprovements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome.SummaryWhen indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.

Purpose of ReviewThe purpose of this study is to provide an update to the orthopedic field in regard to treatment of the Hill-Sachs lesion and anterior shoulder instability. The review highlights the most current knowledge of epidemiology, clinical evaluation, and surgical methods used to treat Hill-Sachs lesions. It also details the relevant clinical and surgical findings that have been made throughout the literature in the past couple of years.Recent FindingsThe most recent literature covering the Hill-Sachs lesion has focused on the relatively new and unexplored topic of the importance of concomitant injuries while treating a humeral head defect. The glenoid track concept has been clinically validated as a method to predict engagement. 3D-CT has become the “gold standard” for Hill-Sachs imaging; however, it has been noted that 3D-MRI produces results that are not significantly different from CT. Also, it has been found that when the arm is in a position of abduction during the primary injury, there is a higher risk of engagement and subsequent dislocation. Recent studies have demonstrated successful results stemming from purely arthroscopic procedures in treating Hill-Sachs lesions.SummaryAnterior shoulder instability, specifically the Hill-Sachs lesion, is an area of orthopedic study that is highly active and constantly producing new studies in an attempt of gaining the best outcomes for patients. The past few years have yielded many excellent discoveries, but there is still much more work to be done in order to fully understand the role of the Hill-Sachs lesion in anterior shoulder instability.

Purpose of ReviewGlenoid Bone Loss is a commonly encountered problem in anterior shoulder instability. In this article, we review current techniques for diagnosis, indications and management of glenoid bone loss.Recent FindingsMultiple bone grafting techniques are available depending on the glenoid defect size including the coracoid, distal clavicle, iliac crest, and allograft distal tibia. Advancement in imaging methods allows for more accurate quantification of bone loss. Indications and techniques are continuing to evolve, and emerging evidence suggests that smaller degrees of bone loss “subcritical” may be best treated with bone grafting.SummaryFuture directions for innovation and investigation include improved arthroscopic techniques and a refinement of indications for the type of bone grafts and when to indicate a patient of arthroscopic repair versus glenoid bone grafting for smaller degrees of bone loss to ensure successful outcome.

Purpose The purpose of this study was to clinically validate the Hill–Sachs interval to glenoid track width ratio (H/G ratio) compared with the instability severity index (ISI) score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair. Methods A retrospective evaluation was performed using data from patients with anteroinferior shoulder instability who underwent arthroscopic Bankart repair with a follow-up period of at least 24 months. A receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values for the H/G ratio and the ISI score to predict an increased risk of recurrent instability. The area under the ROC curve (AUC) of the two methods and the sensitivity and specificity of their optimal cut-off values were compared. Results A total of 222 patients were included, among whom 31 (14.0%) experienced recurrent instability during the follow-up period. The optimal cut-off values for predicting an increased risk of recurrent instability were an H/G ratio of ≥ 0.7 and ISI score of ≥ 4. There were no significant differences between the AUC of the two methods (H/G ratio AUC = 0.821, standard error = 0.035 and ISI score AUC = 0.792, standard error = 0.04; n.s.) nor between the sensitivity and specificity of the optimal cut-off values (n.s. and n.s., respectively). Conclusions The H/G ratio is comparable to the ISI score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair. Surgeons are recommended to consider other strategies to treat anterior shoulder instability if H/G ratio is ≥ 0.7. Level of evidence III.

Purpose This study aims to assess the clinical outcomes in the management of post-traumatic posterior shoulder instability (PSI) with a focus on the decision-making process for operative and conservative treatments. Introduction PSI can result from traumatic events, impacting a patient’s quality of life. This study delves to better indicate decision-making for operative indication of post-traumatic PSI patients. Methods Patients who sustained posterior shoulder dislocations were selected from a single surgeon’s database within a five-year period. Cases of degenerative or genetically caused PSI were excluded, resulting in a cohort of 28. Patients were initially managed conservatively but indicated for surgery if they were unable to actively stabilize the shoulder or exhibited bony or cartilage defects confirmed through imaging. If conservative treatment did not yield significant improvements, it was classified as a failure, and operative intervention was recommended. The WOSI Score, ROM, and X-ray were employed to evaluate the success of treatment. Results Out of the 28 patients, 11 received conservative, seven immediate surgeries, and ten transitioned from conservative to operative treatment. The overall success rate showed 25 good to excellent results. In the persistent conservative treatment group, the initial WOSI score was significantly lower compared to the operative group. Conclusion This study suggests that post-traumatic PSI can be successfully managed conservatively with initial low clinical symptoms (low WOSI score) and in the absence of absolute indications for operative treatment. When surgery is necessary, arthroscopic procedures proved effective in achieving good to excellent results in 16 out of 17 cases.

Purpose To compare rates of recurrent instability, revision surgery and functional outcomes following arthroscopic anterior capsulolabral repair for recurrent anterior instability using knot-tying versus knotless suture anchor techniques. Methods  Patients who had undergone arthroscopic anterior labrum and capsular repair for recurrent anterior glenohumeral instability using knotless anchors were identified. Those with minimum 2-year follow-up were matched (1:2) to knot-tying anchor repair patients. Rates of failure and recurrent instability were compared, as well as Visual Analog Scale (VAS), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), University of California Los Angeles (UCLA) and Rowe scores. Results One hundred and two patients (89 males, 13 females) with a mean age of 24.3 ± 9.6 were included. Repair was performed with knotless anchors in 34 and knot-tying anchors in 68 shoulders. At mean follow-up of 4.8 ± 2.5 years, re-dislocation rates between groups were not significantly different (knotless anchor: 9% versus knot-tying group: 15%, n.s.), but the knot-tying group showed a higher re-subluxation rate ( p  = 0.039). 12 (18%) revisions were performed in the knot-tying group at a mean 2.9 years after surgery and 1 (3%) revision in the knotless anchors group at 1.4 years (n.s.). There was no difference in mean VAS with use (1.3 ± 1.9 versus 0.8 ± 1.5, n.s.), SANE scores (91.8 ± 12.7 versus 92.0 ± 11.0, n.s.), QuickDASH scores (4.1 ± 5.5 versus 3.0 ± 6.5, n.s.), UCLA Shoulder Score (32.5 ± 3.6 versus 33.2 ± 3.1, n.s.), or Rowe scores (90.5 ± 18.5 versus 92.2 ± 16.6, n.s.) between knotless and knot-tying groups, respectively. VAS at rest was higher in the knotless group (0.7 ± 1.5 vs 0.1 ± 0.4, p  = 0.021). Conclusions Knotless anchors demonstrated similar rates of re-dislocation and revision surgery, and lower rates of recurrent subluxation, compared to knot-tying anchors. Patients achieved good-to-excellent functional outcomes. This supports the efficacy of knotless anchors as an alternative to knot-tying anchors for arthroscopic anterior labral repair of recurrent anterior shoulder dislocation. Level of evidence III.

Background: While glenoid bone loss (GBL) after anterior shoulder instability correlates with poor functional outcomes, the specific effects of GBL in posterior and combined-type shoulder instability remain poorly characterized, especially in a high-risk military population. Purpose/Hypothesis: The purpose of this study was to compare GBL between unidirectional anterior or posterior instability versus combined-type instability in active-duty servicemembers. It was hypothesized that total GBL and GBL in the direction of instability would be greater in those with combined-type instability compared with unidirectional instability. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Active-duty servicemembers who underwent shoulder stabilization surgery between January 2010 and December 2019 were eligible for inclusion. Patients with multidirectional instability, concomitant rotator cuff tears, osteochondritis dissecans of the glenoid or humeral head, superior labral anterior-posterior tears, biceps pathologies, and humeral avulsion of the glenohumeral ligament were excluded. Patients were grouped according to direction of instability (anterior, posterior, or combined), and patient characteristics, instability characteristics, suture anchor use, and GBL were compared between the 3 cohorts. Results: In total, 117 patients met the study inclusion criteria. The mean patient age was 29 years, 89.7% were male, the dominant extremity was involved in 63.2%, 65.8% attributed their injuries to a singular traumatic event, and the mean follow-up was 7.9 years. There was no significant difference regarding patient characteristics, injury mechanism, or follow-up time between the 3 cohorts. As compared with the combined-type instability cohort, mean anterior GBL was greater in the anterior instability cohort (8.00% ± 4.40% vs 4.98% ± 5.26% for combined; P = .012), while mean posterior GBL was greater in the posterior instability cohort (7.44% ± 4.54% vs 4.86% ± 5.69% for combined; P = .024). There was no significant difference in mean total GBL between the combined-type (9.84% ± 7.82%) and either of the unidirectional cohorts (anterior: 8.00% ± 4.40% [P = .231]; posterior: 7.44% ± 4.54% [P = .082]). Conclusion: GBL in the direction of instability was found to be significantly greater in the unidirectional versus combined-type instability cohorts.