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Editorial Commentary: Can Orthopaedic Surgeons Agree on Choice of Procedure for Anterior Shoulder Instability Based on Risk Factors? Personal and Training Biases Confound Our Surgical Decision Making

      Abstract

      Diagnosing and treating anterior shoulder instability can be a challenging clinical problem. Although operative management of shoulder instability has been reported to result in good to excellent functional outcomes, there is still controversy regarding the timing of surgery, how to treat first-time dislocations, and which surgical procedures to use. Patient-specific factors including age, sex, activity level, types of sport, and other comorbidities will influence treatment. In addition, the unique pathology in the shoulder, including presence and degree of bone loss, and concomitant soft tissue pathology will influence the choice of procedures for anterior stabilization. Surgeon-specific factors such as surgeon's preference, which procedure the surgeon is comfortable with, and training and experience are also important. Finally, the financial burden of the procedure cannot be overlooked. With so many factors playing a role in a surgeon's treatment algorithm, a thorough preoperative assessment is important in guiding decision making. Whether preoperative consideration of the risk factors can guide orthopaedic surgeons to choose the correct procedure and eventually be translated into improved clinical outcomes is still debatable. Alongside careful analysis of the patient's relevant history, the surgeon must also deal with development of new techniques, new implants, and economic factors.
      Despite robust and improved methods for surgically treating anterior shoulder instability, concern persists regarding overall outcomes, especially in regard to recurrence. It is worth noting that different studies define recurrence and failure differently, which can influence the reported incidence rate. Studies have reported recurrent anterior instability rates as high as 22% to 35% after arthroscopic stabilization with >10 years of follow-up.
      • van der Linde J.A.
      • van Kampen D.A.
      • Terwee C.B.
      • Dijksman L.M.
      • Kleinjan G.
      • Willems W.J.
      Long-term results after arthroscopic shoulder stabilization using suture anchors: An 8- to 10-year follow-up.
      • Castagna A.
      • Markopoulos N.
      • Conti M.
      • Delle Rose G.
      • Papadakou E.
      • Garofalo R.
      Arthroscopic bankart suture-anchor repair: Radiological and clinical outcome at minimum 10 years of follow-up.
      The causes of such high recurrence rates may be accredited to both patient- and surgeon-related factors, including patient age, sex, bone defects, number of dislocations, number of anchors used for the procedure, and the patient's postsurgical activity levels.
      In their article, “Factors Influencing Surgeon's Choice of Procedure for Anterior Shoulder Instability: A Multicenter Prospective Cohort Study,” Bishop, Jones, Hettrich, Wolf, and the MOON Shoulder Group
      • Bishop J.Y.
      • Hidden K.A.
      • Jones G.L.
      • Hettrich C.M.
      • Wolf B.R.
      MOON Shoulder Group
      Factors influencing surgeon’s choice of procedure for anterior shoulder instability: A multicenter prospective cohort study.
      analyzed which risk factors affect surgeons' choice. Of the 564 patients in the cohort, most (82%) were treated with arthroscopic stabilization. A total of 38 (6.7%) patients were treated with an open Bankart procedure and 72 (12.8%) with a Latarjet procedure. The reasons for performing a Latarjet included symptom duration, number of dislocations, revision surgery, Hill–Sachs lesion size, and glenoid bone loss. Even without any of these predictors, athletes performing high-risk sports (contact, collision, and combat sports) were 2.6 times more likely to have a Latarjet. Whether symptom duration, number of dislocations, and glenoid bone loss are independent risk factors for needing a Latarjet is not clear; however, we believe that they are most likely interrelated. Longer duration of symptoms of instability and having many dislocations before surgery have been reported to be associated with glenoid bone loss.
      • McNeil J.W.
      • Beaulieu-Jones B.R.
      • Bernhardson A.S.
      • et al.
      Classification and analysis of attritional glenoid bone loss in recurrent anterior shoulder instability.
      Furthermore, it is possible that longer symptom duration and number of dislocations before surgery negatively affect the soft tissue stabilization components. The best predictors for performing an open Bankart procedure were number of dislocations, revision surgery, and glenoid bone loss. The authors found that what best determined open versus arthroscopic Bankart was history of prior shoulder surgery.
      • Bishop J.Y.
      • Hidden K.A.
      • Jones G.L.
      • Hettrich C.M.
      • Wolf B.R.
      MOON Shoulder Group
      Factors influencing surgeon’s choice of procedure for anterior shoulder instability: A multicenter prospective cohort study.
      It is not surprising that the arthroscopic Bankart procedure is the most common anterior shoulder stabilization procedure, and that there are relatively few open Bankart procedures being performed. Some studies have shown that arthroscopic Bankart has comparable outcomes to open Bankart surgery (however, open Bankart outcomes are quite enviable, with a reported 2% to 4% recurrence rate).
      • Hobby J.
      • Griffin D.
      • Dunbar M.
      • Boileau P.
      Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations.
      • Petrera M.
      • Patella V.
      • Patella S.
      • Theodoropoulos J.
      A meta-analysis of open versus arthroscopic Bankart repair using suture anchors.
      • Pagnani M.J.
      • Dome D.C.
      Surgical treatment of traumatic anterior shoulder instability in american football players.
      Arthroscopic surgery is modern, permits examination of every part of the joint, and decreases the patient's postoperative pain. Another benefit is the possibility to assess concomitant lesions, such as a Hill–Sachs lesion, and perform a remplissage in the same procedure when necessary. Many orthopaedic surgeons are well equipped to perform both open and arthroscopic shoulder stabilization procedures; however, a relatively small number will perform a Latarjet compared with the number of surgeons that will stabilize a patient with Bankart procedures. It is interesting to see that in this study by Bishop et al.,
      • Bishop J.Y.
      • Hidden K.A.
      • Jones G.L.
      • Hettrich C.M.
      • Wolf B.R.
      MOON Shoulder Group
      Factors influencing surgeon’s choice of procedure for anterior shoulder instability: A multicenter prospective cohort study.
      78 (12.8%) patients were treated with Latarjet, yet only 38 (6.7%) were treated with an open Bankart. Despite the commonly reported complications and increased risk of developing or worsening glenohumeral osteoarthritis associated with the Latarjet procedure, there is increasing interest in using it as the primary procedure, as has been pioneered in many European countries. This shift may also be influenced by the long-term higher recurrence rates associated with soft tissue procedures. In 2010, it was reported that, irrespective of the types of patients and lesions, 72% of French shoulder surgeons preferred open Latarjet bone block procedures for treating traumatic recurrent anterior shoulder instability, whereas 90% of shoulder surgeons in other countries preferred arthroscopic Bankart repair.
      • Thomazeau H.
      • Courage O.
      • Barth J.
      • et al.
      Can we improve the indication for Bankart arthroscopic repair? A preliminary clinical study using the ISIS score.
      The French influence is important to help us improve outcomes.
      As of late, the Latarjet procedure has shown success when performed arthroscopically by an increasing number of surgeons. As a rule of thumb, a surgeon should always be capable of converting a procedure from arthroscopic to open surgery when in trouble. Indications for Latarjet include age, glenoid bone loss, contact sport participation, and revision surgery. Longer symptom duration and a greater number of dislocations predispose the glenoid to increased bone loss, more soft tissue injury, and further recurrent instability. This has led some authors to advocate for early surgery in young, active patients, which can result in overtreatment and of course inflate the economic burden of surgery on both the patient and surgeon alike.
      There is a continuous search for factors that can guide orthopaedic surgeons how to produce the best outcomes. Brown et al.
      • Brown L.
      • Rothermel S.
      • Joshi R.
      • Dhawan A.
      Recurrent instability after arthroscopic Bankart reconstruction: A systematic review of surgical technical factors.
      analyzed the technical issues associated with anchors in a systematic review of recurrence after arthroscopic stabilization. Although there was a tendency to favor using an increased number of anchors, nonabsorbable anchors, and knotted anchors, the review presented no significant historical differences in the risk of recurrent instability after arthroscopic Bankart reconstruction.
      Competitive athletes are a particularly challenging and demanding patient population. Nakagawa et al.
      • Nakagawa S.
      • Mae T.
      • Sato S.
      • Okimura S.
      • Kuroda M.
      Risk Factors for the postoperative recurrence of instability after arthroscopic Bankart repair in athletes.
      performed a cohort study that showed an increased risk of recurrence in this group if the athlete was <20 years old or had a glenoid bone injury. The concern of reduced external rotation in this patient group might be the reason most surgeons opt to perform a Latarjet rather than combining arthroscopic Bankart with a remplissage.
      Glenoid bone loss, in addition to age, is paramount to consider when choosing a stabilization procedure. It is not easy to measure the amount of humeral bone loss preoperatively.
      • Bakshi N.K.
      • Patel I.
      • Jacobson J.A.
      • Debski R.E.
      • Sekiya J.K.
      Comparison of 3-dimensional computed tomography-based measurement of glenoid bone loss with arthroscopic defect size estimation in patients with anterior shoulder instability.
      In contrast to measuring Hill–Sachs lesions, there are good inter- and intraobserver reliabilities for measuring the size of glenoid bone loss on 3-dimensional computed tomography scan. In our respective practices, we use computed tomography scans liberally preoperatively in those with risk factors such as bone loss on x-ray and magnetic resonance imaging, numerous recurrences, long history (time) of recurrence since first instability event, and a history of progressive ease of dislocation. This change in practice has led to an increased number of open, and specifically Latarjet, procedures. However, there is still no consensus on how many and what risk factors are important to consider for procedure choice.
      In the end, the choice of instability repair is still open to debate. Until we can get more prospective evidence that delineates the importance of patient history, examination, and radiographic parameters, it is going to be difficult to truly ascertain what procedure is correct for every patient. Personal and training bias is clearly evident in our world and is magnified in the treatment of shoulder instability, as high-end evidence is still lacking to guide our procedural decision making. It is true that some surgeons, to reduce recurrences, would perform a Latarjet on every patient they encounter with recurrent anterior instability; however, this would not be common practice worldwide. Certainly arthroscopic Bankart, as shown by Bishop et al.,
      • Bishop J.Y.
      • Hidden K.A.
      • Jones G.L.
      • Hettrich C.M.
      • Wolf B.R.
      MOON Shoulder Group
      Factors influencing surgeon’s choice of procedure for anterior shoulder instability: A multicenter prospective cohort study.
      remains the workhorse for the vast majority of our worldwide anterior instability procedures. However, our personal and training biases continue to confound our decision making, and until we have additional evidence, it will still be a challenge to delineate the best patient-specific procedure for recurrent anterior shoulder instability.

      Supplementary Data

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