Myself, I'd like to thank AOSSM and Anna for allowing us to present our findings. So our disclosure is available on the Academy website, but do not pertain to this research. So adolescents, as we all know, are at high risk for recurrent instability following arthroscopic bank art repair, with numerous authors citing failure rates of 10 to 47%. Glenoid bone loss is a very well-established risk factor for recurrent instability. However, humeral bone loss, secondary to a Hill-Sax defect, has gained increasing attention as a potential contributor to recurrent instability. The off-track concept describes the interaction between the humeral and glenoid bone loss, and may better describe the dynamic interactions that contribute to instability, with some authors reporting a higher incidence of off-track lesions in adolescents as compared to adults. Below describe six preoperative risk factors that increase the risk for recurrent instability following primary arthroscopic stabilization. These risk factors are then compiled into a score, and this helps to shed some light on the high rates of recurrent instability among adolescents, as at baseline, their age and activity level generates at least a score of five. In an effort to better describe the dynamic interactions between humeral and glenoid bone loss, Burkhardt and colleagues described the on- and off-track concept, in which they used a modeling study to show how Hill-Sax defect engages in the glenoid bone loss. And for these off-track lesions, they made treatment recommendations. The purpose of our study was to evaluate the outcomes of adolescent traumatic unidirectional anterior shoulder instability that was treated with arthroscopic Bankart repair, and assess for clinical and radiographic predictors of failure. And our primary research question was, does the presence of an off-track lesion in an adolescent patient predict failure with arthroscopic Bankart repair at minimum two-year follow-up? We included all patients under the age of 19 years of age, treated with arthroscopic anterior labral repair. All patients had a preoperative MRI and minimum two-year follow-up. We looked at demographic and preoperative characteristics, as you can see listed here, and our primary outcomes were two. One, revision instability for recurrent, revision surgery, excuse me, for recurrent instability, and then the second, patients with subjective instability who did not undergo revision surgery. We collected patient-reported outcome scores, including PASS and SANE scores, and Tegner score, both pre-op, the highest post-op, and then current at last follow-up. We performed an extensive radiographic assessment, looking at glenoid track, hill-sex depth, hill-sex interval, and the IAAA, and you can see all of those measurements demonstrated here, with a total of three independent observers measured at two time points to generate good to excellent intra- and inter-rater reliabilities. Our patient cohort consisted of 59 total patients, the majority being male, with a median age of 16 years. 71% played contact sports, most commonly being football, and among our adolescent cohort, age, gender, and contact sports did not predict revision or recurrent instability. A total of 10 patients, or 17%, had revision surgery for recurrent instability, while another eight patients had subjective instability, but had not undergone further surgery. Upon radiographic analysis, glenoid diameter was the only radiographic variable, which was significantly different between revision instability cohort and the no revision or instability cohort. However, based on the small difference in size between groups, we're unsure of this clinical significance. A total of five patients, or 8.5%, measured as off-track, with a hill-sex interval to glenoid track ratio greater than one, and this was not associated in our cohort with an increased risk of revision or instability. We then performed a subgroup analysis of the 38 patients who had a hill-sex defect, and this was about 65% of our entire cohort. We found similar rates of revision surgery and subjective instability among these patients. However, when we look specifically at the hill-sex interval and hill-sex depth shown on these axial MRI sequences, those patients who underwent revision surgery had significantly increased hill-sex intervals and depth as compared to those with subjective instability, as well as those without revision surgery or subjective instability. And among those patients with a hill-sex interval greater than or equal to 15 millimeters, 50% of these patients had subsequent revision surgery and subjective instability. Patient-reported outcome measures, as you can imagine, were significantly lower in those with revision or instability, and there was a trend towards decreased rates of return to sport among those patients with revision surgery instability, although this did not reach statistical significance. In conclusion, the treatment of adolescent shoulder instability is fraught with high rates of recurrent instability, as well as revision surgery, which together were approximately 31% in our study, and this was associated with inferior patient-reported outcome measures. Off-track lesions, however, were only identified in 8.5% of our patients, and were not an independent risk factor for recurrent instability, and other authors have shown similar findings. Among patients with a hill-sex defect, however, greater hill-sex interval and depth was associated with revision surgery. We feel that the results of this study suggest there should be a shift in the treatment of adolescent unidirectional anterior shoulder instability. While off-track lesions are certainly a clear indication for the addition of remplisage with or without glenoid augmentation, perhaps the on-track lesion with an increased hill-sex interval and depth may also warrant these additional procedures among our adolescent patients who are already at a higher risk for failure, and further studies will be necessary to evaluate the effect on remplisage or glenoid augmentation in this population on outcomes. Thank you.

arthroscopic Bankart repair

adolescents

traumatic anterior shoulder instability

off-track lesion

Hill-Sachs defect