Thank you. Thank you all for your time and attention and sticking with us through Sunday and also I'm sort of pinch hitting for Dr. Smart here so she gets the credit for putting most of this together and doing the lion's share of the work for this study. Disclosure is available online, not relevant to this talk. So she sort of laid the background for you in her talk already. The main take home here, shoulder dislocations in older patients are probably a little bit more frequent than most of us would anticipate as 20% of all first time shoulder dislocations actually occur in patients over the age of 60. As we all know these can result in substantial morbidity to these patients. Anterior inferior glenoid rim fractures also known as bony Bankart lesions are common, typically associated with traumatic anterior instability. Fractures likely occur due to the weak and osteoporotic bone and they may play a role in shoulder stability and or stiffness. Their impact on recurrent instability is not as well studied as labor injuries in younger athletes as most of our research efforts have focused on these younger patients. So the purpose of this study was to describe the incidence of glenoid rim fractures in anterior instability patients who are over the age of 50 at the time of their first dislocation, to compare treatment strategies and clinical outcomes of patients with and without an associated rim fracture, and to identify risk factors for progression to surgical management for their glenoid rim fracture. So as Dr. Smart outlined we used the Rochester epidemiology database and essentially what we did was we took the larger epidemiologic study that she started with and then we pulled out the glenoid rim fractures to look at them in greater detail for this study. Just to add a little bit of clarity to what the rep actually is. So it's essentially a collaboration and a combined medical record system for all of the residents that live in southeastern Minnesota. It initially started in Olmstead County but it spread out across Minnesota and Wisconsin. So these are people who are residents of these areas, not patients who are referred in from outside. So these are all people who are local to our area, not those that are traveling for their medical care. So we queried the database using ICD-9 diagnosis codes. One of the strengths of the epidemiology project is that it then allows us to actually go into the medical record and review documentation, notes, operative reports, and et cetera to confirm everything. So we identified all patients over 50 with anterior shoulder instability from 1994-2016. We then manually reviewed all the charts to identify patients who met our inclusion and exclusion criteria. They were included if they had one or more instability events and that first event had to be after the age of 50 and we wanted a minimum of two year clinical and radiographic follow-up. They were excluded if they were less than 50 at the time of their first instability event, if they had posterior or multidirectional instability. We then identified all patients who had the rim fractures and then we matched them one-to-one with anterior instability patients who did not have a glenoid rim fracture and then performed a comparative analysis between the two groups. So of the total study cohort, as Dr. Smart just presented, 23 patients out of all of our instability cohort had an anterior glenoid rim fracture at the time of their initial presentation. So that tells us the overall frequency of these bony baycart lesions in this patient population is roughly one in four. So then this is the glenoid rim fracture group matched to our controls. There was really no significant differences between the two based on our matching. So we were able to match them based on age, sex, BMI, their occupation, and some medical comorbidities. The main differences between the two groups in terms of their imaging, there was a significantly higher rate of hill sex lesions in the patients with the glenoid rim fractures, which makes sense, but a lower rate of rotator cuff tears. So we sort of think about this as that the energy exits somewhere and it may go through the glenoid and result in a fracture or if not, the rotator cuff is probably at a greater risk. In terms of treatment, overall there was no significant difference in treatment strategies between the two in terms of how many had surgery, what types of surgeries were used, et cetera. Twenty-nine percent of the patients with a glenoid rim fracture did undergo surgery. The one thing that trended towards significance here was obviously there was more rotator cuff pathology in the controls. So that trended towards significance but didn't reach significance likely due to our small sample size. So a few numbers to remember, about a fourth of patients get a glenoid rim fracture and of those about a third required surgery or 29%. And then we looked to see what were the greatest risk factors that predict progression to surgical intervention and as you would expect, fragment size was the most common. So a fragment size that was greater than 33% of the glenoid increased the risk for needing surgery and a BMI greater than 30. Don't know exactly why that is but maybe that's a relatively higher energy injury and may result in a larger fragment size or more damage to the shoulder. In terms of outcomes, there was no difference between the two groups in terms of rate of recurrent instability, ability to return to work, progression of osteoarthritis which was surprising to us or revision surgery. There was higher pain in the control cohort which may be secondary to those rotator cuff tears that those patients had. So obvious limitations here, retrospective review, large sample size overall but still a relatively small number that actually had glenoid rim fractures. So we were underpowered for some of the subgroup analyses that we wanted to do and obviously there's a potential for sampling bias in this. So a few take home points, 23% or roughly one quarter of all patients over 50 with a first time shoulder instability event present with a glenoid rim fracture. Most of them did not require surgery. So again, 71% did not need surgery, only about 30% actually needed surgery. And then the two main risk factors to suggest progression to surgery would be a fragment size that's larger than 33% of the glenoid width or BMI greater than 30. And in patients without glenoid rim fractures were more likely to have pain but overall the presence of a glenoid rim fracture did not pretend a worse prognosis on all the other outcome measures that we looked at in the study. Thank you very much.

shoulder dislocations

older patients

glenoid rim fractures

morbidity

surgical management