Good morning. My name is Stephanie Bowden. I'm an orthopedic surgery resident at UPMC in Pittsburgh. I'd like to thank my co-authors, the Academy, AOSSM, and SACOS for allowing us to present our work. Disclosures can be found on the Academy app. Recurrent anterior shoulder instability after arthroscopic bankart repair presents a challenging clinical problem. Numerous studies have identified risk factors for failure after arthroscopic bankart repair including younger age, male sex, increased generalized and shoulder laxity, critical and subcritical bone loss, participation in contact sports, and less than three anchors used for repair. We've all become familiar with the concept of the glenoid track and there is no question that a persistent off-track lesion following stabilization is a significant risk factor for failure. Recent studies have shown that the glenoid track should be considered more dynamically rather than the traditional binary on versus off-track concept as a subset of on-track lesions may be at increased risk for failure after arthroscopic bankart repair alone. Distance to dislocation is a newer concept that calculates the difference between the glenoid track and the health sex interval. On-track lesions are those with a DTD greater than zero and near track lesions are those with a DTD between less than eight to ten millimeters. This measurement has been found to have good and excellent in turn intra-rater reliability. Near-track lesions are an increased risk of failure after arthroscopic bankart repair alone. While the glenoid track concept continues to evolve, it may remain limited and that it relies on bony anatomy without consideration of capsule ligamentous integrity or the effect that capsular laxity may have on the glenohumeral contact points throughout the shoulder range of motion. The purpose of our study was to determine if capsule ligamentous laxity affects failure after arthroscopic bankart repair and patients with a smaller distance to dislocation or near track lesions. We hypothesize that patients with capsule ligamentous laxity or hyper laxity would be at an increased risk of recurrent instability following arthroscopic bankart repair alone. This was a single institution retrospective review of prospectively collected data from all patients who underwent primary arthroscopic bankart repair alone for anterior shoulder instability between 2007 and 2019. Patients were included if they had clinical and intraoperative findings consistent with anterior instability and documentation of shoulder examination under anesthesia. Patients were excluded if their surgery was a revision stabilization procedure, if they had a concomitant remplissage, less than three anchors used in repair, over 20% glenoid bone loss, or less than two years of clinical follow-up. Capsule ligamentous shoulder laxity or hyper laxity was defined as external rotation greater than 85 degrees or greater than two plus load and shift in two or more planes. Measurements of glenoid bone loss, helix interval and glenoid track were performed based on prior described methods. Distance to dislocation was calculated as previously described. Near-track lesions were defined as on-track lesions with a distance to dislocation of less than 10 millimeters. 173 patients with a mean age of 20.5 years and a mean follow-up of 7.4 years were included in analysis. There were no significant differences in baseline characteristics between patients who had hyper laxity and normal laxity at time of surgery, except those with hyper laxity were less often contact athletes and had more anchors used in repair. Overall 23.1% of patients had recurrent subjective instability with 16.8% having a recurrent frank dislocation and 6.4% reporting recurrent instability without a frank dislocation. 15.6% of patients underwent subsequent revision stabilization. A multivariate analysis, younger age and smaller distance to dislocation, hyper laxity and greater than one instability episode pre-op were found to be independently predictive of recurrent instability. When stratified by distance to dislocation, laxity status and bone loss, patients with hyper laxity and near-track lesions had the highest risk of failure with a 34-fold increased risk of failure and a failure rate of 60%. Near-track lesions in patients with hyper laxity was significantly predictive of failure with an area under the curve of 0.91. The risk of failure remained elevated at 50% even in patients with no glenoid bone loss. The major finding in this study is that shoulder capsule ligamentous laxity at the time of exam under anesthesia is independently predictive of recurrent instability after arthroscopic bankart repair alone for primary anterior glenohumeral instability with a 4.37 increased odds of failure. This effect is magnified in patients with near-track lesions with a 34-fold increased likelihood of failure in this high-risk patient population. In patients with near-track lesions and hyper laxity a 60% failure rate was found with high failure rates even in patients with no glenoid bone loss. While our study is not the first to identify capsule ligamentous shoulder laxity as a risk factor for failure after arthroscopic bankart repair alone, it is the first to quantify the significant increased odds of failure in patients with shoulder hyper laxity at time of EUA and the first to suggest that this is even more critical in patients with a smaller distance to dislocation. As our understanding of the glenoid track continues to evolve, surgeons may need to consider the glenoid track more as a continuum with evolving surgical algorithms other than an arthroscopic bankart repair alone, particularly in patients with near-track lesions and capsule ligamentous shoulder hyper laxity. Future studies should evaluate if the addition of a ronplasage can mitigate the effects of hyper laxity in patients with near-track lesions and additionally studies should try to examine if the glenoid track can be measured more dynamically preoperatively in order to identify and help direct appropriate surgical management in these high-risk patient population. Thank you.

recurrent anterior shoulder instability

arthroscopic bankart repair

risk factors

glenoid track concept

capsule ligamentous laxity