Abstract
Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability. Methods: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results: The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors. Conclusion: Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization. Level of Evidence: Level V, expert opinion.
| Original language | English |
|---|---|
| Pages (from-to) | 214-223.e7 |
| Journal | Arthroscopy - Journal of Arthroscopic and Related Surgery |
| Volume | 38 |
| Issue number | 2 |
| DOIs | |
| Publication status | Published - Feb 2022 |
Bibliographical note
Publisher Copyright:© 2021 Arthroscopy Association of North America
Funding
The authors report the following potential conflicts of interest or sources of funding: I.W. reports grants from Aesculap, Arthrex, and Linvatec and personal fees from Smith & Nephew, outside the submitted work. L.N. reports grants from Tornier and personal fees from Arthrex and Tornier, outside the submitted work. G.A. reports personal fees from ConMed and Exactech, and other from Wright Medical, outside the submitted work. H.M. reports personal fees from ConMed and DJO, outside the submitted work. L.J. reports grants from Arthrex, Mitek, and Smith & Nephew, outside the submitted work. E.S. reports grants from Arthrex, Cartiheal, Fidia, and Organogenesis; personal fess from Arthrex, Fidia, Flexion Therapeutics, JRF, Organogenesis, Smith & Nephew, and Subchondral Solutions; and other from Better PT, outside the submitted work. M.A. reports grants from Concours, personal fees from Mitek, outside the submitted work. R.A.A. reports grants from Arthrex and DJO, personal fees from Smith & Nephew, and other from Biorez, outside the submitted work. A.B. reports personal fees and other from Arthrex, outside the submitted work. E.C. reports grants and personal fees from Depuy and Smith & Nephew and personal fees from Stryker and Wright Medical, outside the submitted work. K.C. reports grants and personal fees from Mitek and Samumed, and personal fees from Stryker, outside the submitted work. B.C. reports grants from Aesculap, Arthrex, and Regentis, personal fees from Arthrex, Regentis, and Samumed, and other from Arthrex, Athletico, Bandgrip, JRF, Ossio, Regentis, and Smith & Nephew, outside the submitted work. P.C. reports personal fees and other from Arthrex and other from Wright, outside the submitted work. F.C. reports personal fees and other from Arthrex, outside the submitted work. B.E. reports grants from Arthrex, DePuy, Linvatec, Smith & Nephew, and Stryker, and personal fees from Arthrex, outside the submitted work. L.F. reports personal fees from Tornier and Wright and other from Wright, outside the submitted work. R.F. reports grants from Arthrex and Smith & Nephew and personal fees from Allosource, Arthrex, JRF, and Ossur, outside the submitted work. L.F. reports grants from Smith & Nephew and personal fees from Arthrex and Smith & Nephew, outside the submitted work. G.G. reports personal fees from Additive Orthopaedics, DJO, Tornier, and Mitek and other from Arthrex, CultivateMD, DJO, Genesys, Patient IQ, ROM 3, SouthTech, and Tornier outside the submitted work. G.D. reports personal fees from Wright, outside the submitted work. P.H. reports personal fees from Arthrex, outside the submitted work. A.I. reports grants from Arthrex, personal fees from Arthrosurface, and other from Arthrex and Arthrosurface, outside the submitted work. J.K. reports personal fees from Flexion, outside the submitted work. A.K. reports grants from Aesculap, Arthrex, Arthritis Foundation, Ceterix, and Histogenics; personal fees from Arthrex, JRF, and Vericel; and other from Arthrex, outside the submitted work. M.K. reports grants from Aesculap, Arthritis Foundation, Ceterix, and Histogenics; and personal fees and other from JRF, Vericel, and Arthrex, outside the submitted work. Y.K. reports personal fees from DJO, outside the submitted work. W.L. reports nonfinancial support from Zimmer, outside the submitted work. A.M. reports grants and personal fees from Arthrex, outside the submitted work. P.M. reports grants from Arthrex, ConMed, Ossur, and Zimmer, outside the submitted work. E.M. reports grants from Arthrex, Biomet, Breg, DJO, Mitek, Ossur, and Smith & Nephew and other from Zimmer, outside the submitted work. R.M. reports grants from Arthrex, ConMed, Mitek, and Stryker, outside the submitted work. P.M reports grants from Arthrex, Ossur, Siemens, and Smith & Nephew; personal fees from Arthrex; and other from MedBridge, Arthrex, and VuMedi, outside the submitted work. P.M. reports grants from Arthrex, personal fees from Arthrex and Mitek; and other from Arthrex and NCS Lab, outside the submitted work. M.S. reports grants from Arthrex, ConMed, Linvatec, and Wright; personal fees from Arthrex, ConMed, DJO, Exactech, and Wright; and other from Arthrex and Wright, outside the submitted work. N.V. reports grants from Arthrex, Breg, Ossur, Smith & Nephew, and Wright; personal fees from Mininvasive and Orthospace; and other from Cymedica, Omeros, and Smith & Nephew, outside the submitted work. M.V. reports personal fees from Acumed and Exactech, outside the submitted work. G.W. reports personal fees from Wright, outside the submitted work. R.W. reports other from Orthonet, outside the submitted work. B.W. reports grants from Arthrex; personal fees from FH Ortho and Vericel; nonfinancial support from Kaliber AI and Sparta Science; and other from Sparta Science and Vivorte, outside the submitted work. J.Z. reports personal fees from MTF and other from Apos Therapy, Exactech, and Hip Innovation Technology, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material . The Anterior Shoulder Instability International Consensus Group includes Michael J. Alaia, Robert A. Arciero, Asheesh Bedi, Robert H. Brophy, Emilio Calvo, Kirk A. Campbell, Cordelia W. Carter, J Tristan Cassidy, Michael G. Ciccotti, Brian J. Cole, Philippe Collin, Frank A. Cordasco, Sara E. Edwards, Brandon J. Erickson, Luc Favard, Rachel M. Frank, Lennard Funk, Grant E. Garrigues, Giovanni Di Giacomo, Guillem Gonzalez-Lomas, Philipp R. Heuberer, Andreas B. Imhoff, John D. Kelly, Moin Khan, Aaron J. Krych, John E Kuhn, Young M. Kwon, Alexandre L?dermann, William N. Levine, Darren Lim Fat, Augustus D. Mazzocca, Peter B. MacDonald, Eric C. McCarty, Robert J. Meislin, Peter J. Millett, Diarmuid C. Molony, Cathal J. Moran, Philipp Moroder, Daniel Moya, Kieran O'Shea, Brett D. Owens, Matthew T. Provencher, Yong Girl Rhee, Scott A. Rodeo, Andrew S. Rokito, Claudio Rosso, Markus Scheibel, Nikhil N. Verma, Mandeep S. Virk, Gilles Walch, Russell F. Warren, Brian R. Waterman, Daniel B. Whelan, and Joseph D. Zuckerman. The authors report the following potential conflicts of interest or sources of funding: I.W. reports grants from Aesculap, Arthrex, and Linvatec and personal fees from Smith & Nephew, outside the submitted work. L.N. reports grants from Tornier and personal fees from Arthrex and Tornier, outside the submitted work. G.A. reports personal fees from ConMed and Exactech, and other from Wright Medical, outside the submitted work. H.M. reports personal fees from ConMed and DJO, outside the submitted work. L.J. reports grants from Arthrex, Mitek, and Smith & Nephew, outside the submitted work. E.S. reports grants from Arthrex, Cartiheal, Fidia, and Organogenesis; personal fess from Arthrex, Fidia, Flexion Therapeutics, JRF, Organogenesis, Smith & Nephew, and Subchondral Solutions; and other from Better PT, outside the submitted work. M.A. reports grants from Concours, personal fees from Mitek, outside the submitted work. R.A.A. reports grants from Arthrex and DJO, personal fees from Smith & Nephew, and other from Biorez, outside the submitted work. A.B. reports personal fees and other from Arthrex, outside the submitted work. E.C. reports grants and personal fees from Depuy and Smith & Nephew and personal fees from Stryker and Wright Medical, outside the submitted work. K.C. reports grants and personal fees from Mitek and Samumed, and personal fees from Stryker, outside the submitted work. B.C. reports grants from Aesculap, Arthrex, and Regentis, personal fees from Arthrex, Regentis, and Samumed, and other from Arthrex, Athletico, Bandgrip, JRF, Ossio, Regentis, and Smith & Nephew, outside the submitted work. P.C. reports personal fees and other from Arthrex and other from Wright, outside the submitted work. F.C. reports personal fees and other from Arthrex, outside the submitted work. B.E. reports grants from Arthrex, DePuy, Linvatec, Smith & Nephew, and Stryker, and personal fees from Arthrex, outside the submitted work. L.F. reports personal fees from Tornier and Wright and other from Wright, outside the submitted work. R.F. reports grants from Arthrex and Smith & Nephew and personal fees from Allosource, Arthrex, JRF, and Ossur, outside the submitted work. L.F. reports grants from Smith & Nephew and personal fees from Arthrex and Smith & Nephew, outside the submitted work. G.G. reports personal fees from Additive Orthopaedics, DJO, Tornier, and Mitek and other from Arthrex, CultivateMD, DJO, Genesys, Patient IQ, ROM 3, SouthTech, and Tornier outside the submitted work. G.D. reports personal fees from Wright, outside the submitted work. P.H. reports personal fees from Arthrex, outside the submitted work. A.I. reports grants from Arthrex, personal fees from Arthrosurface, and other from Arthrex and Arthrosurface, outside the submitted work. J.K. reports personal fees from Flexion, outside the submitted work. A.K. reports grants from Aesculap, Arthrex, Arthritis Foundation, Ceterix, and Histogenics; personal fees from Arthrex, JRF, and Vericel; and other from Arthrex, outside the submitted work. M.K. reports grants from Aesculap, Arthritis Foundation, Ceterix, and Histogenics; and personal fees and other from JRF, Vericel, and Arthrex, outside the submitted work. Y.K. reports personal fees from DJO, outside the submitted work. W.L. reports nonfinancial support from Zimmer, outside the submitted work. A.M. reports grants and personal fees from Arthrex, outside the submitted work. P.M. reports grants from Arthrex, ConMed, Ossur, and Zimmer, outside the submitted work. E.M. reports grants from Arthrex, Biomet, Breg, DJO, Mitek, Ossur, and Smith & Nephew and other from Zimmer, outside the submitted work. R.M. reports grants from Arthrex, ConMed, Mitek, and Stryker, outside the submitted work. P.M reports grants from Arthrex, Ossur, Siemens, and Smith & Nephew; personal fees from Arthrex; and other from MedBridge, Arthrex, and VuMedi, outside the submitted work. P.M. reports grants from Arthrex, personal fees from Arthrex and Mitek; and other from Arthrex and NCS Lab, outside the submitted work. M.S. reports grants from Arthrex, ConMed, Linvatec, and Wright; personal fees from Arthrex, ConMed, DJO, Exactech, and Wright; and other from Arthrex and Wright, outside the submitted work. N.V. reports grants from Arthrex, Breg, Ossur, Smith & Nephew, and Wright; personal fees from Mininvasive and Orthospace; and other from Cymedica, Omeros, and Smith & Nephew, outside the submitted work. M.V. reports personal fees from Acumed and Exactech, outside the submitted work. G.W. reports personal fees from Wright, outside the submitted work. R.W. reports other from Orthonet, outside the submitted work. B.W. reports grants from Arthrex; personal fees from FH Ortho and Vericel; nonfinancial support from Kaliber AI and Sparta Science; and other from Sparta Science and Vivorte, outside the submitted work. J.Z. reports personal fees from MTF and other from Apos Therapy, Exactech, and Hip Innovation Technology, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
| Funders | Funder number |
|---|---|
| Arthrex and Arthrosurface | |
| Arthrex and Mitek | |
| Arthrex and Smith & Nephew | |
| Ceterix | |
| CultivateMD | |
| Cymedica | |
| Flexion Therapeutics | |
| Joseph D. Zuckerman | |
| MedBridge | |
| Mitek | |
| Omeros | |
| Smith & Nephew | |
| Sparta Science and Vivorte | |
| Tornier | |
| Vericel | |
| Wright Medical | |
| Arthritis Foundation | |
| Arthrex | |
| Kreftforeningen | |
| Joseph Rowntree Foundation | |
| Fidia Farmaceutici |
ASJC Scopus Subject Areas
- Orthopedics and Sports Medicine