Summary

Labral augmentation by using a by using a porcine dermal collagen matrix was proved to be a viable option to address labral reconstruction when labral deficiency is encountered as a main problem in the setting of subcritical bone defects in traumatic recurrent anterior glenohumeral instability

Abstract

Background

In the setting of subcritical bone loss, soft-tissue procedures are sometimes inadequate to prevent recurrent instability after surgery. Especially in long-lasting recurrent instability, poor tissue quality does not allow re-creation of a strong anterior soft-tissue restraint. The purpose of the present study was to assess efficacy of labral augmentation by biologic scaffolding in the treatment of traumatic recurrent anterior shoulder instability.

Methods

A retrospective study on consecutive cases was conducted. All patients with a history of recurrent anterior shoulder instability were considered eligible for the study. All the eligible patients underwent a standard x-ray protocol (true anteroposterior and axillary view), besides a computed tomography (CT) scan to rule out critical bone defects and a magnetic resonance imaging (MRI) to check out soft tissue lesions. As thorough appraisal of the capsule-labral complex quality could not be done by means of imaging tools, final decision about the enrollment was taken during arthroscopy. Inclusion criteria were: history of recurrent unilateral anterior shoulder instability, age older than 18, and intraoperative finding of hypoplastic/insufficient glenoid labrum. Exclusion criteria were: contact or collision sports activity, anterior glenoid bone loss exceeding 20% of the inferior glenoid area, bilateral instability, posterior/multidirectional instability, bony Bankart, presence of an engaging Hill-Sachs lesion as assessed during surgery, concomitant injuries to the biceps tendon (SLAP lesions), HAGL or reverse-HAGL lesions, posterior labral tears, associated rotator cuff tears, previous surgery to the same shoulder, infections, and neurologic disorders. All patients underwent an arthroscopic labral augmentation by using a porcine dermal collagen matrix rolled-up to obtain a cylindrical scaffold about 5-mm thick, perfectly fitting the length of the labral lesion. Bilateral postoperative MRI were performed at 6 months follow-up. Clinical follow-up was performed at minimum 2 years after surgery. Primary outcome was the recurrence of the glenohumeral instability. Secondary outcomes were functional assessment by Rowe score, and subjective assessment by short version of Disabilities of the Arm, Shoulder and Hand (Quick-DASH), and Western Ontario Shoulder Instability (WOSI) questionnaires. Also scaffold integrity and integration with surrounding tissue was assessed on postoperative MRI exams. Pre- and postoperative outcomes were compared with a two-way paired t-test for normally distributed data, otherwise the Wilcoxon signed-rank test was used. Significance was set at p < 0.05.

Results

Twenty consecutive patients were enrolled. The mean age was 27.4 ± 5.9 years (range: 19-38 years). Mean follow up was 38.7 + 3 months (range: 36-46 months). Only one patient (5%) reported recurrent anterior instability. Pre- and postoperative clinical outcomes showed significant improvements (p< 0.0001). Mean Rowe score changed from 15 + 6.5 to 90.7 + 6.3; mean DASH score changed from 56.8 + 10.8 to 13.7 + 5.7; mean WOSI changed from 1609 + 217 to 271 + 97. MRIs showed no differences between morphological labral augmentation characteristics and the contralateral unaffected labrum (p<0.26).

Conclusion

Labral augmentation by using a biologic scaffold is a viable option to address labral reconstruction when labral deficiency is encountered as a main problem in the setting of traumatic recurrent anterior glenohumeral instability.