Patient, surgical factors may impact failure, outcomes after shoulder instability surgery
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Key takeaways:
- Surgeons should consider including a sports psychologist in their return to play protocols.
- Physical exam is important to identify large Hill-Sachs lesions and other predictors of bone loss.
KOLOA, Hawaii — Launched in 2011, the Multicenter Orthopedic Outcomes Network Shoulder Instability Group, also known as the MOON study group, aimed to determine predictors of failure and poor outcomes after surgery for shoulder instability.
In her presentation at Orthopedics Today Hawaii, Julie Y. Bishop, MD, said that by reviewing data from the MOON study group, she identified five areas impacting orthopedic practice. One area includes mental health and how psychological measures impact patient outcomes.
By reviewing 2-year baseline predictors of the Western Ontario Shoulder Instability Index, the American Shoulder and Elbow Surgeons score and the single assessment numeric evaluation score, Bishop said younger patient age, revision surgery, smoking, visual instability and higher scores on the personality assessment screener (PAS) were predictors of poor patient-reported outcomes (PROs).
“The strongest predictor of poor PROs was the PAS. And this is a validated questionnaire, 22 questions, and it is to access the potential for a patient’s emotional and behavioral problems to have a clinical significance,” Bishop said.
According to Bishop, surgeons should be aware that “there is more to return to play and outcomes than just the technical aspect.” She added that surgeons should consider including a sports psychologist in their return to play protocols and look at a patient’s grit, resilience and non-physical factors in addition to the physical exam.
Glenoid bone loss
Bishop said patients with multiple dislocations had more glenoid bone loss on preoperative imaging, leading to bony Bankart lesions and biceps pathology. When looking at the incidence of bone and cartilage lesions at the time of stabilization surgery, Bishop said there was a 23% rate of bone and cartilage lesions among 550 patients, with a rate of 20% among primary surgeries and a rate of 47.6% among revision surgeries.
“I think this supports strong consideration for operating on the first-time dislocator,” she said. “There is definitely clear data that more dislocations lead to more damage and more extensive surgery.”
In terms of surgical position, Bishop said surgeons who perform surgery with the patient in the lateral decubitus position reported longer labral tear length, more extension into the inferior quadrant and more anchors in the inferior quadrant.
“I think there is increasing expert opinion that we need to have more fixation inferiorly. We do not know yet the impact on outcomes, and this remains to be seen as we are analyzing all of this data,” Bishop said.
Disparities, predictors of bone loss
Racial disparities also existed among patients undergoing shoulder instability surgery, with significantly more dislocations, articular cartilage lesions, glenoid bone loss, Hill-Sachs lesions and bony augmentation among historically underrepresented groups, according to Bishop.
“Know this disparity exists and have more informed discussions with the patient and families,” she said. “Early surgery leads to less damage and better results, but be engaged with the athletic trainers at the high schools, colleges [and] sports teams that you cover. If you are covering a high school game, find the parents, talk to them [and] engage all stakeholders in the care of these athletes.”
Finally, Bishop said predictors of bone loss of more than 10% and combined defects of 20% included patient age, race and number of dislocations. She added predictors for any Hill-Sachs lesions and large Hill-Sachs lesions included patient age, race, number of dislocations and higher degrees of apprehension.
“Physical exam does matter,” Bishop said. “The more apprehension when you externally rotate with the arm in by the side is reflective of a larger Hill-Sachs.”
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Bishop JY. Top 5 changes to your approach to instability patients supported by the MOON study group. Presented at: Orthopedics Today Hawaii; Jan. 12-16, 2025; Koloa, Hawaii.
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