Purpose
To evaluate whether complex glenoid labral tears (i.e., those involving >120°of the glenoid labrum) are related to demographics, injury patterns, and surgical procedures/timing in patients undergoing primary arthroscopic labral repair.
Methods
This retrospective chart review included patients with traumatic shoulder instability who underwent primary arthroscopic labral repair between 2012 and 2020. Patients with atraumatic multidirectional instability, clinical ligamentous laxity, or previous shoulder surgeries were excluded. Variables analyzed included age, sex, body mass index, contact sports participation, number of dislocations (<1, 1, 2, >2), direction of instability, labral tear size, time to surgery, number of anchors, and concomitant procedures. Complex labral tears involved >120° of the glenoid rim. Cohorts of “simple” anterior or posterior tears (<120°) were used for comparison. Statistical analyses used t tests, Mann-Whitney U , χ 2, and the Fisher exact tests with a significance level of 0.05 and Bonferroni correction at 0.002.
Results
In total, 477 patients (364 simple labral tear patients– 280 anterior and 84 posterior; 113 complex labral tear patients) met inclusion criteria (mean age: 27 years; range: 14-72 years). In all tear size groups, it was more common to have >2 dislocations than ≤2 dislocations (120° = 48.6%, 240° = 40.4%, 360° = 83.3%), but these differences were not statistically significant ( P =.067). Time from first injury/instability event to surgery (in months) was not a predictor of tear size (simple = 45 ± 70 months, complex = 38 ± 67 months). There was no statistical difference between tear size groups and patient demographics in sex, contact sport participation, tobacco use, instability direction (anterior versus posterior), body mass index, age, or association of concomitant procedures. The number of anchors used was the only variable found to correlate with tear size ( P <.001).
Conclusions
Complex glenoid labral tears did not correlate with the number of preoperative instability events, direction of instability, time to surgery, or previously cited factors such as contact sports or BMI in patients arthroscopically treated for shoulder instability.
Level of Evidence
Level III, retrospective comparative cohort.
Shoulder instability remains among the most common injuries to the shoulder girdle. Inciting shoulder instability injuries occur along a spectrum but are largely categorized into dislocations and subluxations with varying degrees of severity. Shoulder dislocations, specifically, account for approximately 50% of all joint dislocations, making them the most commonly dislocated joint in the body. ,,,, The estimated lifetime incidence rate of shoulder dislocation is nearly 24 per 100,000 person-years in the United States. , Of these, anterior dislocations are more common (>95% of all dislocations) than posterior dislocations. ,,,,,,,, After a dislocation or subluxation event, injury patterns and patient demographics substantially influence treatment protocols and serve as predictors of recurrent instability. For example, labral pathologies—namely, Bankart and Bankart variant lesions—are the most common injuries associated with shoulder instability and are considered the most important causes of recurrent instability. ,, The risk factors for recurrence and failure of operative intervention have been extensively studied in shoulder instability cohorts. These have included young age, male sex, contact athletes, the presence of humeral or glenoid bone loss, and <4 anchors used for repair, among others. ,,,,,,,, Some of these risk factors also have been shown to correlate with larger (>270°) glenoid labral tears. Notably, although labral tear size is one of the most critical considerations for surgical planning, it is not reliably predicted with clinical and radiographic findings. ,,,
Inability to reliably characterize labral tear size is one of several factors convoluting the optimal approach to a patient with shoulder instability. These other factors include potentially unsatisfactory outcomes of conservative treatment, rates of recurrence despite surgical repair, and lack of appropriate dissemination and implementation of evidence-based medicine regarding first-time anterior dislocations. ,,,,,,,, The optimal approach is further complicated in that, until more recently, much of the evidence surrounding labral tear characteristics in shoulder instability historically failed to delineate between those who sustained a single anterior shoulder dislocation compared with those who experienced multiple dislocations. Furthermore, how labral tear size characteristics relate to inciting events of shoulder instability and recurrent episodes of shoulder instability remain unknown. However, patients frequently ask, “Will my labral tear be worse if I have more dislocations?” Overall, data are limited regarding direct comparisons of labral tear size to shoulder instability cohorts regarding demographics, instability histories, and surgery characteristics.
Therefore, this study aimed to evaluate whether complex glenoid labral tears (i.e., those involving >120° of the glenoid labrum) are related to demographics, injury patterns, and surgical procedures/timing in patients undergoing primary arthroscopic labral repair. We hypothesized that patients who experienced a single instability event would be more likely to have simple unidirectional tears and those with multiple instability events would be more likely to have larger, complex labral tears with additional concomitant pathology requiring repair at the time of surgery.
Methods
This single-center study was approved by the institutional review board. A retrospective chart review was performed for consecutive patients who underwent arthroscopic glenoid labral repair surgery by 6 surgeons for shoulder instability between 2012 and 2020. The data were entered by a fellowship-trained shoulder and elbow surgeon, an orthopaedic surgery resident, and 2 medical students. Patients were identified using the Current Procedural Terminology code 29806 and the electronic medical records were reviewed for demographic data—age, sex, laterality, and body mass index (BMI); instability history (i.e., number of dislocations) and direction; activity level including involvement in contact/collision sports; time from injury/instability event to surgery; and comorbidities. Specifically, the documented direction of instability complaints was confirmed through collective gathering of chief complaints, radiographic history, and physical examination maneuvers. Instability history further included the number of instability events (<1, 1, 2, >2 dislocations). That is, patients groups into “1”, “2,” or “>2” were described on the basis of the number of discrete dislocations that they experienced as documented by history. Furthermore, patients classified as having “<1” instability event were subgrouped into 2 categories: (1) those that only were experiencing pain without subjective instability—“pain only”—or (2) those with no known personal or clinical documentation of dislocation but with complaints of subluxation—“subluxators.” All records to confirm the chief complaint of direction of instability were reviewed by the senior authors (J.J.E. and P.N.C.). Operative reports were reviewed to confirm labral tear size, implant usage (number), and concomitant procedures. Only patients with a chief complaint of anterior or posterior instability who received an arthroscopic surgical repair were included. Patients presenting with or treated for isolated superior labral tears were excluded. Additional exclusion criteria were patients with a primary diagnosis of multidirectional instability with known ligamentous laxity and/or those who received previous shoulder surgeries of any kind.
For this study, labral tear size was categorized into simple tears (unidirectional anterior or posterior tears involving <120° of the glenoid rim) and complex tears (>120° of the glenoid rim) with the anterior, posterior, and superior aspects of the labrum assumed to each represent a respective third of the labral circumference. Namely, the schema for tear characteristics was designated as superior tears from 10 to 2 o’clock, anterior tears from 2 to 6 o’clock, and posterior tears from 6 to 10 o’clock. For example, a simple <120° tear could include an isolated anterior labral tear or an isolated posterior labral tear. A complex >120° tear could include anterior and posterior aspects of the labrum, anterior and superior aspects of the labrum, posterior and superior aspects of the labrum, or anterior, posterior, and superior aspects of the labrum.
Statistical Analysis
All analyses were conducted in Excel 16 (Microsoft, Redmond, WA) and SPSS 29 (IBM, Armonk, NY). Data were analyzed for normality using the Kolmogorov-Smirnov test and parametric and nonparametric test were used as appropriate depending upon data normality. Categorical data were compared between groups using χ 2 tests and Fisher exact tests depending upon cell populations. Continuous data were compared between groups using Student t tests and Mann-Whitney U tests as appropriate, depending upon data normality. After the exclusion of multidirectional instability patients and patients with previous shoulder surgeries, we compared patients with simple labral tears (120°) with those with complex labral tears (240°/360°). Two-tailed tests were performed in all cases and Bonferroni-corrected P values of <.002 were considered significant.
Results
Over the 8-year period, 633 patients were identified as having received an arthroscopic labral repair. In total, 477 of 633 (75.4%) patients with diagnosed anterior or posterior instability met inclusion criteria with 364 patients in the simple labral tear group (280 simple anterior tears and 84 simple posterior tears) and 113 patients in the complex labral tear group.
Comparisons were made between all simple tears and complex tears. The number of anchors used was the only variable found to correlate with tear size with 3 ± 1 and 5 ± 1 in the simple and complex groups, respectively ( P <.001) ( Table 1 ). There was no statistical difference between tear size groups and patient demographics including male sex, contact sport participation, anterior instability, BMI, age at surgery, or association of concomitant procedures ( Table 2 ). All tear size groups had a greater percentage of patients with >2 dislocations as opposed to <1, 1, or 2 dislocations (120° = 48.6%, 240°/360° = 37.2%), but these differences were not statistically significant ( P =.067). Both simple and complex groups more commonly experienced dislocations (75.5% and 64.6%, respectively) rather than subluxations (7.7% and 14.2%, respectively). Time from first dislocation to surgery (in months) was not a predictor of a simple or complex tear (120° = 45 ± 70 months, 240°/360° = 38 ± 67 months).
Table 1
Surgical Characteristics Comparing Those With Simple Glenoid Labral Tears (120°) With Those With Complex Glenoid Labral Tears (240° and 360°), Excluding Multidirectional Instability
| Surgical Characteristics | Tear Size | P Value | |
|---|---|---|---|
|
Simple (120°)
(n = 364) |
Complex (240°/360°)
(n = 113) |
||
| Number of anchors | 3 ± 1 | 5 ± 1 | <.001 |
| Capsular plication | 43% (158/364) | 38% (43/113) | .314 |
| HAGL repair | 1% (5/364) | 4% (4/113) | .226 |
| Remplissage | 12% (42/364) | 11% (12/113) | .788 |
| Rotator interval closure | 1% (1/364) | 0% (0/113) | 1.000 |
| Subacromial decompression | 3% (12/364) | 2% (2/113) | .535 |
| Rotator cuff repair | 3% (12/364) | 4% (4/113) | 1.000 |
| Distal clavicle excision | 3% (9/364) | 2% (2/113) | 1.000 |
| Biceps tenodesis/tenotomy | 9% (31/364) | 7% (8/113) | .626 |
NOTE. Categorical variables are shown as % (n) and continuous variables are shown as mean ± standard deviation. Significant differences are shown in bold.
HAGL, humeral avulsion of the glenohumeral ligament.
Table 2
Demographics, Instability Histories, and Instability Directions Comparing Those With Simple Glenoid Labral Tears (120°) With Those With Complex Glenoid Labral Tears (240° and 360°)
| Tear Size | P Value | ||
|---|---|---|---|
|
Simple (120°)
(n = 364) |
Complex (240°/360°)
(n = 113) |
||
| Demographic | |||
| Age at surgery, yr | 27±10 | 27±9 | .212 |
| Male | 75% (272/364) | 83% (94/113) | .063 |
| Contact/collision athlete | 45% (162/364) | 50% (56/113) | .346 |
| Body mass index | 27±6 | 27±6 | .278 |
| Instability history | |||
| Previous dislocation | 76% (275/364) | 65% (73/113) | .022 |
| Subluxators | 8% (28/364) | 14% (16/113) | .038 |
| Pain only | 17% (61/364) | 21% (24/113) | .277 |
| 1 previous dislocation | 18% (67/364) | 16% (18/113) | .548 |
| 2 previous dislocations | 10% (36/364) | 12% (13/113) | .621 |
| >2 previous dislocations | 47% (171/364) | 37% (42/113) | .067 |
| Time from first dislocation to surgery, mo | 45±70 | 38±67 | .140 |
| Instability direction | |||
| Anterior | 77% (280/364) | 82% (93/113) | .226 |
| Posterior | 23% (84/364) | 18% (20/113) | .226 |
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