Management of Failed Multidirectional Shoulder Instability Surgery: To Revise or Not to Revise.

Background: Multidirectional instability (MDI) of the shoulder is a complex condition with a high rate of recurrence after surgical intervention in the younger population. This study was undertaken to determine the best treatment strategy for adolescent patients who fail their index surgical capsulorrhaphy.

Methods: Patients managed surgically over a 6-year period for MDI at a pediatric facility with 2 years minimum follow-up were evaluated via demographics, arthroscopic findings, and patient-reported outcomes (PROs): qDASH (short form Disabilities Arm, Shoulder, and Hand), PASS (Pediatric and Adolescent Shoulder Survey), and SANE (Single Assessment Numerical Evaluation). Treatment failure was defined as the need for a revision procedure, a PASS score less than 85, or a SANE score less than 75. Three cohorts were developed for comparison: successful, and unsuccessful (those electing a revision surgery, and those without a revision surgery).

Results: A total of 27 patients (34 total shoulders) with a mean age 16.1±2.0 years (70% female) were identified who met criteria with a mean overall follow-up duration of 6.3±2.4 years. 50% (17/34) had a failed initial procedure with 5 electing to undergo revision surgery. The successful cohort mean qDASH 1.3±2.3, PASS 94.7±3.8, and SANE 92.8±6.7 scores were better than the unsuccessful cohorts (P<0.001), who had similar mean outcome scores (P>0.2) between revision and no revision cohorts, respectively: qDASH (12.4±5.9 vs. 13.6±11), PASS (74.7±12.0 vs. 71.8±23.8), and SANE (74.3±8.2 vs. 65.6±25.0). However, 1/5 (20%) of the revision cohort did achieve acceptable PROs after the revision surgery.

Conclusions: A revision surgery following failed index MDI procedure does not appear to improve patient-reported outcome scores for all adolescents. Surgeons should counsel patients and families on the potential outcomes of the primary and/or revision surgery for this condition to improve the shared decision-making process. Future study into risk factors for failure, improved patient selection criteria, and even utilization of open techniques is warranted for adolescents with MDI and involuntary instability of their shoulders.

Level of evidence: Level III-comparative study.