Dynamic Anterior Stabilization for Anterior Shoulder Instability: A Meta-Analysis and Systematic Review of Clinical and Biomechanical Studies

Dynamic Anterior Stabilization for Anterior Shoulder Instability: A Meta-Analysis and Systematic Review of Clinical and Biomechanical Studies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dynamic Anterior Stabilization for Anterior Shoulder Instability: A Meta-Analysis and Systematic Review of Clinical and Biomechanical Studies Abdulaziz F. Ahmed, Ashraf Hantouly, Loay Salman, Sathish Muthu, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6656456/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Dynamic anterior shoulder stabilization (DAS) combined with Bankart repair (BR) has emerged as a promising technique for managing anterior shoulder instability (ASI) in cases of subcritical anterior glenoid bone loss (GBL). This study aims to systematically evaluate the biomechanical outcomes, clinical outcomes, and complication rates of DAS combined with BR for ASI. Methods A comprehensive search of PubMed, Embase, and Scopus was conducted through August 2024 to identify biomechanical and clinical studies assessing DAS in ASI. Exclusion criteria included reviews, surgical techniques, case reports, and abstracts. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Biomechanical outcomes of interest included glenohumeral anterior translation, joint stability under various loading conditions, and load-to-dislocation. Clinical outcomes evaluated included patient-reported shoulder scores, range of motion (ROM), and complication rates. A meta-analysis was performed using a random-effects model, with using weighted mean differences (WMD) for continuous variables to compare pre-to-post treatment effects. Results Five biomechanical studies (60 cadaveric shoulders, glenoid bone loss (GBL) 10%-20%) demonstrated that DAS significantly improved anterior glenohumeral stability and load-to-dislocation compared to isolated BR, particularly in models with <20% GBL and on-track Hill-Sachs lesions (HSL). DAS using the long head of the biceps tendon (LHBT) provided superior stability under higher loads compared to the conjoint tendon (CJT) in one study but was less effective than the Latarjet procedure in 20% GBL and remplissage in off-track HSL. Clinical outcomes from three studies (100 shoulders, mean age ranged from 23.4 to 21, GBL 8.2%-10.5%) revealed significant pre-to-post intervention improvements in Rowe scores (mean difference [WMD] = 58.7; p < 0.001) and forward elevation (WMD = 4.8; p = 0.02), with no significant changes in external or internal rotation range of motion. Return-to-sport rates were high (90% at any level, 71% at the same level), with 8% experiencing recurrent instability and 2% requiring reoperation. No significant differences were observed between DAS techniques using LHBT or CJT. Conclusion Based on limited evidence from biomechanical studies and clinical case series, DAS combined with BR offered significant biomechanical improvements, substantial patient-reported outcome improvements, better forward elevation, high return-to-sport rates, and a low complication profile for ASI with subcritical GBL. However, caution is advised when considering DAS in cases with off-track HSL and GBL of approximately 20%, as it was found that DAS offers less stability biomechanically when compared to Remplissage and Latarjet and increased reoperations in such scenarios. Shoulder instability Bankart repair Dynamic stabilization Glenoid bone loss Biceps tendon Laterjet Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Anterior glenohumeral instability is a common condition, particularly affecting the younger population. 10 , 14 It significantly impacts daily activities and sports participation. The incidence of anterior shoulder dislocation is approximately 23.1 per 100,000 individuals, with high recurrence rate. 16 , 15 This condition places a substantial burden on both patients and healthcare systems globally and can lead to significant morbidity. Treatment for anterior shoulder instability can range from non-operative to surgical interventions. Non-operative treatment has been associated with a high failure (recurrence) rate in high-risk individuals, such as younger age at the time of first dislocation, males, and those with hyperlaxity and associated greater tuberosity fractures. 9 , 11 Surgical intervention remains the standard of care in many cases of ASI. Bankart repair is a frequently performed surgical intervention for ASI and is associated with satisfactory clinical outcomes. 12 However, when in isolation, it has a high recurrence rate, particularly in high-risk patients and those with critical glenoid bone loss (> 15–20%). 12,15 Consequently, adjuvant procedures like remplissage and the Latarjet technique are often used, depending on the severity of glenoid bone loss. 21 , 6 While remplissage effectively addresses humeral head defects, it has been associated with complications such as limited external rotation, posterior shoulder pain, and infraspinatus weakness. 3 In contrast, the Latarjet procedure has efficacy through its combined bone block and sling effect 6 , but it carries a risk of complications related to graft and hardware, as well as significant technical challenges, especially when performed arthroscopically. 7 , 11 Dynamic anterior stabilization has emerged as a novel technique, providing an anterior sling augment effect to complement BR. This approach offers the potential for enhanced stability compared to isolated BR while minimizing the complications associated with coracoid transfer procedures. 18 , 19 DAS involves anchoring the intra-articular portion of the long head of the biceps tendon or the conjoined tendon through a subscapularis split to the anterior glenoid rim, combined with a Bankart repair. However, the biomechanical and clinical evidence supporting DAS remains limited. Therefore, the aim of this systematic review was to systematically evaluate the biomechanical outcomes, clinical outcomes, and complication rates of DAS combined with Bankart repair for ASI. We hypothesized that DAS would demonstrate a low rate of recurrence and complications, particularly in patients with subcritical glenoid bone loss. Methods This systematic review and meta-analysis was conducted with strict adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 17 The main focus was clinical and biomechanical evaluating Dynamic anterior shoulder stabilization in anterior shoulder instability cases. Search strategy Three online databases (PubMed, Embase, and Scopus) were search in August 2024 from inception till the search date to identify all the articles on the topic eligible for screening. Moreover, the references of all eligible articles were assessed to capture all related articles. The following keywords were used: [Shoulder] AND [Instability] AND [Dynamic] AND [Anterior] AND [Stabilization or Stabilisation]. Study screening Two authors conducted a systematic blinded screening process to select the eligible articles. The screening process was structured in two phases; title and abstract screening phase and full-text screening phase. Any discrepancy between the two reviewers was solved with discussion with a senior author. The selection of the studies was conducted using the Rayyan app. 22 Eligibility criteria All clinical and biomechanical articles, published in English, investigating DAS in ASI cases published until the search date were included. Studies must report at least one outcome of interest. Exclusion criteria comprised articles not available in full text, reviews, surgical techniques, case reports, abstracts, preprints, letters to editor and studies with insufficient data on relevant outcomes. Data abstraction Two authors conducted data abstraction and the data was cross checked to ensure accuracy. Biomechanical outcomes of interest included glenohumeral anterior translation, joint stability under various loading conditions, and load-to-dislocation. Clinical outcomes included patient-reported shoulder scores, range of motion (ROM), and complication rates. Risk of bias assessment The quality of the biomechanical studies was assessed using the Quality Appraisal for Diverse Studies (QuADS) tool. 8 QuADS is designed to evaluate the quality of qualitative, quantitative, and mixed-method studies included in systematic reviews. It is developed to allow a thorough assessment of various studies while remaining adaptable to different research methodologies. 8 The quality of the included clinical studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. 26 These criteria assign a maximum score of 16 for non-comparative studies and 24 for comparative studies. Non-comparative studies were categorized as very low quality (0–4), low quality (5–7), fair quality (8–12), and high quality (≥13). 27 Similarly, comparative studies were categorized as very low quality (0–6), low quality (7–10), fair quality (11–15), good quality (16–20), and high quality (≥20). 27 Two authors independently assessed the quality of the biomechanical and clinical studies, with all evaluations cross-checked. Any disagreements were discussed and resolved through discussion with a senior author. Table 1 shows the quality of the included studies. Statistical analysis For biomechanical studies, no formal statistical pooling was performed due to heterogeneity in methodologies, including variability in GBL models, treatments compared, and biomechanical parameters assessed. Descriptive statistics were used to summarize key findings, including stability, load-to-dislocation, and the comparative effectiveness of DAS against other procedures. For clinical studies, a meta-analysis was performed for select outcomes where sufficient data were available. Pre- to post-treatment weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated for continuous outcomes, including Rowe score and ROM parameters (forward elevation, external rotation, internal rotation). Statistical significance was set at a p-value of < 0.05. Heterogeneity was assessed using the I² statistic, and a random-effects model was applied to account for variations across studies. Return-to-sport rates and recurrent instability rates were summarized as proportions. Data analyses were performed using Stata/IC (Stata Statistical Software, 2021, Release 17; StataCorp, College Station, TX, USA). Results Search results A total of 304 studies were imported into Rayan 22 , and after the removal of 113 duplicates, 191 studies remained for title and abstract screening. Subsequently, 18 studies underwent full-text eligibility assessment, resulting in the exclusion of ten studies. Ultimately, eight studies met the inclusion/exclusion criteria and were included in this review (Figure 1). Among these eight studies there were five biomechanical 13,18-20,29 studies and three clinical ones 3,4,28 . Biomechanical studies Five biomechanical studies encompassing 60 cadaveric shoulder specimens were included with a glenoid bone loss (GBL) ranging between 10%-20% (Table 2). 13,18-20,29 DAS was performed by transferring the long head of the biceps tendon (LHBT) to the anterior glenoid only in four studies, while one study utilized either the LHBT or the conjoint tendon (CJT). Comparisons were various across studies, however tested treatments where isolated DAS, DAS + BR, isolated BR, remplissage, and the Latarjet procedure. DAS consistently demonstrated significant improvements in anterior glenohumeral stability and load-to-dislocation compared to isolated BR, particularly in models with < 20% GBL and on-track Hill-Sachs lesion (HSL). In one study that compared two DAS techniques, LHBT transfer provided superior stability under higher loads compared to CJT. Despite these biomechanical advantages, DAS was less effective than the Latarjet and remplissage procedures in scenarios involving GBL of 20% or off-track HSL, respectively. Clinical studies Three clinical studies involving 100 shoulders with a mean GBL ranging between 8.2% to 10.5% evaluated the outcomes of DAS (Table 2). 3,4,28 The mean age ranged from 23.4 years to 31.0 years, and the majority of patients were males. (84%). Two clinical studies employed DAS with LHBT, and one clinical study evaluated both DAS with a LHBT and CJT. Only one study reported HSL which was off-track. In term of clinical outcomes, a pre-to-post meta-analytic comparison was possible for the Rowe score, forward elevation ROM, external rotation ROM, and internal rotation ROM. At a mean follow-up ranging from 24 to 45.3 months, all studies reported significant pre-to-post intervention improvements in Rowe scores, with a mean difference of 58.7 points (WMD = 58.7; 95% CI, 50.3-67.2; p < 0.001) (Figure 1). Additionally, forward elevation significantly increased (WMD = 4.80; 95% CI, 0.8-8.8; p = 0.02) (Figure 2) without any statistically significant different in external or internal rotation. Return-to-sport rates were high, with a mean rate of 90% for return to sports at any level at two years, and a mean rate of 71% for returning at a similar level. Recurrent instability was reported in 8% (N=8 out 100) of patients in the form of postoperative apprehension in three, subluxation in one and re-dislocation in four, of which three were found to have an off-track HSL. Reoperations included revision to Latarjet in 2% (n=2) due to recurrent instability, and one capsular release due to post-operative stiffness. In terms of DAS technique, there was no statistically significant difference between DAS with LHBT or CJT. Discussion The principal finding of this study is that DAS significantly improves biomechanical glenohumeral properties including anterior glenohumeral stability and load-to-dislocation compared to BR alone in cadaveric models with up to 20% anterior GBL. Clinically, DAS has been shown to lead to significant improvements in patient-reported outcomes and ROM at a two-year follow-up in patients with anterior shoulder instability and GBL ranging from 8.2–18.5%. Furthermore, DAS has demonstrated high return-to-sport rates, with 90% of patients returning to sports at any level and 71% achieving similar performance levels. These findings align with existing evidence supporting the efficacy of DAS. 3 , 4 , 13 , 18 – 20 , 28 , 29 For patients with recurrent anterior instability and subcritical GBL, DAS offers a balanced intermediate solution between the high recurrence rates associated with isolated BR and the increased complication risks of bony reconstruction for this specific patient population. Subcritical anterior GBL, recently reported in the 13.5–17.5% range, has been identified as a threshold where isolated BR frequently results in poor patient-reported outcomes and recurrence of instability. Shaha et al. observed significantly reduced Western Ontario Shoulder Instability Index in American football players with GBL ≥ 13.5% treated with isolated BR. 23 While bony reconstruction reliably addresses instability in such cases, it carries a higher complication rate compared to soft-tissue capsulorraphy. Dekker et al. reported an alarming 27.4% recurrence rate following isolated BR in active-duty military personnel with GBL > 15%, with a recurrence rate as high as 66.7% in patients younger than 20 years. 5 Similarly, Shin et al. demonstrated that isolated BR results in higher redislocations and subjective instability for anterior shoulder instability with GBL of 17.3% or higher. 24 A recent systematic review reported a 16.1% complication rate for the Latarjet procedure, including transient nerve injuries, hardware issues, and nonunion. Although alternative bone reconstruction techniques, such as distal tibia allograft or iliac crest autograft, can mitigate some complications, they still involve higher risks than BR including high rates of allograft resorption and donor site morbidity, respectively. 14 DAS thus emerges as a promising surgical option, effectively bridging the gap between the recurrence rates of isolated BR and the complications associated with bony reconstruction. Biomechanical studies further support the efficacy of DAS. Mehl et al. demonstrated that DAS significantly reduced anterior glenohumeral translation compared to isolated BR, particularly in 10% and 20% glenoid defect models. 19 However, in 20% defects, DAS introduced posterior and inferior shifts of the humeral head and increased inferior translation in the ABER position. In another study that compared DAS to Isolated BR and Latarjet, Lobao et al. found that DAS using LHBT transfer significantly increased pectoralis major load-to-dislocation and restored glenohumeral positioning in a cadaveric model of chronic instability which was significant superior to BR (P = .015). 18 However, the Latarjet procedure provided superior stabilization in a 20% subcritical defect model (P < .001). Kang et al. compared two different DAS techniques in cadaveric models and found that labral repair with a DAS using either the conjoined tendon or LHBT reduced anterior-inferior translation and partially restored glenohumeral stability compared to BR. 13 Although DAS using the LHBT tendon technique demonstrated superior stability under higher loading conditions compared to using the conjoined tendon, both techniques improved glenohumeral compression force without restricting ROM. Although, these findings indicate that DAS appropriately restored glenohumeral stability in the subcritical GBL range, a bone reconstruction procedure is likely the optimal option when GBL is 20% or above. This systematic review demonstrated that there are only three case series currently published on DAS with each demonstrated significant improvement in patient-reported outcomes and low complication rates at a follow-up period of at least 2 years. Collin et al. reported significant improvements in Rowe scores from 36.1 ± 16.2 to 89.8 ± 20.1 ( P < .001) in 30 shoulders with a mean follow-up of 3.2 years, with no complications and preserved ROM. 3 Recurrence occurred in 13.6%, with two requiring Latarjet revision. In a prospective case series, de Campos Azevedo and Angelo demonstrated that onlay DAS using the long head of the biceps (LHB) for ≤ 20% glenoid bone loss resulted in significant improvements in functional scores ( P < .001) and ROM ( P < .05). 4 Among 15 patients with a mean follow-up of 23.9 months, 93.3% returned to sports, and 60.0% achieved preinjury levels. Only one redislocation occurred, and MRI confirmed successful LHB healing in all cases. Wu et al. compared the clinical outcomes of DAS using the LHBT versus the conjoined tendon in patients with anterior shoulder instability and < 15% GBL. 28 In this retrospective study of 63 patients with a minimum follow-up of 3 years. Return-to-sport rates were similarly high (90.1% DAS using LHBT, and 86.7% DAS using the conjoined tendon, P = .700), with no recurrent dislocations in either group. Minor complications included one case of occasional subluxation in the DAS group using the LHBT and one patient with postoperative shoulder stiffness in the DAS using the conjoined tendon group requiring debridement. This systematic review has several limitations. First, it included only three clinical studies, all of which were Level IV evidence case series. The lack of higher-level evidence, such as randomized controlled trials or comparative cohort studies, limits the robustness of the conclusions. Second, no clinical comparisons were available between DAS and other established procedures, including Bankart repair and bone reconstruction techniques like the Latarjet procedure. Consequently, future studies are warranted to directly compare DAS with these approaches in patients with recurrent shoulder instability and subcritical glenoid bone loss. Despite these limitations, the primary strength of this review lies in being the first to systematically summarize the biomechanical and clinical outcomes of DAS, providing a valuable synthesis for orthopaedic surgeons. Conclusion This systematic review demonstrates that DAS significantly improves patient-reported outcomes and return-to-sport rates while maintaining a low complication profile for patients with anterior shoulder instability with a mean subcritical GBL ranging between 8.2–18.5%. However, the current evidence is limited to Level IV studies and lacks direct comparisons to other established stabilization procedures. Comparative biomechanical studies support its efficacy in reducing glenohumeral translation and increasing load-to-dislocation when compared to BR alone in models with GBL up to 20%. Biomechanical studies also demonstrated that DAS failed to improve glenohumeral biomechanics when GBL excessed 20%. Declarations Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors. Human Ethics and Consent to Participate declarations: not applicable Consent for publication Not applicable Funding The authors did not receive support from any organization for the submitted work. Author Contribution All authors had substantial contribution to the design of the study. LS and SM collected data. AA, AH and GH participated in data interpretation. AA performed statistical analysis. LS, SM and AH participated in quality assessment. AA, AH, LS and SM participated in manuscript drafting. AH and AA prepared the final version of the manuscript which reviewed by all authors. GH, MS, KK, BZ and KA supervised the whole project, helped prepare the manuscript and reviewed the final manuscript. 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Quality assessment of the included studies Clinical Study/ MINORS assessment domains A clearly stated aim Inclusion of Consecutive patients Prospective collection of Data Endpoints appropriate to the aim of the study Unbiased assessment of the study endpoints Follow-up period appropriate to the aim of the study Loss to follow up less than 5% Prospective calculation of the study size Adequate control group Contemporary groups Baseline equivalence of groups Adequate statistical analyses Total Wu (2023) 28 2 2 2 2 2 2 2 0 2 1 2 2 21/24 De Campos Azevedo and Ângelo (2023) 4 2 2 2 2 1 1 0 0 NA NA NA NA 10 Collin (2022) 3 2 1 1 2 2 2 2 0 NA NA NA NA 12 Table 2 . Summary of Biomechanical Studies. Biomechanical Studies Journal N Cadaveric Models DAS Technique Repair Tested Conditions Outcomes Mehl (2019) 19 OJSM 24 Isolated Bankart lesion 10-20% GBL LHBT Isolated BR DAS DAS significantly improved anterior translation compared to isolated BR in 10% and 20% GBL models DAS caused increased posterior and inferior shift in ABER position in 20% GBL models Kang (2022) 13 Arthroscopy 12 0-20% GBL LHBT CJT Isolated BR DAS with LHBT + BR DAS with CJT + BR DAS using LHBT provided better stability for anterior translation and superior-inferior translation compared to DAS using CJT Adding BR to either DAS technique resulted further improvement in glenohumeral compressive forces. Nicholson (2022) 20 JSES 8 0-15% GBL LHBT Isolated BR Isolated DAS DAS + BR Latarjet DAS + BR significant improved anterior translation compared to BR alone or DAS alone Latarjet was superior to all tested conditions for reducing anterior translation. Lobao (2022) 18 JSES 8 0-20% GBL LHBT Isolated BR DAS Latarjet DAS was superior to isolated BR in increasing load to dislocation in GBL below 20% DAS failed to increase loads to dislocation in 20% GBL Latarjet demonstrated significantly higher loads to dislocation in 20% GBL Wu (2024) 29 Arthroscopy 8 0-15% GBL HSL: on-track and off-track LHBT Isolated BR BR + remplissage BR+ DAS BR + remplissage and BR + DAS significantly improved anterior instability compared to BR alone BR + DAS failed to restore instability compared BR + remplissage in off-track HSL. OJSM: Orthopaedic Journal of Sports Medicine; JSES: Journal of Shoulder and Elbow Surgery; N: Number; DAS: dynamic anterior stabilization; LHBT: long head of biceps tendon; CJT: conjoint tendon; BR: Bankart repair; GBL: glenoid bone loss; ABER: Abduction and External Rotation; HSL: Hill-Sachs Lesion. Table 3 . Summary of Clinical Studies. Clinical Studies Journal Study Design; LOE Number of Shoulders DAS Technique Outcomes Complications and Reoperations Collin (2022) 3 JSES International Case series; Level 4 30 LHBT transfer to the anterior glenoid + BR Rowe score improved by a mean of 53.6 points ROM unchanged 3 re-dislocations 2 revisions to Latarjet de Campos Azevedo and Ângelo (2023) 4 ASMR Case series; Level 4 15 LHBT transfer to the anterior glenoid + BR WOSI improved by a mean of 74 points Rowe score improved by a mean of 959.27 points Statistical significant improvement in all ROM parameters RTS was 93.33% RTS-SL was 60% 1 Apprehension 2 re-dislocations Reoperations not reported Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 24 Jun, 2025 Reviews received at journal 24 Jun, 2025 Reviewers agreed at journal 05 Jun, 2025 Reviewers invited by journal 04 Jun, 2025 Editor assigned by journal 04 Jun, 2025 Submission checks completed at journal 04 Jun, 2025 First submitted to journal 13 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6656456","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":467094765,"identity":"a28b0959-ec13-4fa1-9664-b63f9150f1b2","order_by":0,"name":"Abdulaziz F. Ahmed","email":"","orcid":"","institution":"University of Missouri","correspondingAuthor":false,"prefix":"","firstName":"Abdulaziz","middleName":"F.","lastName":"Ahmed","suffix":""},{"id":467094766,"identity":"aa2261aa-fb2c-433b-a23e-00f6aff725ca","order_by":1,"name":"Ashraf Hantouly","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYJACZijVwPABSLGxE6EBpEWCgYGxgXEGSAszKVqYeZAsxQn4G/gPMBfU3Knjl0hsk7b5tU2ej5mB8cPHHNxaJA4AbZlx7JmE5Ayglty+24ZtQAHJmdvwWAPSwsN2WMLgBkhLz21GoBY2Zl48WuTBWv5BtVj23LYnqMUApIW3DaqF4cftRIJaDA8zGxzm7TssObPnYbNlb8Pt5DZmxma8fpE73vjwMc+3w/z87MkHb/z4c9t2fnvzwQ8f8XkfGAsHoEwWCcY2EM3YgEc9mu4PDH+IVjwKRsEoGAUjCAAAnPdKVPXJ4eUAAAAASUVORK5CYII=","orcid":"","institution":"Aspetar orthopedics and sports medicine hospital","correspondingAuthor":true,"prefix":"","firstName":"Ashraf","middleName":"","lastName":"Hantouly","suffix":""},{"id":467094767,"identity":"698fa438-26fd-46e7-b71c-3e4935e3eeb1","order_by":2,"name":"Loay Salman","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"prefix":"","firstName":"Loay","middleName":"","lastName":"Salman","suffix":""},{"id":467094768,"identity":"8c8ec1a4-5c08-4448-a99c-0c42b489ff0d","order_by":3,"name":"Sathish Muthu","email":"","orcid":"","institution":"Government Medical College","correspondingAuthor":false,"prefix":"","firstName":"Sathish","middleName":"","lastName":"Muthu","suffix":""},{"id":467094769,"identity":"24514e23-dd20-4f4b-9702-2d4d0a02bc57","order_by":4,"name":"Matthew J Smith","email":"","orcid":"","institution":"University of Missouri","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"J","lastName":"Smith","suffix":""},{"id":467094770,"identity":"d438ec12-e32e-4511-a124-7c9d8bcfb1ae","order_by":5,"name":"Keith Kenter","email":"","orcid":"","institution":"University of Missouri","correspondingAuthor":false,"prefix":"","firstName":"Keith","middleName":"","lastName":"Kenter","suffix":""},{"id":467094771,"identity":"0047b0c8-a291-4c01-9b86-e15d30402ca3","order_by":6,"name":"Bashir Zikria","email":"","orcid":"","institution":"Johns Hopkins Medicine","correspondingAuthor":false,"prefix":"","firstName":"Bashir","middleName":"","lastName":"Zikria","suffix":""},{"id":467094772,"identity":"1178e438-a762-4743-a468-14ce9aa399b6","order_by":7,"name":"Khalid Alkhelaifi","email":"","orcid":"","institution":"Aspetar orthopedics and sports medicine hospital","correspondingAuthor":false,"prefix":"","firstName":"Khalid","middleName":"","lastName":"Alkhelaifi","suffix":""},{"id":467094773,"identity":"9cae875b-aaea-4c64-91e0-c6878ee18ff3","order_by":8,"name":"Gazi Huri","email":"","orcid":"","institution":"Aspetar orthopedics and sports medicine hospital","correspondingAuthor":false,"prefix":"","firstName":"Gazi","middleName":"","lastName":"Huri","suffix":""}],"badges":[],"createdAt":"2025-05-13 14:23:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6656456/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6656456/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84340380,"identity":"95ce491b-5340-41b4-9f23-40658257b836","added_by":"auto","created_at":"2025-06-10 18:25:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32636,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of inclusion of studies into analysis.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6656456/v1/f38e6e81eaeb0aaa58a5c71c.png"},{"id":84340381,"identity":"40a14aa4-97ba-498e-b86d-0e32dc8164d7","added_by":"auto","created_at":"2025-06-10 18:25:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":288699,"visible":true,"origin":"","legend":"\u003cp\u003eA forest plot of the pre-to-post treatment effect on Rowe scores following dynamic anterior stabilization in clinical studies.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6656456/v1/5fa45efe6381e1d849f62f77.png"},{"id":84339629,"identity":"eca7d26e-bb61-4ca0-8c18-2a3b5ef69f0a","added_by":"auto","created_at":"2025-06-10 18:17:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":282663,"visible":true,"origin":"","legend":"\u003cp\u003eA forest plot of the pre-to-post treatment on external rotation following dynamic anterior stabilization in clinical studies.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6656456/v1/8d04f456ab5f85ff5decf63a.png"},{"id":84340390,"identity":"dcf9785d-aef4-4a02-98f4-0f5bd09c02a2","added_by":"auto","created_at":"2025-06-10 18:25:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":222970,"visible":true,"origin":"","legend":"\u003cp\u003eA forest plot of the pre-to-post treatment on internal rotation following dynamic anterior stabilization in clinical studies.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6656456/v1/2817367b47c31a1846be16c6.png"},{"id":84339634,"identity":"23f5a619-2b95-4bf4-9430-28449339ff1e","added_by":"auto","created_at":"2025-06-10 18:17:01","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":249986,"visible":true,"origin":"","legend":"\u003cp\u003eA forest plot of the pre-to-post treatment on forward elevation effect following dynamic anterior stabilization in clinical studies.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6656456/v1/f6c3640aef858b676ac29e18.png"},{"id":84341803,"identity":"5e444321-a6dc-43c4-840a-1c17721d7aa7","added_by":"auto","created_at":"2025-06-10 18:41:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1634885,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6656456/v1/d6b5aa01-f2bb-44d2-99f2-037d7d13eb3b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dynamic Anterior Stabilization for Anterior Shoulder Instability: A Meta-Analysis and Systematic Review of Clinical and Biomechanical Studies","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnterior glenohumeral instability is a common condition, particularly affecting the younger population.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e It significantly impacts daily activities and sports participation. The incidence of anterior shoulder dislocation is approximately 23.1 per 100,000 individuals, with high recurrence rate.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e This condition places a substantial burden on both patients and healthcare systems globally and can lead to significant morbidity.\u003c/p\u003e \u003cp\u003eTreatment for anterior shoulder instability can range from non-operative to surgical interventions. Non-operative treatment has been associated with a high failure (recurrence) rate in high-risk individuals, such as younger age at the time of first dislocation, males, and those with hyperlaxity and associated greater tuberosity fractures.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSurgical intervention remains the standard of care in many cases of ASI. Bankart repair is a frequently performed surgical intervention for ASI and is associated with satisfactory clinical outcomes.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e However, when in isolation, it has a high recurrence rate, particularly in high-risk patients and those with critical glenoid bone loss (\u0026gt;\u0026thinsp;15\u0026ndash;20%).\u003csup\u003e12,15\u003c/sup\u003e Consequently, adjuvant procedures like remplissage and the Latarjet technique are often used, depending on the severity of glenoid bone loss.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e While remplissage effectively addresses humeral head defects, it has been associated with complications such as limited external rotation, posterior shoulder pain, and infraspinatus weakness.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e In contrast, the Latarjet procedure has efficacy through its combined bone block and sling effect\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, but it carries a risk of complications related to graft and hardware, as well as significant technical challenges, especially when performed arthroscopically.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDynamic anterior stabilization has emerged as a novel technique, providing an anterior sling augment effect to complement BR. This approach offers the potential for enhanced stability compared to isolated BR while minimizing the complications associated with coracoid transfer procedures.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e DAS involves anchoring the intra-articular portion of the long head of the biceps tendon or the conjoined tendon through a subscapularis split to the anterior glenoid rim, combined with a Bankart repair. However, the biomechanical and clinical evidence supporting DAS remains limited.\u003c/p\u003e \u003cp\u003eTherefore, the aim of this systematic review was to systematically evaluate the biomechanical outcomes, clinical outcomes, and complication rates of DAS combined with Bankart repair for ASI. We hypothesized that DAS would demonstrate a low rate of recurrence and complications, particularly in patients with subcritical glenoid bone loss.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis systematic review and meta-analysis was conducted with strict adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).\u003csup\u003e17\u003c/sup\u003e The main focus was clinical and biomechanical evaluating Dynamic anterior shoulder stabilization in anterior shoulder instability cases.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSearch strategy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThree online databases (PubMed, Embase, and Scopus) were search in August 2024 from inception till the search date to identify all the articles on the topic eligible for screening. Moreover, the references of all eligible articles were assessed to capture all related articles. The following keywords were used: [Shoulder] AND [Instability] AND [Dynamic] AND [Anterior] AND [Stabilization or Stabilisation].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy screening\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo authors conducted a systematic blinded screening process to select the eligible articles. The screening process was structured in two phases; title and abstract screening phase and full-text screening phase. Any discrepancy between the two reviewers was solved with discussion with a senior author. The selection of the studies was conducted using the Rayyan app.\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEligibility criteria\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll clinical and biomechanical articles, published in English, investigating DAS in ASI cases published until the search date were included. Studies must report at least one outcome of interest. Exclusion criteria comprised articles not available in full text, reviews, surgical techniques, case reports, abstracts,\u0026nbsp;preprints, letters to editor and studies with insufficient data on relevant outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData abstraction\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo authors conducted data abstraction and the data was cross checked to ensure accuracy. Biomechanical outcomes of interest included glenohumeral anterior translation, joint stability under various loading conditions, and load-to-dislocation. Clinical outcomes included patient-reported shoulder scores, range of motion (ROM), and complication rates.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRisk of bias assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe quality of the biomechanical studies was assessed using the Quality Appraisal for Diverse Studies (QuADS)\u0026nbsp;tool.\u003csup\u003e8\u003c/sup\u003e QuADS is designed to evaluate the quality of qualitative, quantitative, and mixed-method studies included in systematic reviews. It is developed to allow a thorough assessment of various studies while remaining adaptable to different research methodologies.\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe quality of the included clinical studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.\u003csup\u003e26\u003c/sup\u003e These criteria assign a maximum score of 16 for non-comparative studies and 24 for comparative studies. Non-comparative studies were categorized as very low quality (0\u0026ndash;4), low quality (5\u0026ndash;7), fair quality (8\u0026ndash;12), and high quality (\u0026ge;13).\u003csup\u003e27\u003c/sup\u003e Similarly, comparative studies were categorized as very low quality (0\u0026ndash;6), low quality (7\u0026ndash;10), fair quality (11\u0026ndash;15), good quality (16\u0026ndash;20), and high quality (\u0026ge;20).\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eTwo authors independently assessed the quality of the biomechanical and clinical studies, with all evaluations cross-checked. Any disagreements were discussed and resolved through discussion with a senior author. Table 1 shows the quality of the included studies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor biomechanical studies, no formal statistical pooling was performed due to heterogeneity in methodologies, including variability in GBL models, treatments compared, and biomechanical parameters assessed. Descriptive statistics were used to summarize key findings, including stability, load-to-dislocation, and the comparative effectiveness of DAS against other procedures. For clinical studies, a meta-analysis was performed for select outcomes where sufficient data were available. Pre- to post-treatment weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated for continuous outcomes, including Rowe score and ROM parameters (forward elevation, external rotation, internal rotation). Statistical significance was set at a p-value of \u0026lt; 0.05. Heterogeneity was assessed using the I\u0026sup2; statistic, and a random-effects model was applied to account for variations across studies. Return-to-sport rates and recurrent instability rates were summarized as proportions. Data analyses were performed using Stata/IC (Stata Statistical Software, 2021, Release 17; StataCorp, College Station, TX, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eSearch results\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA total of 304 studies were imported into Rayan\u003csup\u003e22\u003c/sup\u003e, and after the removal of 113 duplicates, 191 studies remained for title and abstract screening. Subsequently, 18 studies underwent full-text eligibility assessment, resulting in the exclusion of ten studies. Ultimately, eight studies met the inclusion/exclusion criteria and were included in this review (Figure 1). Among these eight studies there were five biomechanical\u003csup\u003e13,18-20,29\u003c/sup\u003e studies and three clinical ones\u003csup\u003e3,4,28\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBiomechanical studies\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFive biomechanical studies encompassing 60 cadaveric shoulder specimens were included with a glenoid bone loss (GBL) ranging between 10%-20% (Table 2).\u003csup\u003e\u0026nbsp;13,18-20,29\u003c/sup\u003e DAS was performed by transferring the long head of the biceps tendon (LHBT) to the anterior glenoid only in four studies, while one study utilized either the LHBT or the conjoint tendon (CJT). Comparisons were various across studies, however tested treatments where isolated DAS, DAS + BR, isolated BR, remplissage, and the Latarjet procedure. DAS consistently demonstrated significant improvements in anterior glenohumeral stability and load-to-dislocation compared to isolated BR, particularly in models with \u0026lt; 20% GBL and on-track Hill-Sachs lesion (HSL). In one study that compared two DAS techniques, LHBT transfer provided superior stability under higher loads compared to CJT. Despite these biomechanical advantages, DAS was less effective than the Latarjet and remplissage procedures in scenarios involving GBL of 20% or off-track HSL, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical studies\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThree clinical studies involving 100 shoulders with a mean GBL ranging between 8.2% to 10.5% evaluated the outcomes of DAS (Table 2).\u003csup\u003e3,4,28\u003c/sup\u003e The mean age ranged from 23.4 years to 31.0 years, and the majority of patients were males. (84%). Two clinical studies employed DAS with LHBT, and one clinical study evaluated both DAS with a LHBT and CJT. \u0026nbsp;Only one study reported HSL which was off-track. In term of clinical outcomes, a pre-to-post meta-analytic comparison was possible for the Rowe score, forward elevation ROM, external rotation ROM, and internal rotation ROM. At a mean follow-up ranging from 24 to 45.3 months, all studies reported significant pre-to-post intervention improvements in Rowe scores, with a mean difference of 58.7 points (WMD = 58.7; 95% CI, 50.3-67.2; p \u0026lt; 0.001) (Figure 1). Additionally, forward elevation significantly increased (WMD = 4.80; 95% CI, 0.8-8.8; p = 0.02) (Figure 2) without any statistically significant different in external or internal rotation. Return-to-sport rates were high, with a mean rate of 90% for return to sports at any level at two years, and a mean rate of 71% for returning at a similar level. Recurrent instability was reported in 8% (N=8 out 100) of patients in the form of postoperative apprehension in three, subluxation in one and re-dislocation in four, of which three were found to have an off-track HSL. Reoperations included revision to Latarjet in 2% (n=2) due to recurrent instability, and one capsular release due to post-operative stiffness. In terms of DAS technique, there was no statistically significant difference between DAS with LHBT or CJT.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe principal finding of this study is that DAS significantly improves biomechanical glenohumeral properties including anterior glenohumeral stability and load-to-dislocation compared to BR alone in cadaveric models with up to 20% anterior GBL. Clinically, DAS has been shown to lead to significant improvements in patient-reported outcomes and ROM at a two-year follow-up in patients with anterior shoulder instability and GBL ranging from 8.2\u0026ndash;18.5%. Furthermore, DAS has demonstrated high return-to-sport rates, with 90% of patients returning to sports at any level and 71% achieving similar performance levels. These findings align with existing evidence supporting the efficacy of DAS.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFor patients with recurrent anterior instability and subcritical GBL, DAS offers a balanced intermediate solution between the high recurrence rates associated with isolated BR and the increased complication risks of bony reconstruction for this specific patient population. Subcritical anterior GBL, recently reported in the 13.5\u0026ndash;17.5% range, has been identified as a threshold where isolated BR frequently results in poor patient-reported outcomes and recurrence of instability. Shaha et al. observed significantly reduced Western Ontario Shoulder Instability Index in American football players with GBL\u0026thinsp;\u0026ge;\u0026thinsp;13.5% treated with isolated BR.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e While bony reconstruction reliably addresses instability in such cases, it carries a higher complication rate compared to soft-tissue capsulorraphy. Dekker et al. reported an alarming 27.4% recurrence rate following isolated BR in active-duty military personnel with GBL\u0026thinsp;\u0026gt;\u0026thinsp;15%, with a recurrence rate as high as 66.7% in patients younger than 20 years.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Similarly, Shin et al. demonstrated that isolated BR results in higher redislocations and subjective instability for anterior shoulder instability with GBL of 17.3% or higher.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e A recent systematic review reported a 16.1% complication rate for the Latarjet procedure, including transient nerve injuries, hardware issues, and nonunion. Although alternative bone reconstruction techniques, such as distal tibia allograft or iliac crest autograft, can mitigate some complications, they still involve higher risks than BR including high rates of allograft resorption and donor site morbidity, respectively.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e DAS thus emerges as a promising surgical option, effectively bridging the gap between the recurrence rates of isolated BR and the complications associated with bony reconstruction.\u003c/p\u003e \u003cp\u003eBiomechanical studies further support the efficacy of DAS. Mehl et al. demonstrated that DAS significantly reduced anterior glenohumeral translation compared to isolated BR, particularly in 10% and 20% glenoid defect models.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e However, in 20% defects, DAS introduced posterior and inferior shifts of the humeral head and increased inferior translation in the ABER position. In another study that compared DAS to Isolated BR and Latarjet, Lobao et al. found that DAS using LHBT transfer significantly increased pectoralis major load-to-dislocation and restored glenohumeral positioning in a cadaveric model of chronic instability which was significant superior to BR (P\u0026thinsp;=\u0026thinsp;.015).\u003csup\u003e18\u003c/sup\u003e However, the Latarjet procedure provided superior stabilization in a 20% subcritical defect model (P\u0026thinsp;\u0026lt;\u0026thinsp;.001). Kang et al. compared two different DAS techniques in cadaveric models and found that labral repair with a DAS using either the conjoined tendon or LHBT reduced anterior-inferior translation and partially restored glenohumeral stability compared to BR.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Although DAS using the LHBT tendon technique demonstrated superior stability under higher loading conditions compared to using the conjoined tendon, both techniques improved glenohumeral compression force without restricting ROM. Although, these findings indicate that DAS appropriately restored glenohumeral stability in the subcritical GBL range, a bone reconstruction procedure is likely the optimal option when GBL is 20% or above.\u003c/p\u003e \u003cp\u003eThis systematic review demonstrated that there are only three case series currently published on DAS with each demonstrated significant improvement in patient-reported outcomes and low complication rates at a follow-up period of at least 2 years. Collin et al. reported significant improvements in Rowe scores from 36.1\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2 to 89.8\u0026thinsp;\u0026plusmn;\u0026thinsp;20.1 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) in 30 shoulders with a mean follow-up of 3.2 years, with no complications and preserved ROM.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Recurrence occurred in 13.6%, with two requiring Latarjet revision. In a prospective case series, de Campos Azevedo and Angelo demonstrated that onlay DAS using the long head of the biceps (LHB) for \u0026le;\u0026thinsp;20% glenoid bone loss resulted in significant improvements in functional scores (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and ROM (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05).\u003csup\u003e4\u003c/sup\u003e Among 15 patients with a mean follow-up of 23.9 months, 93.3% returned to sports, and 60.0% achieved preinjury levels. Only one redislocation occurred, and MRI confirmed successful LHB healing in all cases. Wu et al. compared the clinical outcomes of DAS using the LHBT versus the conjoined tendon in patients with anterior shoulder instability and \u0026lt;\u0026thinsp;15% GBL.\u003csup\u003e28\u003c/sup\u003e In this retrospective study of 63 patients with a minimum follow-up of 3 years. Return-to-sport rates were similarly high (90.1% DAS using LHBT, and 86.7% DAS using the conjoined tendon, P\u0026thinsp;=\u0026thinsp;.700), with no recurrent dislocations in either group. Minor complications included one case of occasional subluxation in the DAS group using the LHBT and one patient with postoperative shoulder stiffness in the DAS using the conjoined tendon group requiring debridement.\u003c/p\u003e \u003cp\u003eThis systematic review has several limitations. First, it included only three clinical studies, all of which were Level IV evidence case series. The lack of higher-level evidence, such as randomized controlled trials or comparative cohort studies, limits the robustness of the conclusions. Second, no clinical comparisons were available between DAS and other established procedures, including Bankart repair and bone reconstruction techniques like the Latarjet procedure. Consequently, future studies are warranted to directly compare DAS with these approaches in patients with recurrent shoulder instability and subcritical glenoid bone loss. Despite these limitations, the primary strength of this review lies in being the first to systematically summarize the biomechanical and clinical outcomes of DAS, providing a valuable synthesis for orthopaedic surgeons.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis systematic review demonstrates that DAS significantly improves patient-reported outcomes and return-to-sport rates while maintaining a low complication profile for patients with anterior shoulder instability with a mean subcritical GBL ranging between 8.2\u0026ndash;18.5%. However, the current evidence is limited to Level IV studies and lacks direct comparisons to other established stabilization procedures. Comparative biomechanical studies support its efficacy in reducing glenohumeral translation and increasing load-to-dislocation when compared to BR alone in models with GBL up to 20%. Biomechanical studies also demonstrated that DAS failed to improve glenohumeral biomechanics when GBL excessed 20%.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval\u003c/h2\u003e\n\u003cp\u003eThis article does not contain any studies with human participants or animals performed by any of the authors. Human Ethics and Consent to Participate declarations: not applicable\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAll authors had substantial contribution to the design of the study. LS and SM collected data. AA, AH and GH participated in data interpretation. AA performed statistical analysis. LS, SM and AH participated in quality assessment. AA, AH, LS and SM participated in manuscript drafting. AH and AA prepared the final version of the manuscript which reviewed by all authors. GH, MS, KK, BZ and KA supervised the whole project, helped prepare the manuscript and reviewed the final manuscript.\u003c/p\u003e\n\u003ch2\u003eCode availability\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCerciello S, Corona K, Morris BJ, Santagada DA, Maccauro G. Early Outcomes and Perioperative Complications of the Arthroscopic Latarjet Procedure: Systematic Review and Meta-analysis. Am J Sports Med. 2019 Jul;47(9):2232-2241. DOI: 10.1177/0363546518783743.\u003c/li\u003e\n \u003cli\u003eCho CH, Na SS, Choi BC, Kim DH. Complications Related to Latarjet Shoulder Stabilization: A Systematic Review. Am J Sports Med. 2023 Jan;51(1):263-270. DOI: 10.1177/03635465211042314.\u003c/li\u003e\n \u003cli\u003eCollin P, Nabergoj M, Denard PJ, Wang S, Bothorel H, L\u0026auml;dermann A. Arthroscopic Biceps Transfer to the Glenoid With Bankart Repair Grants Satisfactory 2-Year Results for Recurrent Anteroinferior Glenohumeral Instability in Subcritical Bone Loss. Arthroscopy. 2022 Jun;38(6):1766-1771. DOI: 10.1016/j.arthro.2021.11.043.\u003c/li\u003e\n \u003cli\u003ede Campos Azevedo C, \u0026Acirc;ngelo AC. Onlay Dynamic Anterior Stabilization With Biceps Transfer for the Treatment of Anterior Glenohumeral Instability Produces Good Clinical Outcomes and Successful Healing at a Minimum 1 Year of Follow-Up. Arthrosc Sports Med Rehabil. 2023 Feb 23;5(2):e445-e457. DOI: 10.1016/j.asmr.2023.01.012.\u003c/li\u003e\n \u003cli\u003eDekker TJ, Peebles LA, Bernhardson AS, Rosenberg SI, Murphy CP, Golijanin P, Provencher MT. 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Predicting recurrent shoulder instability. Br J Sports Med. 2015 Jul;49(14):911-2. DOI: 10.1136/bjsports-2015-094584.\u003c/li\u003e\n \u003cli\u003eItoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000 Jan;82(1):35-46. DOI: 10.2106/00004623-200001000-00005.\u003c/li\u003e\n \u003cli\u003eKang Y, Wang L, Wang M, Wei Y, Li Y, Jiang J, Yu S, Zhao J, Xie G. Bankart Repair With Transferred Long Head of the Biceps Provides Better Biomechanical Effect Than Conjoined Tendon Transfer in Anterior Shoulder Instability With 20% Glenoid Defect. Arthroscopy. 2022 Sep;38(9):2628-2635. DOI: 10.1016/j.arthro.2022.03.022.\u003c/li\u003e\n \u003cli\u003eL\u0026auml;dermann A, Lubbeke A, Stern R, Cunningham G, Bellotti V, Gazielly DF. Risk factors for dislocation arthropathy after Latarjet procedure: a long-term study. Int Orthop. 2013 Jun;37(6):1093-8. 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DOI: 10.1136/bmj.b2700.\u003c/li\u003e\n \u003cli\u003eLobao MH, Abbasi P, Murthi AM. Long head of biceps transfer to augment Bankart repair in chronic anterior shoulder instability with and without subcritical bone loss: a biomechanical study. J Shoulder Elbow Surg. 2022 May;31(5):1062-1072. DOI: 10.1016/j.jse.2021.10.027.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMehl J, Otto A, Imhoff FB, Murphy M, Dyrna F, Obopilwe E, Cote M, L\u0026auml;dermann A, Collin P, Beitzel K, Mazzocca AD. Dynamic Anterior Shoulder Stabilization With the Long Head of the Biceps Tendon: A Biomechanical Study. Am J Sports Med. 2019 May;47(6):1441-1450. DOI: 10.1177/0363546519833990.\u003c/li\u003e\n \u003cli\u003eNicholson AD, Carey EG, Mathew JI, Pinnamaneni S, Jahandar A, Kontaxis A, Dines DM, Dines JS, Blaine TA, Fu MC, Rodeo SA, Warren RF, Gulotta LV, Taylor SA. Biomechanical analysis of anterior stability after 15% glenoid bone loss: comparison of Bankart repair, dynamic anterior stabilization, dynamic anterior stabilization with Bankart repair, and Latarjet. J Shoulder Elbow Surg. 2022 Nov;31(11):2358-2365. DOI: 10.1016/j.jse.2022.04.017.\u003c/li\u003e\n \u003cli\u003eNourissat G, Kilinc AS, Werther JR, Doursounian L. A prospective, comparative, radiological, and clinical study of the influence of the \u0026quot;remplissage\u0026quot; procedure on shoulder range of motion after stabilization by arthroscopic Bankart repair. Am J Sports Med. 2011 Oct;39(10):2147-52. DOI: 10.1177/0363546511416315.\u003c/li\u003e\n \u003cli\u003eOuzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016 Dec 5;5(1):210. DOI: 10.1186/s13643-016-0384-4.\u003c/li\u003e\n \u003cli\u003eShaha JS, Cook JB, Song DJ, Rowles DJ, Bottoni CR, Shaha SH, Tokish JM. Redefining \u0026quot;Critical\u0026quot; Bone Loss in Shoulder Instability: Functional Outcomes Worsen With \u0026quot;Subcritical\u0026quot; Bone Loss. Am J Sports Med. 2015 Jul;43(7):1719-25. DOI: 10.1177/0363546515578250.\u003c/li\u003e\n \u003cli\u003eShin SJ, Kim RG, Jeon YS, Kwon TH. Critical Value of Anterior Glenoid Bone Loss That Leads to Recurrent Glenohumeral Instability After Arthroscopic Bankart Repair. Am J Sports Med. 2017 Jul;45(9):1975-1981. DOI: 10.1177/0363546517697963.\u003c/li\u003e\n \u003cli\u003eShin SJ, Koh YW, Bui C, Jeong WK, Akeda M, Cho NS, McGarry MH, Lee TQ. What Is the Critical Value of Glenoid Bone Loss at Which Soft Tissue Bankart Repair Does Not Restore Glenohumeral Translation, Restricts Range of Motion, and Leads to Abnormal Humeral Head Position? Am J Sports Med. 2016 Nov;44(11):2784-2791. DOI: 10.1177/0363546516656367.\u003c/li\u003e\n \u003cli\u003eSlim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003 Sep;73(9):712-6. DOI: 10.1046/j.1445-2197.2003.02748.x.\u003c/li\u003e\n \u003cli\u003eVivekanantha P, Diao YD, Cohen D, Abouali J, Hantouly A, de Sa D. Posterior tibial slope, notch width index and tibial tubercle to trochlear groove distance contribute to development of mucoid degeneration of the anterior cruciate ligament: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2023 Aug;31(8):3454-3464. DOI: 10.1007/s00167-023-07435-7.\u003c/li\u003e\n \u003cli\u003eWu C, Xu J, Fang Z, Chen J, Ye Z, Wang L, Kang Y, Zhao S, Xu C, Zhao J. Arthroscopic Dynamic Anterior Stabilization Using Either Long Head of the Biceps or Conjoined Tendon Transfer for Anterior Shoulder Instability Results in a Similarly Low Recurrence Rate. Arthroscopy. 2023 Jul;39(7):1618-1627. 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DOI: 10.1016/j.arthro.2024.01.023.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eQuality assessment of the included studies\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Study/ MINORS assessment domains\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eA clearly stated aim\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInclusion of Consecutive patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProspective collection of Data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndpoints appropriate to the aim of the study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnbiased assessment of the study endpoints\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up period appropriate to the aim of the study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLoss to follow up less than 5%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProspective calculation of the study size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdequate control group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContemporary groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline equivalence of groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdequate statistical analyses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWu (2023)\u003csup\u003e28\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e21/24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDe Campos Azevedo and \u0026Acirc;ngelo (2023)\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCollin (2022)\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Summary of Biomechanical Studies.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBiomechanical Studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJournal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCadaveric Models\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDAS Technique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepair Tested Conditions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eMehl (2019)\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eOJSM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eIsolated Bankart lesion\u003cbr\u003e\u0026nbsp;10-20% GBL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eLHBT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eIsolated BR\u003cbr\u003e\u0026nbsp;DAS\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDAS significantly improved anterior translation compared to isolated BR in 10% and 20% GBL models\u003c/li\u003e\n \u003cli\u003eDAS caused increased posterior and inferior shift in ABER position in 20% GBL models\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eKang (2022)\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eArthroscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0-20% GBL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eLHBT\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCJT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eIsolated BR\u003cbr\u003e\u0026nbsp;DAS with LHBT + BR\u003c/p\u003e\n \u003cp\u003eDAS with CJT + BR\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDAS using LHBT provided better stability for anterior translation and superior-inferior translation compared to DAS using CJT\u003c/li\u003e\n \u003cli\u003eAdding BR to either DAS technique resulted further improvement in glenohumeral compressive forces.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eNicholson (2022)\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eJSES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0-15% GBL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eLHBT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eIsolated BR\u003cbr\u003e\u0026nbsp;Isolated DAS\u003cbr\u003e\u0026nbsp;DAS + BR\u003cbr\u003e\u0026nbsp;Latarjet\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDAS + BR significant improved anterior translation compared to BR alone or DAS alone\u003c/li\u003e\n \u003cli\u003eLatarjet was superior to all tested conditions for reducing anterior translation.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eLobao (2022)\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eJSES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0-20% GBL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eLHBT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eIsolated BR\u003c/p\u003e\n \u003cp\u003eDAS\u003c/p\u003e\n \u003cp\u003eLatarjet\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDAS was superior to isolated BR in increasing load to dislocation in GBL below 20%\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDAS failed to increase loads to dislocation in 20% GBL\u003c/li\u003e\n \u003cli\u003eLatarjet demonstrated significantly higher loads to dislocation in 20% GBL\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eWu (2024)\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eArthroscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0-15% GBL\u003cbr\u003e\u0026nbsp;HSL: on-track and off-track\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eLHBT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eIsolated BR\u003cbr\u003e\u0026nbsp;BR + remplissage\u003cbr\u003e\u0026nbsp;BR+ DAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 342px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBR + remplissage and BR + DAS significantly improved anterior instability compared to BR alone\u003c/li\u003e\n \u003cli\u003eBR + DAS failed to restore instability compared BR + remplissage in off-track HSL.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOJSM: Orthopaedic Journal of Sports Medicine; JSES: Journal of Shoulder and Elbow Surgery; N: Number; DAS: dynamic anterior stabilization; LHBT: long head of biceps tendon; CJT: conjoint tendon; BR: Bankart repair; GBL: glenoid bone loss; ABER: Abduction and External Rotation; HSL: Hill-Sachs Lesion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e. Summary of Clinical Studies.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJournal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Design; LOE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Shoulders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDAS Technique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplications and Reoperations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eCollin (2022)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eJSES International\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eCase series; Level 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003eLHBT transfer to the anterior glenoid + BR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eRowe score improved by a mean of 53.6 points\u003c/li\u003e\n \u003cli\u003eROM unchanged\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e3 re-dislocations\u003c/li\u003e\n \u003cli\u003e2 revisions to Latarjet\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003ede Campos Azevedo and \u0026Acirc;ngelo (2023)\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eASMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eCase series; Level 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003eLHBT transfer to the anterior glenoid + BR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eWOSI improved by a mean of 74 points\u003c/li\u003e\n \u003cli\u003eRowe score improved by a mean of 959.27 points\u003c/li\u003e\n \u003cli\u003eStatistical significant improvement in all ROM parameters\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRTS was 93.33%\u003c/li\u003e\n \u003cli\u003eRTS-SL was 60%\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e1 Apprehension\u003c/li\u003e\n \u003cli\u003e2 re-dislocations\u003c/li\u003e\n \u003cli\u003eReoperations not reported\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-orthopaedics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [International Orthopaedics](https://link.springer.com/journal/264)","snPcode":"264","submissionUrl":"https://submission.springernature.com/new-submission/264/3","title":"International Orthopaedics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Shoulder instability, Bankart repair, Dynamic stabilization, Glenoid bone loss, Biceps tendon, Laterjet","lastPublishedDoi":"10.21203/rs.3.rs-6656456/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6656456/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDynamic anterior shoulder stabilization (DAS) combined with Bankart repair (BR) has emerged as a promising technique for managing anterior shoulder instability (ASI) in cases of subcritical anterior glenoid bone loss (GBL). This study aims to systematically evaluate the biomechanical outcomes, clinical outcomes, and complication rates of DAS combined with BR for ASI.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethods\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive search of PubMed, Embase, and Scopus was conducted through August 2024 to identify biomechanical and clinical studies assessing DAS in ASI. Exclusion criteria included reviews, surgical techniques, case reports, and abstracts. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.\u003c/p\u003e\n\u003cp\u003eBiomechanical outcomes of interest included glenohumeral anterior translation, joint stability under various loading conditions, and load-to-dislocation. Clinical outcomes evaluated included patient-reported shoulder scores, range of motion (ROM), and complication rates. A meta-analysis was performed using a random-effects model, with using weighted mean differences (WMD) for continuous variables to compare pre-to-post treatment effects.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFive biomechanical studies (60 cadaveric shoulders, glenoid bone loss (GBL) 10%-20%) demonstrated that DAS significantly improved anterior glenohumeral stability and load-to-dislocation compared to isolated BR, particularly in models with \u0026lt;20% GBL and on-track Hill-Sachs lesions (HSL). DAS using the long head of the biceps tendon (LHBT) provided superior stability under higher loads compared to the conjoint tendon (CJT) in one study but was less effective than the Latarjet procedure in 20% GBL and remplissage in off-track HSL. Clinical outcomes from three studies (100 shoulders, mean age ranged from 23.4 to 21, GBL 8.2%-10.5%) revealed significant pre-to-post intervention improvements in Rowe scores (mean difference [WMD] = 58.7; p \u0026lt; 0.001) and forward elevation (WMD = 4.8; p = 0.02), with no significant changes in external or internal rotation range of motion. Return-to-sport rates were high (90% at any level, 71% at the same level), with 8% experiencing recurrent instability and 2% requiring reoperation. No significant differences were observed between DAS techniques using LHBT or CJT.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBased on limited evidence from biomechanical studies and clinical case series, DAS combined with BR offered significant biomechanical improvements, substantial patient-reported outcome improvements, better forward elevation, high return-to-sport rates, and a low complication profile for ASI with subcritical GBL. However, caution is advised when considering DAS in cases with off-track HSL and GBL of approximately 20%, as it was found that DAS offers less stability biomechanically when compared to Remplissage and Latarjet and increased reoperations in such scenarios.\u003c/p\u003e","manuscriptTitle":"Dynamic Anterior Stabilization for Anterior Shoulder Instability: A Meta-Analysis and Systematic Review of Clinical and Biomechanical Studies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-10 18:16:56","doi":"10.21203/rs.3.rs-6656456/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-24T16:07:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-24T15:36:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273225631877336302713809456195257040105","date":"2025-06-05T14:41:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-05T03:08:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-05T02:28:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-05T02:25:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Orthopaedics","date":"2025-05-13T14:17:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-orthopaedics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [International Orthopaedics](https://link.springer.com/journal/264)","snPcode":"264","submissionUrl":"https://submission.springernature.com/new-submission/264/3","title":"International Orthopaedics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2a1b78c2-b216-43b3-9ce9-e4a077bf474a","owner":[],"postedDate":"June 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-11T03:23:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-10 18:16:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6656456","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6656456","identity":"rs-6656456","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}