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Abstract
Over the last several decades there has been an improved understanding of the intricate anatomy that provides stability to the glenohumeral joint. In addition, significant advances in identifying the pathologic etiology of the unstable shoulder have occurred because of basic science glenohumeral ligament cutting studies, clinical evaluation, and the advent of arthroscopic evaluation and treatment of the unstable shoulder. This article will review the pertinent anatomy of the normal glenohumeral joint and will carefully review the pathoanatomy found in the unstable shoulder. Sports medicine specialists who treat athletes with unstable shoulders should have a firm understanding of both the normal and pathologic shoulder conditions to be able to provide the best care for these athletes.
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Affiliation(s)
- W N Levine
- The Shoulder Service, New York Orthopaedic Hospital, Columbia-Presbyterian Medical Center, New York, USA
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153
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Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000; 16:677-94. [PMID: 11027751 DOI: 10.1053/jars.2000.17715] [Citation(s) in RCA: 1212] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Our goal was to analyze the results of 194 consecutive arthroscopic Bankart repairs (performed by 2 surgeons with an identical suture anchor technique) in order to identify specific factors related to recurrence of instability. TYPE OF STUDY Case series. MATERIALS AND METHODS We analyzed 194 consecutive arthroscopic Bankart repairs by suture anchor technique performed for traumatic anterior-inferior instability. The average follow-up was 27 months (range, 14 to 79 months). There were 101 contact athletes (96 South African rugby players and 5 American football players). We identified significant bone defects on either the humerus or the glenoid as (1) "inverted-pear" glenoid, in which the normally pear-shaped glenoid had lost enough anterior-inferior bone to assume the shape of an inverted pear; or (2) "engaging" Hill-Sachs lesion of the humerus, in which the orientation of the Hill-Sachs lesion was such that it engaged the anterior glenoid with the shoulder in abduction and external rotation. RESULTS There were 21 recurrent dislocations and subluxations (14 dislocations, 7 subluxations). Of those 21 shoulders with recurrent instability, 14 had significant bone defects (3 engaging Hill-Sachs and 11 inverted-pear Bankart lesions). For the group of patients without significant bone defects (173 shoulders), there were 7 recurrences (4% recurrence rate). For the group with significant bone defects (21 patients), there were 14 recurrences (67% recurrence rate). For contact athletes without significant bone defects, there was a 6.5% recurrence rate, whereas for contact athletes with significant bone defects, there was an 89% recurrence rate. CONCLUSIONS (1) Arthroscopic Bankart repairs give results equal to open Bankart repairs if there are no significant structural bone deficits (engaging Hill-Sachs or inverted-pear Bankart lesions). (2) Patients with significant bone deficits as defined in this study are not candidates for arthroscopic Bankart repair. (3) Contact athletes without structural bone deficits may be treated by arthroscopic Bankart repair. However, contact athletes with bone deficiency require open surgery aimed at their specific anatomic deficiencies. (4) For patients with significant glenoid bone loss, the surgeon should consider reconstruction by means of the Latarjet procedure, using a large coracoid bone graft.
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Affiliation(s)
- S S Burkhart
- Department of Orthopaedic Surgery, Baylor College of Medicine and the University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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154
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Lee SU, Lang P. MR and MR arthrography to identify degenerative and posttraumatic diseases in the shoulder joint. Eur J Radiol 2000; 35:126-35. [PMID: 10963918 DOI: 10.1016/s0720-048x(00)00228-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
MR imaging provides a comprehensive evaluation of a wide spectrum of both intraarticular and extraarticular pathology of the shoulder. MR imaging enables the detection or exclusion of degenerative and posttraumatic diseases of the shoulder with a reasonable accuracy. MR arthrography is useful in the visualization of subtle anatomic details and further improves the differentiation. In this article, findings of MR imaging and MR arthrography of degenerative and posttraumatic shoulder diseases (impingement syndrome, rotator cuff tears, and glenohumeral instability) has been reviewed.
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Affiliation(s)
- S U Lee
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305-5105, USA
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155
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Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up. J Bone Joint Surg Am 2000; 82-A:991-1003. [PMID: 10901314 DOI: 10.2106/00004623-200007000-00011] [Citation(s) in RCA: 291] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous studies on arthroscopic treatment of anterior-inferior glenohumeral instability have focused on the repair of lesions of the anterior-inferior aspect of the labrum (Bankart lesions) and have demonstrated failure rates of as high as 50 percent. The current investigation supports the concept that anterior-inferior instability is associated with multiple lesions and that success rates can be increased by treating all of the lesions at the time of the operation. We present the results of arthroscopic treatment of anterior-inferior gleno-humeral instability after a minimum duration of followup of two years. METHODS The study group consisted of fifty-three patients who had a mean age of thirty-two years (range, fifteen to fifty-eight years) at the time of the operation. There were forty-four male and nine female patients. The mean interval from the time of the operation to the final follow-up evaluation was thirty-three months (range, twenty-six to sixty-three months). The scores on the American Shoulder and Elbow Surgeons (ASES) Shoulder Index and the rating systems of Constant and Murley, Rowe et al., and the University of California at Los Angeles (UCLA) were recorded preoperatively and at the time of the final follow-up. RESULTS Preoperatively, none of the patients had an overall rating of good or excellent according to the system of Rowe et al.; however, 92 percent (forty-nine) of the fifty-three patients had a rating of good or excellent at the time of the final follow-up. The mean score improved from 45.5 points to 91.7 points on the ASES Shoulder Index, from 56.4 points to 91.8 points with the system of Constant and Murley, from 11.3 points to 91.9 points with the system of Rowe et al., and from 17.6 points to 32.0 points according to the UCLA Shoulder Score (p = 0.001 for all comparisons). The mean passive external rotation with the shoulder in 90 degrees of abduction measured 88.2 degrees. Thirty-four of thirty-eight patients returned to their desired level of sports activity following the operation. Four patients who had persistent instability were considered to have had a failure of the index operation, and one of them had a second operative procedure. CONCLUSIONS The results of the present study suggest that our technique of arthroscopic treatment of anterior-inferior glenohumeral instability is better than previous arthroscopic techniques and is equivalent to open repair. We believe that the improved rate of success demonstrated in the present study was the result of repair not only of the anterior-inferior (Bankart) lesion but also (where necessary) of inferior and superior labral tears. Additionally, soft-tissue tension within the capsule and ligaments was corrected with use of a suture technique but was supplemented by laser thermal capsulorrhaphy in forty-eight of the fifty-three shoulders. Rotator interval repair was considered a critical factor in fourteen of the fifty-three shoulders.
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Affiliation(s)
- G M Gartsman
- Texas Orthopedic Hospital, Fondren Orthopedic Group, Houston, Texas 77030, USA.
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156
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Abstract
PURPOSE To evaluate the long-term results after arthroscopic transglenoid suture repair for initial anterior shoulder dislocation. TYPE OF SYUDY: Outcome study. MATERIALS AND METHODS Selection for surgery was based on the sporting ambitions of the patients and the documentation of instability. Evidence of instability included the sonographic documentation of ventral drawer compared with the unaffected opposite shoulder as well as instability testing under anesthesia. Patients with preoperatively stable shoulder or multidirectional instability underwent conservative therapy. All patients underwent surgical repair with a transglenoid suture technique, initially using a single drill hole; in recent years, however, we have used 2 drill holes placed in the 3 o'clock and 5 o'clock positions. Postoperative care was initiated with 4-week immobilization in a Gilchrist bandage. Subsequently, physiotherapeutic mobilization was started, avoiding rotational movements for the first 3 weeks. In the period between 1988 and 1995, 72 patients with traumatic first-time dislocation underwent arthroscopic stabilization at the Department of Trauma Surgery of the Krankenhaus der Barmherzigen Brüder Eisenstadt. The patients included 61 men and 11 women with an average age of 27.2 years (range, 19 to 39 years). RESULTS The clinical instability documented showed a significant correlation to the instability found under anesthesia that was documented immediately before arthroscopic exploration. Arthroscopic exploration revealed a Bankart lesion in 25 cases (34.7%), with a small bone fragment found in 6 of these cases. Forty-three patients showed an avulsion of the capsulolabral complex displaced medially to the neck of the scapula, combined with a bucket-handle lesion of the superior anteroposterior labrum in 12 of these cases. Sixty-seven patients (93%) were available for clinical follow-up after an median of 66 months (range, 24 to 108 months) with patients achieving an average 91.3 points in the Carter-Rowe score. Five of the patients (6.9%) (average age, 20.4 years) experienced postoperative redislocation after 3 to 11 months being the result of an adequate trauma in 2 of the patients. All patients with redislocation had originally presented with a Bankart lesion, with medially displaced capsulolabral complex combined with a bucket-handle lesion of the proximal labrum in 2 patients. Eighty-five percent of the patients have resumed full sporting activity and presently have full load-bearing capacity of the operated shoulder. CONCLUSIONS Compared with the poor results after conservative therapy with recurrence rates of up to 90% for young, athletically active patients, arthroscopic treatment has been shown to be highly efficient.
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Affiliation(s)
- H Boszotta
- Department of Trauma Surgery, Krankenhaus der Barmherzigen Brüder Eisenstadt, Eisenstadt, Austria.
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157
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Cole BJ, Romeo AA, Warner JJ. Arthroscopic bankart repair with the suretac device for traumatic anterior shoulder instability in athletes. OPER TECHN SPORT MED 2000. [DOI: 10.1053/otsm.2000.9798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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158
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Doukas WC, Speer KP. Anatomy, pathophysiology, andbiomechanics of shoulder instability. OPER TECHN SPORT MED 2000. [DOI: 10.1053/otsm.2000.9801] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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159
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Affiliation(s)
- M Grigorian
- Department of Radiology, University of California, San Francisco 94117, USA
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160
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Abstract
The ability to image lesions associated with glenohumeral instability has evolved significantly over the past 2 decades. In the past, several imaging techniques ranging from conventional radiography to computerized axial arthrography and, most recently, to magnetic resonance imaging have been used to depict various labral abnormalities. In most instances, conventional radiography remains the initial imaging study for evaluating the patient with persistent shoulder pain and instability. Recently, however, magnetic resonance arthrography has been firmly established as the imaging modality of choice for demonstrating specific soft tissue abnormalities associated with glenohumeral instability. This article will review the role of various imaging modalities including conventional radiography, conventional arthrography, computerized axial arthrography, magnetic resonance imaging, and magnetic resonance arthrography. Emphasis will be placed on the role of magnetic resonance arthrography as it pertains to the lesions associated with glenohumeral instability. A thorough discussion of the appearance of normal anatomic structures, anatomic variations that mimic abnormality, and the various lesions associated with glenohumeral instability will be provided.
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Affiliation(s)
- T G Sanders
- Department of Radiology, Wilford Hall United States Air Force Medical Center, Lackland AFB, Texas 78236-5300, USA
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161
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Cole BJ, Warner JJ. Arthroscopic versus open Bankart repair for traumatic anterior shoulder instability. Clin Sports Med 2000; 19:19-48. [PMID: 10652663 DOI: 10.1016/s0278-5919(05)70294-5] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
After more than 15 years of experience, arthroscopic shoulder stabilization is becoming less controversial. Historically, recurrence rates following arthroscopic stabilization have been higher than with open stabilization. Although a negligible advantage may exist in terms of expedited postoperative rehabilitation and improved postoperative recovery of motion, critics suggest that its use in contact athletes be limited. The indications for arthroscopic stabilization are expanding, in part, because of improved understanding of the pathophysiology of shoulder instability. Understanding the mechanism of recurrent instability following arthroscopic stabilization offers clues to how physicians can prevent unsatisfactory results in the future. With newer instrumentation and the ability to thermally treat capsular tissue, coexisting pathology, such as capsular plastic deformation, rotator interval lesions, and unrecognized intra-articular pathology, can now be addressed arthroscopically. The judicious use of these techniques is warranted until long-term study results become available. Ideal patients for arthroscopic Bankart repair have a discrete Bankart lesion; a robust, well-developed IGHL; no significant capsular laxity or intraligamentous injury; and an absence of concomitant intra-articular pathology. Additional findings on MR imaging or CT evidence of a discrete labral lesion and pure unidirectional anterior instability during EUA are also good prognostic indicators for arthroscopic Bankart repair. Arthroscopic criteria that render patients less appropriate for an arthroscopic repair include capsular injury, capsular laxity, a bony Bankart lesion, glenohumeral arthritis, and a rotator cuff tear. The authors' believe that either absent or patulous, poorly developed glenohumeral ligaments represent a poor prognostic indicator for a successful outcome following standard arthroscopic Bankart repair. Individuals with poor-quality tissue are more predictably managed using open capsulorrhaphy. Patients with pathologic ligamentous laxity in the absence of a Bankart lesion or any apparent intraligamentous injury to the IGHL are also good candidates for treatment with an open capsulorrhaphy. Findings determined from a thorough physical examination, EUA, and the pathology appreciated during diagnostic arthroscopy help to appropriately choose the surgical procedure that effectively addresses pathology in patients who present with recurrent traumatic anterior instability. Patient preferences and surgical experience are important determinants of procedure selection, and current arthroscopic techniques lack the versatility to uniformly address the entire spectrum of pathology that may be associated with traumatic anterior shoulder instability. Surgeons should always be prepared to convert to an open-stabilization technique if the arthroscopic technique is deficient in addressing all pathology identified at the time of surgery.
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Affiliation(s)
- B J Cole
- Department of Orthopaedics, Rush Medical College of Rush University, Chicago, Illinois, USA
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162
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Abstract
Complications associated with arthroscopic shoulder stabilization are relatively common. Excluding recurrence, complications are rarely disabling. Current statistics undoubtedly underestimate the true incidence of complications. Many complications, including neurovascular injuries and articular damage, are preventable and can be minimized through familiarity with anatomy, proper surgical technique and instrumentation, and clinical experience. Nevertheless, despite these efforts, a few complications, including recurrent instability, persist. Despite careful patient selection and attention to labral pathology and capsular laxity, arthroscopic repairs continue to have success rates lower than those achieved through open means. While cautiously proceeding toward a more complete understanding of the instability continuum, surgeons must maintain a high index of suspicion for new techniques that purport to "solve" the problem of arthroscopic shoulder stabilization, lest the history of enthusiastic but ultimately unsubstantiated claims is repeated. Outcomes must withstand the rigors of scientific scrutiny and the test of time. Without this cautious vigilance, the appeal of today's solutions becomes the fodder of tomorrow's articles about the complications of arthroscopic shoulder stabilization.
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Affiliation(s)
- B S Shaffer
- Department of Orthopaedics, Georgetown University School of Medicine, Washington, DC, USA
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163
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Abstract
Magnetic resonance imaging (MRI) is frequently considered the best method of diagnosis in musculoskeletal disorders. Intraarticular fluid improves joint assessment by helping to delineate intraarticular structures, separating otherwise closely-apposed structures, and filling potential spaces which lie within or communicate with the joint. Initially, it was anticipated that plain MRI would replace arthrography. The message from our surgical colleagues is that this ideal has not yet been achieved. Greater precision should reduce the need for more invasive techniques, such as diagnostic arthroscopy which is why direct and indirect MR arthrography are being employed. This article reviews the current status of MR arthrography as an evolving technique in the imaging of joint disorders.
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Affiliation(s)
- W C Peh
- Department of Diagnostic Radiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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164
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Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study. J Shoulder Elbow Surg 1999; 8:66-74. [PMID: 10077800 DOI: 10.1016/s1058-2746(99)90058-7] [Citation(s) in RCA: 149] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The aim of this study was to evaluate the evolution of intraarticular disease in posttraumatic shoulder instability. Ninety-one patients with posttraumatic shoulder instability were examined arthroscopically. The intraarticular disease was recorded on a special documentation sheet (containing 67 descriptive items). The patients were divided into 5 subgroups: first-time dislocation (n = 9); first or second recurrence (n = 12); 3 to 5 recurrences (n = 23); 6 or more recurrences (n = 32); and chronic subluxations (n = 15). All data were examined statistically. Each lesion was correlated with stage of evolution, age, and number of recurrences. The most frequent lesions were regrouped into "lesion families." The initial and most constant lesion was the periosteal disinsertion of the anteroinferior labrum (single lesion). The labral detachment was succeeded in a second stage by the disinsertion of the glenohumeral ligament complex (double lesion). With additional recurrences, stress mechanisms altered the detached structures through tissue damage (triple lesion). The fourth stage saw the extension of the degenerative process, which led to failure at the insertion site and destruction of the labrum-ligament complex (quadruple lesion). This study reveals that recurrences progressively damage stabilizing structures. A pathophysiological classification into 4 stages is proposed, however, that would permit a precise therapeutic strategy for arthroscopic shoulder stabilization.
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165
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Abstract
Traumatic anterior shoulder instability has been shown to be associated with a spectrum of capsulolabral pathology, including separation of the labrum (Bankart lesion), capsular rupture, and humeral avulsion of the glenohumeral ligaments (HAGL lesion). We describe a case of combined Bankart and HAGL lesions, a condition that has not been described before. Careful anatomic repair of both components of this bipolar capsular injury resulted in an excellent outcome.
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Affiliation(s)
- J J Warner
- Department of Orthopaedic Surgery, University of Pittsburgh, PA 15213, USA
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166
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167
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168
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169
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Tirman PF, Steinbach LS, Belzer JP, Bost FW. A practical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 1997; 28:483-515. [PMID: 9257962 DOI: 10.1016/s0030-5898(05)70306-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Our understanding of shoulder disorders has changed considerably as a result of improved diagnostic tools, such as arthroscopy and multiplanar imaging modalities. The diagnosis of the cause of shoulder pain can be difficult because a spectrum of disorders, including cervical spine disease, acromioclavicular arthritis, and shoulder instability. Impingement and denervation syndromes can present with similar clinical findings. Accurate depiction of anatomic abnormalities is important for treatment planning. The purpose of this article is to report on the application of available imaging modalities, with emphasis on MR imaging. A strategy for the appropriate use of these studies and their variations of technique is also provided.
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Affiliation(s)
- P F Tirman
- San Francisco Magnetic Resonance Center, San Francisco, California 94118-1944, USA
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170
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Torchia ME, Caspari RB, Asselmeier MA, Beach WR, Gayari M. Arthroscopic transglenoid multiple suture repair: 2 to 8 year results in 150 shoulders. Arthroscopy 1997; 13:609-19. [PMID: 9343651 DOI: 10.1016/s0749-8063(97)90189-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
One hundred fifty-six arthroscopic transglenoid multiple suture repairs were performed for chronic anterior shoulder instability. In 150 shoulders (96% follow-up), the outcome with respect to recurrence of instability and the Bankart Score was determined a minimum of 2 years and a mean of 4.1 years after surgery (range, 2 to 8.2 years). During the follow-up interval, 11 shoulders (7.3%) redislocated. Fourteen other shoulders (9.3%) had at least one episode that we interpreted as recurrent subluxation. Shoulders with a Bankart lesion and younger patients had a higher probability of recurrent instability (P < .05). We concluded that this method is most effective in shoulders without a Bankart lesion and in patients older than 25 years of age (regardless of pathology).
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Affiliation(s)
- M E Torchia
- Department of Orthopedics, Mayo Clinic, Rochester, Minnesota 55905, USA
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171
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Affiliation(s)
- N G Mohtadi
- Department of Surgery, Foothills Hospital/Faculty of Medicine, University of Calgary, Alberta
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172
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Magnetic resonance imaging of theshoulder: Rotator cuff disease and glenohumeral instability. OPER TECHN SPORT MED 1997. [DOI: 10.1016/s1060-1872(97)80024-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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173
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Stoller DW. MR ARTHROGRAPHY OF THE GLENOHUMERAL JOINT. Radiol Clin North Am 1997. [DOI: 10.1016/s0033-8389(22)00580-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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174
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Abstract
This article describes a new lesion associated with anterior instability of the shoulder. The bony humeral avulsion of the glenohumeral ligaments (BHAGL) is a rare lesion that may occur after anterior dislocation of the shoulder. There is a bone fragment noted on radiographs of the shoulder that may appear similar to a bony glenoid avulsion. Computed tomography typically will show that the bone is attached to the glenohumeral ligaments and does not originate from the glenoid. Arthroscopy may or may not show the lesion. This variant of anterior shoulder instability may present with impingement or instability symptoms. If symptoms fail to respond to conservative management, treatment through open excision of the bony fragment and reattachment of the glenohumeral ligaments to their origin on the anterior aspect of the humerus is indicated.
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Affiliation(s)
- M A Oberlander
- Coastal Orthopaedic Group, Concord, California 94520, USA
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175
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176
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177
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Guanche CA, Quick DC, Sodergren KM, Buss DD. Arthroscopic versus open reconstruction of the shoulder in patients with isolated Bankart lesions. Am J Sports Med 1996; 24:144-8. [PMID: 8775110 DOI: 10.1177/036354659602400204] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We compared open and arthroscopic stabilizations of true Bankart lesions in patients with traumatic, unidirectional anterior glenohumeral dislocations. The 27 patients were men (age range, 18 to 56 years) who were involved in recreational sports. One group (15 patients) had elected an arthroscopic Bankart repair; the other group (12 patients) had chosen open stabilization with a standard deltopectoral approach. Patients were followed up 17 to 42 months after surgery by examination, radiographs, and interviews. In the open repair group, 1 of the 12 patients experienced a subluxation in the follow-up period, but no patients had dislocations or reoperations. In the arthroscopic group, 5 of 15 patients had experienced subluxation or dislocation; of these 5 patients, 2 underwent reoperation. The arthroscopic group had significantly worse results in satisfaction, stability, apprehension, and loss of forward flexion in the operated limb. In summary, the arthroscopic procedure did not significantly improve function; instead, it produced an increased failure rate compared with the open procedure. Therefore, we believe that open stabilization remains the procedure of choice for patients with true Bankart lesions.
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Affiliation(s)
- C A Guanche
- Minneapolis Sports Medicine Center, MN 55454, USA
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178
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179
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Feller JF, Tirman PF, Steinbach LS, Zucconi F. Magnetic resonance imaging of the shoulder: review. Semin Roentgenol 1995; 30:224-40. [PMID: 7570077 DOI: 10.1016/s0037-198x(05)80013-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- J F Feller
- Department of Radiology, David Grant Medical Center, Travis AFB, CA 94535-1800, USA
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180
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181
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Warner JJ, Miller MD, Marks P. Arthroscopic Bankart repair with the Suretac device. Part II: Experimental observations. Arthroscopy 1995; 11:14-20. [PMID: 7727006 DOI: 10.1016/0749-8063(95)90083-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthroscopic Bankart repair using the Suretac device (Acufex Microsurgical, Mansfield, MA) was developed as an alternative to both the staple and suture repair techniques. While offering some technical advantages compared with these other approaches, it's technical limitations and pitfalls have only been described anecdotally based on the clinical experience of several surgeons. The purpose of this study was to define these limitations and pitfalls. Eight cadaver shoulders underwent arthroscopic Bankart repair using the Suretac device after first arthroscopically creating a Bankart lesion. These shoulders were then dissected to reveal the placement of the Suretacs and the adequacy of the Bankart lesion repair. Glenoids were transected in the transverse plane and embedded in clear methylmethacrylate to show placement of the Suretac device relative to the articular surface. There were several technical errors that occurred: (1) Inadequate abrasion of the anterior and inferior juxta-articular scapular neck; (2) inadequate superior and medial shift of the inferior glenohumeral ligament before placement of the lowest Suretac, (3) medial placement of the Suretac relative to the articular margin; and (4) insufficient capture and compression of capsular tissue by the Suretac device. This procedure is technically difficult and careful attention must be paid to each step of preparation and repair. Recognition of the common errors may help the surgeon to avoid these pitfalls in the clinical situation.
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Affiliation(s)
- J J Warner
- Shoulder Service, University of Pittsburgh, Pennsylvania 15213, USA
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182
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Warner JJ, Miller MD, Marks P, Fu FH. Arthroscopic Bankart repair with the Suretac device. Part I: Clinical observations. Arthroscopy 1995; 11:2-13. [PMID: 7727007 DOI: 10.1016/0749-8063(95)90082-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Although arthroscopic Bankart repair has become an accepted surgical stabilization technique for anterior shoulder instability, the failure rate remains unacceptably high. Little information is available concerning healing of the Bankart repair. The purpose of this article is to clarify this issue by analyzing a cohort of 15 patients who underwent a "second-look" arthroscopy to evaluate and treat pain or recurrent instability following arthroscopic Bankart repair with the Suretac device (Acufex Microsurgical, Mansfield, MA). "Second-look" arthroscopy was performed at an average of 9 months following the index surgical procedure. The reasons for this second surgery were recurrent instability in 7, pain in 6, and pain and stiffness in 2. In the 7 patients with recurrent instability, the Bankart repair was found to be completely healed in 3 (43%), partially healed in 1 (14%), and had recurred in 3 (43%); however, 6 of 7 were observed to have lax capsular tissue. In 4 of these cases, retrospective review of the index surgical procedure showed that a technical error had been made during the repair. Two cases had biopsy of the repair site on "second-look" at 6 to 8 months, and this showed residual polyglyconate polymer debris surrounded by a histiocytic infiltrate. In the remaining 8 cases with stable shoulders, the Bankart repair had completely healed in 5 cases (62.5%) and partially healed in 3 cases (37.5%). The higher failure rate with this approach compared with open approaches appears to result from improper patient selection and errors in surgical technique. There is some question concerning healing strength of the Bankart repair, although complete healing of the Bankart does not seem to be a prerequesite for shoulder stability. Success of the procedure might be expected to improve by selecting only patients with unidirectional, posttraumatic, anterior instability who are found to have a discrete Bankart lesion and well-developed ligamentous tissue.
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Affiliation(s)
- J J Warner
- Shoulder Service, University of Pittsburgh, Pennsylvania 15213, USA
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183
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Abstract
The purpose of this paper is to report our experience with an arthroscopic stabilization technique using bone anchors in the treatment of chronic unidirectional anterior-inferior shoulder instability. 30 of 32 patients (average age, 26 years) were followed for an average of 24 months (range 12 to 36). There were 28 patients with dislocations and four with subluxations. In the group of the dislocators five patients had more than 10 dislocations and 15 patients between one and seven (average three). In 68% a sport injury was the reason for the first dislocation. Due to the length of the labroligamentous detachment two to four anchors were used for stabilization. According to the criteria of Rowe, in the group of the subluxators (4) two had an excellent and two a good result. In the group of the dislocators (26) two patients dislocated their shoulder again after reconstruction without a new accident, one had a recurrent dislocation from significant trauma. Two of them had an open stabilization afterwards. Overall there were 53.9% excellent, 34.6% good and 11.5% poor results. In 50% there was no restriction of shoulder motion, 21% had a loss of external rotation of 5 degrees and 29% of 10 degrees. Arthroscopic shoulder stabilization with help of Mitek anchors seems to be a good method for treatment of chronic unidirectional anterior-inferior instabilities with less than 10 dislocations preoperatively. All patients, who suffered a spontaneous recurrent dislocation, had more than 10 dislocations before. In these cases this arthroscopic procedure is not suited to restore stability, even if a Bankart-lesion is present.
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Affiliation(s)
- F Hoffmann
- Orthopädische Klinik im Klinikum Rosenheim, Bereich, Germany
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184
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Williams MM, Snyder SJ, Buford D. The Buford complex--the "cord-like" middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant. Arthroscopy 1994; 10:241-7. [PMID: 8086014 DOI: 10.1016/s0749-8063(05)80105-7] [Citation(s) in RCA: 239] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Two hundred consecutive shoulder arthroscopy videotapes were retrospectively reviewed, paying specific attention to the anatomy of the anterosuperior glenoid quadrant and especially the labroligamentous complex. Normal glenohumeral anatomy and all variations were carefully evaluated and recorded. Twenty-four (12%) patients had a sublabral foramen below the anterosuperior labrum; a "cord-like" middle glenohumeral ligament was present in 75% (18 of 24) of those cases or 9% of the study population. A smaller group of patients demonstrated a unique variant of normal capsulolabral anatomy that, for convenience, is termed the "Buford complex." This unusual variant was noted in 3 of the 200 (1.5%) shoulders and was distinguished by a "cord-like" middle glenohumeral ligament that originated directly from the superior labrum at the base of the biceps tendon and crossed the subscapularis tendon to insert on the humerus. There was no anterior-superior labral tissue present between this attachment and the midglenoid notch. This unusual-appearing anatomical variation may lead the surgeon to confuse this complex with a sublabral hole or a pathologic labral detachment. The labral tissue of the remaining three glenoid quadrants was normal. If the Buford complex is mistakenly reattached to the neck of the glenoid, as illustrated in our case example, severe painful restriction of rotation and elevation will occur.
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Affiliation(s)
- M M Williams
- Southern California Orthopedic Institute, Van Nuys 91405
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