Classification of glenohumeral joint instability

A simple, safe and painless method for acute anterior glenohumeral joint dislocations: "the forward elevation maneuver"

PURPOSE

The glenohumeral joint is the most frequently dislocated joint in the body. Numerous techniques for reducing an acute anterior dislocation of the glenohumeral joint have been described. The goal of this study was to assess the efficacy of Janecki's forward elevation maneuver for reducing a traumatic acute anterior glenohumeral joint dislocation.

METHODS

Between May 2010 and November 2011, the forward elevation maneuver was applied to 27 patients who presented to the emergency department of Yuzuncu Yil University Medical School with a traumatic anterior glenohumeral joint dislocation. For each patient, the forward elevation maneuver was used to reduce the anterior glenohumeral joint dislocation. The type of dislocation, the effectiveness of the procedure in achieving reduction, the need for premedication, the ease of performing the reduction and complications (if present) were noted.

RESULTS

Janecki's forward elevation maneuver was successful for 25 patients (92.6 %) on the first attempt. Premedication was not used for 22 patients, and reduction was successful for 20 of them. The method was not successful in two cases. Twenty-three of the patients (85.2 %) experienced no pain or mild pain. Complications referred to the reduction technique were not found in any patient.

CONCLUSIONS

This paper concludes that Janecki's forward elevation maneuver is a simple, safe, painless, and effective reduction method. Consequently, the forward elevation maneuver seems to be a good method for reducing anterior glenohumeral joint dislocation.

Evaluation of immobilization in external rotation after primary traumatic anterior shoulder dislocation: 5-year results

BACKGROUND

It is still not clear which method is the most efficient for treating primary traumatic anterior shoulder dislocation. Immobilization in external rotation has become increasingly discussed within the last 10 years. The aim of this study was to evaluate the rate of recurrence and clinical outcome of the immobilization in external rotation after primary traumatic anterior dislocation within a midterm period of 5 years. Additionally, a summary of literature is given according to the present knowledge of this issue.

METHODS

From May 2004 to May 2006, 28 patients with primary traumatic anterior shoulder dislocations were included in a prospective MRI-controlled study. After a follow-up of 5 years, the recurrence rate and clinical outcomes of the patients were evaluated using clinical scores (Constant and Murley score, Western Ontario Shoulder Instability Index, Rowe score).

RESULTS

After 5 years, 26 patients (93 %; males, n = 25; female, n = 1; mean age, 29.3 years) were interviewed concerning re-dislocations. In the meantime, four patients (15 %) experienced a re-dislocation (ø 12.2 months) after the end of the immobilization. Overall, 21 patients (75 %) were included in a clinical follow-up (CM score: ø 92.8 points; Western Ontario Shoulder Instability Index: ø 87 %; Rowe score (in 17 patients): ø 94.2 points). Upon clinical examination, unidirectional anterior instability was found in one patient, which corresponds to an overall instability rate of 19 % within the examined patient population including the re-dislocations.

CONCLUSIONS

Immobilization in external rotation shows satisfactory results after 5 years in regard to recurrence and instability rates and clinical outcomes. The data show that with immobilization in external rotation, re-dislocations occur within the first 2 years.

Outcomes of two surgical revision techniques for recurrent anterior shoulder instability following selective capsular repair

INTRODUCTION

Conventional capsulolabral reconstruction for anterior shoulder instability fails with recurrent instability in up to 23% of cases. Few studies have evaluated surgical revision strategies and outcomes. The objective of this study was to evaluate clinical and radiographic outcomes in a homogeneous series of surgical revisions after selective capsular repair (SCR).

HYPOTHESIS

Observed anatomic lesions can guide the choice between repeat SCR and coracoid transfer (Latarjet procedure).

MATERIALS AND METHODS

From January 2005 to January 2009, 11 patients with trauma-related recurrent anterior shoulder instability (episodes of subluxation and/or dislocation) after SCR were included. Mean age was 31 years (range, 19-45 years). At revision, a glenoid bony defect was present in six patients. Repeat SCR was performed in five patients and coracoid transfer in six patients.

RESULTS

After a mean follow-up of 40 months (range, 24-65 months), no patient had experienced further episodes of instability. However, four patients had a positive apprehension test. External rotation decreased significantly by more than 20° after both techniques. The Simple Shoulder Test, Walch-Duplay, and Rowe scores were 10.5, 79, and 85, respectively. No patient had a subscapularis tear. Of these 11 patients, nine were able to resume their sporting activities and eight reported being satisfied or very satisfied with the subjective outcome. Radiographs showed fibrous non-union of the coracoid transfer in one patient.

CONCLUSION

In patients with recurrent anterior shoulder instability after SCR, repeat SCR and coracoid transfer produce similarly satisfactory outcomes. The size of the glenoid bone defect may be the best criterion for choosing between these two procedures. However, open revision surgery may decrease the range of motion, most notably in external rotation.

LEVEL OF EVIDENCE

Level IV.

Reconstruction of a bony bankart lesion: best fit based on radius of curvature

BACKGROUND

The inferior coracoid process has traditionally been considered to be the gold standard for glenoid augmentation after anteroinferior bone loss. Other autograft sites, and more recently, osteochondral allograft sites, have been described as potential donor sources.

PURPOSE

Potential autograft and osteochondral allograft sites were compared to identify the graft source that would provide the best fit for glenoid augmentation.

STUDY DESIGN

Controlled laboratory study.

METHODS

Mose circles, a geometric tool found on a standard goniometer, were used to make radius of curvature measurements of 10 anatomic locations in 17 cadaveric specimens. The bony surface of the glenoid, measured from superior to inferior (G-SI) and from anterior to posterior (G-AP), was used as the standard for comparison. Autograft sites were the inferior coracoid, lateral coracoid, and inner table of the iliac crest. Potential osteochondral allograft sites were the radial head, scaphoid fossa of the distal radius (S-DR), lunate fossa of the distal radius (L-DR), medial tibial plateau, and lateral distal tibia. An acceptable match for autograft sites was based on a paired analysis and defined as a radius of curvature within 5 mm of the G-SI or the G-AP of the same cadaveric specimen. Allograft sites were evaluated using an unpaired analysis in which an ideal fit was defined as a radius of curvature of 25 to 30 mm, based on the interquartile range of the G-SI and G-AP.

RESULTS

The median (interquartile range) radii of curvature for the G-SI and G-AP were 30 mm (range, 25-30 mm) and 25 mm (range, 25-25 mm), respectively. The inferior coracoid was within 5 mm of the G-SI 59% of the time and the G-AP 94% of the time; no measurements from the lateral coracoid or iliac crest were within the range of the glenoid radius of curvature. Analysis of the allograft sites demonstrated an acceptable fit for 94% of the distal tibia, 68% of the medial tibial plateau, 12% of the S-DR, and 0% of the L-DR and the radial head specimens.

CONCLUSION

An autograft of the inferior coracoid or an osteochondral allograft of the lateral distal tibia provided the best match to re-establish the native radius of curvature of the glenoid.

CLINICAL RELEVANCE

To best re-create the native glenohumeral anatomy, surgeons should consider the use of an autograft of the inferior coracoid or an osteochondral allograft of the lateral distal tibia for the reconstruction of osseous glenoid defects.

Histopathologic evaluation of passive stabilizers in shoulder instability

BACKGROUND

The macroscopic pathomorphology in recurrent shoulder instability has been described. However, less is known regarding the histopathologic details of the affected structures. This study evaluates different histopathologic stages of shoulder instability by assessing biopsy specimens of static stabilizers for possible correlations with clinical parameters. Our hypothesis was that clinical parameters of shoulder instability correlate with histopathologic findings.

MATERIALS AND METHODS

Passive shoulder stabilizers (labrum, anterior bundle of the inferior glenohumeral ligament) were biopsied during arthroscopic shoulder stabilization. Samples were submitted to immunohistochemistry, in situ hybridization, and blinded evaluation. Clinical data, comprising age (<30 years or ≥30 years), total number of dislocations (1, 2-3, or >3), and period since initial dislocation (<6 months, 6 months to 6 years, or >6 years), were tested for statistical correlation with the following histopathologic parameters: inflammation, lipomatous changes, vascular proliferation, tissue fragmentation, and cellularity.

RESULTS

Standardized biopsies were performed in 30 consecutive patients (4 women and 26 men; mean age, 32.6 years) with anterior shoulder instability. Microscopic evaluation showed only small variations in histologic changes among all samples. Only limited variations in cell density, matrix swelling, and collagen fiber disruptions were found. Immunohistochemical analysis showed a similar expression of decorin in all samples. Clinical parameters (age, total number of dislocations, and period since initial dislocation) were statistically independent from histopathologic parameters (inflammation, lipomatous changes, vascular proliferation, tissue fragmentation, and cellularity). No correlation was found in patients with 1 dislocation versus those with more than 1 dislocation.

CONCLUSIONS

In contrast to macroscopic findings among different grades of shoulder instability, this study detected no correlation between clinical items (age, total number of dislocations, and period since initial dislocation) and histopathologic parameters. These clinical items seem to be independent from the tissue status of static stabilizers of the shoulder.

The "bony Bankart bridge" technique for restoration of anterior shoulder stability

BACKGROUND

Bony deficiency of the anteroinferior glenoid rim can cause recurrent glenohumeral instability. To address this problem, bony reconstruction is recommended in patients with glenoid bone loss more than 20% to 25%. Recent advances in shoulder surgery techniques allow for the arthroscopic reconstruction of glenoid bone defects to restore stability.

HYPOTHESIS

The all-arthroscopic "bony Bankart bridge" (BBB) technique for bony anterior glenohumeral instability can restore shoulder stability and provide good shoulder function as well as improve patient satisfaction for these difficult-to-treat cases.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A consecutive series of 15 patients with bony anterior shoulder instability were treated using the arthroscopic BBB technique. All patients were assessed with the Disabilities of the Arm, Shoulder and Hand-short version (QuickDASH), American Shoulder and Elbow Surgeons (ASES) score, and Short Form-12 (SF-12) preoperatively and at final evaluation. In addition, a specific questionnaire evaluated patient satisfaction and possible complications.

RESULTS

Two women and 13 men were included in the study, with an average age of 44 years (range, 24-70 years). The average glenoid bone loss was 29% (range, 17%-49%). The mean duration of follow-up was 2.7 years (range, 2.0-4.4 years). At that time, the mean ASES score had improved from 81 (range, 50-98) to 98 (range, 88-100) (P = .133). Although this change was not statistically significant because of low patient numbers, the amount of improvement was almost 3 times the minimal clinically important difference of 6.4 points as reported in previous studies. The mean SF-12 (physical component) improved from 46.8 to 56.2 at final follow-up (P = .015). The mean QuickDASH score at final follow-up was 2.8 (range, 0-15.9), and the mean Single Assessment Numeric Evaluation score was 99 (range, 95-100). There were 14 (93%) stable shoulders and 1 (7%) failure with redislocation from a fall. Median patient satisfaction at final follow-up was 10 (range, 7-10) out of 10.

CONCLUSION

The arthroscopic BBB technique for anterior instability with glenoid rim fracture successfully restores shoulder stability with a high median patient satisfaction (10/10) and a very low complication rate.

Arthroscopic stabilization for voluntary shoulder instability

BACKGROUND

Voluntary shoulder instability is characterized by a patient's ability to sublux their shoulder using selective muscle contraction and relaxation. High failure rates exist with open shoulder stabilization in this group of patients. The purpose of this study was to report the outcomes for patients with voluntary instability treated arthroscopically.

METHODS

All patients with voluntary instability from 2006 to 2008 treated with arthroscopic stabilization were included. All patients had documentation of preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) questionnaire score, visual analogue scale of pain, simple shoulder test, and range of motion. Subjective satisfaction and return to sport was also determined.

RESULTS

Ten patients were identified for inclusion in the study. The average age of the 5 male and 5 female patients was 16.2 ± 2.33 years. Average clinical follow-up period was 31 ± 6.5 months. Visual analogue scale scores improved from 5.33 ± 3.50 preoperatively to 1.44 ± 2.0 postoperatively, ASES scores improved from 52.2 ± 18.7 to 85.9 ± 14.9 and simple shoulder test improved from 8.17 ± 3.19 to 11.4 ± 1.01. All of the functional evaluation scores improved postoperatively (P < 0.05). There was no case of postoperative dislocation or subluxation, all reported excellent subjective outcome, and all those who played sports returned to their previous level.

CONCLUSIONS

Good and excellent outcomes can be obtained with arthroscopic stabilization for patients with voluntary instability. Improved results from previous reports may be related to improved patient selection, surgical technique, and postoperative rehabilitation. Although long-term follow-up and comparative studies are necessary, arthroscopic stabilization seems to be an acceptable treatment option for patients who fail nonoperative treatment.

LEVEL OF EVIDENCE

Level IV, case series, retrospective review.

Arthroscopic posterior bone block: surgical technique

Posterior glenohumeral instability remains a difficult problem. There are still many controversies regarding surgical treatment, due to a lack of understanding the pathomechanical issues leading to posterior instability. This article presents a new arthroscopic technique of posterior bone block augmentation, which we found to be effective, repeatable and successful. This technique can be used for combined soft tissue and bony defects as well as for revisions after previous soft tissue reconstructions.

Quantifying glenoid bone loss in anterior shoulder instability: reliability and accuracy of 2-dimensional and 3-dimensional computed tomography measurement techniques

BACKGROUND

Glenoid support is critical for stability of the glenohumeral joint. An accepted noninvasive method of quantifying glenoid bone loss does not exist.

PURPOSE

To perform independent evaluations of the reliability and accuracy of standard 2-dimensional (2-D) and 3-dimensional (3-D) computed tomography (CT) measurements of glenoid bone deficiency.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Two sawbone models were used; one served as a model for 2 anterior glenoid defects and the other for 2 anteroinferior defects. For each scapular model, predefect and defect data were collected for a total of 6 data sets. Each sample underwent 3-D laser scanning followed by CT scanning. Six physicians measured linear indicators of bone loss (defect length and width-to-length ratio) on both 2-D and 3-D CT and quantified bone loss using the glenoid index method on 2-D CT and using the glenoid index, ratio, and Pico methods on 3-D CT. The intraclass correlation coefficient (ICC) was used to assess agreement, and percentage error was used to compare radiographic and true measurements.

RESULTS

With use of 2-D CT, the glenoid index and defect length measurements had the least percentage error (-4.13% and 7.68%, respectively); agreement was very good (ICC, .81) for defect length only. With use of 3-D CT, defect length (0.29%) and the Pico(1) method (4.93%) had the least percentage error. Agreement was very good for all linear indicators of bone loss (range, .85-.90) and for the ratio linear and Pico surface area methods used to quantify bone loss (range, .84-.98). Overall, 3-D CT results demonstrated better agreement and accuracy compared to 2-D CT.

CONCLUSION

None of the methods assessed in this study using 2-D CT was found to be valid, and therefore, 2-D CT is not recommended for these methods. However, the length of glenoid defects can be reliably and accurately measured on 3-D CT. The Pico and ratio techniques are most reliable; however, the Pico(1) method accurately quantifies glenoid bone loss in both the anterior and anteroinferior locations. Future work is required to implement valid imaging techniques of glenoid bone loss into clinical practice.

CLINICAL RELEVANCE

This is one of the only studies to date that has investigated both the reliability and accuracy of multiple indicators and quantification methods that evaluate glenoid bone loss in anterior glenohumeral instability. These data are critical to ensure valid methods are used for preoperative assessment and to determine when a glenoid bone augmentation procedure is indicated.

The importance of the recognition and treatment of glenoid bone loss in an athletic population

CONTEXT

Osseous injury to the glenoid is increasingly being recognized as one of the most important aspects in the successful management of recurrent shoulder instability. Proper early recognition of glenoid bone injury in the setting of recurrent instability will lead to successful nonoperative and operative decision making, particularly in the athletic patient.

EVIDENCE ACQUISITION

We conducted a MEDLINE search on shoulder instability from 2000 to 2010. The emphasis was placed on patient-oriented Level 1 literature from 2000 to 2010.

RESULTS

After a traumatic anterior dislocation of the shoulder, the most common structural injury is an avulsion of the anteroinferior capsulolabrum, which is also known as a Bankart lesion. If this specific injury is accompanied by an associated fracture in the glenoid rim, the term bony Bankart lesion is more applicable. With diminished articular constraints, the glenohumeral joint is subject to recurrent instability, thereby potentiating the bony injury cycle. Additionally, patients with osseous defects usually complain of instability within the midranges of motion, or they recall a progression of instability. If glenoid bone loss is present, the humeral head often easily subluxates over the glenoid in the midranges of abduction (30°-90°) and lower levels of external rotation. Imaging workup should begin with plain radiographs, but advanced imaging should be obtained if there is any suspicion of bone loss. Treatment includes both nonoperative and operative interventions.

CONCLUSIONS

Estimation of the amount of glenoid bone loss and the failure of nonoperative care is essential for guiding management, patient expectations, and surgical decision making.

Recurrence after arthroscopic Bankart repair: Is quantitative radiological analysis of bone loss of any predictive value?

INTRODUCTION

Bone defects in the humeral head or antero-inferior edge of the glenoid cavity increase recurrence risk following arthroscopic Bankart repair. The present study sought to quantify such preoperative defects using a simple radiological technique and to determine a threshold for elevated risk of recurrence.

MATERIALS AND METHODS

A retrospective study conducted in two centers enrolled patients undergoing primary arthroscopic Bankart repair for isolated anterior shoulder instability in 2005. The principle assessment criterion was revision for recurrent instability. Quantitative radiology comprised: the ratio of notch depth to humeral head radius (D/R) on AP view in internal rotation; Gerber's X ratio between antero-inferior glenoid cavity edge defect length and maximum anteroposterior glenoid cavity diameter on arthro-CT scan; and the D1/D2 ratio between the glenoid joint surface diameters of the pathologic (D1) and healthy (D2) shoulders on Bernageau glenoid profile views. Seventy-seven patients were included, with a mean follow-up of 44 months (range, 36-54).

RESULTS

Overall recurrence rate was 15.6%. Recurrence risk was significantly greater when the humeral notch length was more or equal to 20% of the humeral head diameter and the Gerber ratio more or equal to 40%. On Bernageau views, mean D1/D2 ratio was 4.2% (range, 0-23%) in patients without recurrence, versus 5.1% (range, 0-19) in those with recurrence (P=0.003).

DISCUSSION

Beyond the above thresholds, bone defect as such contraindicates isolated arthroscopic stabilization. The D/R and Gerber ratios are simple and reproducible quantitative measurements can be taken in routine practice, enabling preoperative planning of complementary bone surgery as needed.

LEVEL OF EVIDENCE

Level IV; retrospective cohort study.

Instability of the shoulder following seizures

Dislocation of the shoulder may occur during seizures in epileptics and other patients who have convulsions. Following the initial injury, recurrent instability is common owing to a tendency to develop large bony abnormalities of the humeral head and glenoid and a susceptibility to further seizures. Assessment is difficult and diagnosis may be missed, resulting in chronic locked dislocations with protracted morbidity. Many patients have medical comorbidities, and successful treatment requires a multidisciplinary approach addressing the underlying seizure disorder in addition to the shoulder pathology. The use of bony augmentation procedures may have improved the outcomes after surgical intervention, but currently there is no evidence-based consensus to guide treatment. This review outlines the epidemiology and pathoanatomy of seizure-related instability, summarising the currently-favoured options for treatment, and their results.

An alternative technique for the exact sizing of glenoid bone defects

In posttraumatic shoulder dislocation, the size of a glenoid rim defect can determine the probability of recurrent dislocations. Most attempts to assess the size of such defects are based on the width of a defect in relation to glenoid length or diameter. So far, no method exactly calculating the area of articular surface missing has been reported. With the use of software originally designed for architectural purposes, the exact percentage of a glenoid defect was measured on three-dimensional computed tomography images.

Comparisons of glenoid bony defects between normal cadaveric specimens and patients with recurrent shoulder dislocation: an anatomic study

BACKGROUND

The location and degree of bony defects that can affect clinical outcomes remains controversial in recurrent shoulder dislocation. The purpose of this study was to define the most common location of glenoid bony defects in patients with recurrent shoulder dislocation.

MATERIALS AND METHODS

We analyzed the shape and aspect ratio of 44 glenoids from deceased donors. Glenoid size was analyzed using a 3-dimensional (3D) computed tomography (CT) scan in 24 patients with recurrent shoulder dislocation who underwent arthroscopic Bankart repair. We measured the distances from the center of the longitudinal axis of the glenoid to the anterior glenoid rim at 9 positions, 10° apart, from 3:00 to 6:00 o'clock positions in the cadaver and patient groups. We compared the quantification of glenoid defects in the 24 patients using the 3D CT scan. A predictive model based on a discriminant analysis was developed.

RESULTS

The largest length differences of the glenoid were at the 3:20 o'clock position. When percentage of bone antidefect of the 3:20 o'clock position was used, the model predicted the existence of a defect with 89.7% hit ratio.

CONCLUSIONS

The major direction of the glenoid defect was in a more anterior position rather than the anteroinferior glenoid in patients with recurrent shoulder dislocation. The 3:20 o'clock position was most common location of glenoid defect in shoulder instability. This pattern of bone loss should be considered by the surgeon when operating on these patients, especially when performing arthroscopic procedures for Bankart repair or bone block operations to the glenoid.

Anatomical glenoid reconstruction via a J-bone graft for recurrent posttraumatic anterior shoulder dislocation

OBJECTIVE

To reconstruct the anatomical glenoid shape in cases of osseous glenoid rim defects after recurrent posttraumatic anterior shoulder dislocation to restore stability without severely compromising the range of motion.

INDICATIONS

Osseous glenoid defects after recurrent posttraumatic anterior shoulder dislocation. Suitable for primary stabilization as well as for revision surgery in cases previously operated on.

CONTRAINDICATIONS

Recurrent anterior shoulder dislocations without glenoid rim defects. Hyperlax shoulders with multidirectional instability. Patients over 60 years of age due to compromised bone quality. Teenage patients due to incomplete apophyseal fusion at the iliac crest.

SURGICAL TECHNIQUE

The subscapularis tendon and capsule are split. The humeral head is retracted laterally, and the glenoid defect is prepared and abraded with a rasp. A bicortical iliac crest bone block including crest and outer cortex is harvested and molded in a J-shaped manner. To incorporate the graft, a crevice on the glenoid rim is produced using a chisel. The keel is fitted into the preformed crevice with a spiked impactor. The graft's surface is contoured using a high-speed burr.

RESULTS

A total of 47 shoulders were followed-up after an average of 90 months (range 25-152 months). The mean Rowe scores were 94.3 for the affected shoulder and 96.8 for the uninjured shoulder. The Constant scores reached 93.5 and 95 points, respectively. Loss of external rotation was 4.4°. In addition, 24 shoulders were followed-up by computed tomography (CT). There were no recurrences, with the exception of one traumatic graft fracture. Of 19 patients with arthropathy at follow-up, 11 already had arthropathy prior to the procedure.

Arthroscopic pancapsular plication for multidirectional shoulder instability in overhead athletes

Treating shoulder multidirectional instability with an open stabilization procedure has been reported to have good results. However, few studies exist of arthroscopic plication, especially in overhead athletes. The purpose of this study was to evaluate the clinical outcomes of arthroscopic pancapsular plication for multidirectional instability in overhead athletes.Twenty-three athletes with symptomatic multidirectional instability were treated with arthroscopic pancapsular plication and evaluated at a mean follow-up of 36.3 months (range, 24-61 months). Mean patient age was 23.3 years (range, 19-33 years). Functional outcomes were evaluated with the American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder score, and Rowe instability score. The degree of pain and range of motion were also recorded. All postoperative functional scores were rated good to excellent, with an average ASES score of 88.4 (range, 82-95), average Constant shoulder score of 88.1 (range, 81-100), and average Rowe instability score of 86.7 (range, 80-100). Five patients returned to the same level of competitive sports, and 18 returned to a limited level. All patients were satisfied with the stability postoperatively. No significant change was observed in postoperative range of motion, but patients who returned to a limited level of sports had lower functional scores and more pain than did those who fully returned to sports.Arthroscopic pancapsular plication for treating multidirectional instability in overhead athletes can provide good stability. However, the low rate of return to a full level of overhead sports is a problem. Further evaluation of the benefits of this procedure for overhead athletes with symptomatic multidirectional instability is needed.

Short-term complications of the Latarjet procedure

BACKGROUND

Although the results of the Latarjet procedure have been reported previously, there is little literature regarding the early complications of this procedure. The purpose of this study was to report our experience with the Latarjet procedure for glenohumeral instability and to highlight the initial complications that may occur following this procedure.

METHODS

Forty-seven patients (forty-eight shoulders) underwent the Latarjet procedure for anterior glenohumeral instability between January 2005 and January 2010. All shoulders had some osseous deficiency of the anterior glenoid rim or had undergone an unsuccessful prior soft-tissue Bankart repair. The minimum duration of patient follow-up was six months.

RESULTS

Forty-five shoulders were available for follow-up. The overall complication rate was 25% (twelve of the original forty-eight shoulders). Complications were divided into three groups: infection, recurrent glenohumeral instability, and neurologic injury. A superficial infection developed in three shoulders (6%); in all cases, the infection resolved following irrigation and debridement and administration of antibiotics for up to four weeks. Four shoulders (8%) developed recurrent glenohumeral instability; this occurred within eight months in two shoulders and at nineteen and forty-two months postoperatively in the other two. Five procedures (10%) resulted in a neurologic injury. Two of these involved the musculocutaneous nerve, one involved the radial nerve, and two involved the axillary nerve. The three musculocutaneous and radial nerve injuries involved sensory neurapraxia that resolved fully within two months. Both of the patients with axillary nerve dysfunction continued to have persistent sensory disturbances and one continued to have residual weakness that had not yet resolved fully at the time of the final follow-up.

CONCLUSIONS

The overall complication rate of 25% is higher than that reported in the literature. Although most of these complications resolved completely, two patients continued to have residual neurologic symptoms. Patients should be informed of the risk of complications associated with the Latarjet procedure, although most of the potential complications will resolve.

All-arthroscopic implant-free iliac crest bone grafting: new technique and case report

Glenoid bone loss is a recognized risk for recurrent instability. Open J-graft augmentation has been reported as a well-established procedure for anterior shoulder instability. Few data are available on arthroscopic techniques for the repair of bony Bankart lesions. We describe an all-arthroscopic implant-free iliac crest bone grafting technique and present the case of a 32-year-old hockey player who underwent glenoid reconstruction using this novel arthroscopic repair technique after 2 failed soft-tissue procedures. After 13 months, the patient reached nearly full range of motion with a slight loss of external rotation. The computed tomography scan showed a restoration of the glenoid cavity and complete healing of the graft.

Management of multidirectional instability of the shoulder

Multidirectional shoulder instability is defined as symptomatic instability in two or more directions. Instability occurs when static and dynamic shoulder stabilizers become incompetent due to congenital or acquired means. Nonspecific activity-related pain and decreased athletic performance are common presenting complaints. Clinical suspicion for instability is essential for timely diagnosis. Several examination techniques can be used to identify increased glenohumeral translation. It is critical to distinguish increased laxity from instability. Initial management begins with therapeutic rehabilitation. If surgical management is required, capsular plication has been used successfully. Advanced arthroscopic techniques offer several advantages over traditional open approaches and may have similar outcomes. The role of rotator interval capsular plication is controversial, but it may be used to augment capsular plication in patients with specific patterns of instability. Despite encouraging results, outcomes remain inferior to those associated with traumatic unidirectional instability.

Preoperative analysis of the Hill-Sachs lesion in anterior shoulder instability: how to predict engagement of the lesion

BACKGROUND

It has been reported that engagement of the Hill-Sachs lesion affects postoperative recurrence of anterior shoulder instability. However, no method has been recognized as an effective preoperative means to predict engagement of the Hill-Sachs lesion.

PURPOSE

This study was undertaken to assess the diagnostic validity of computed tomography (CT) with 3-dimensional (3D) reconstruction to judge engagement of the Hill-Sachs lesion preoperatively.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

One hundred four consecutive patients (107 shoulders) who underwent arthroscopic Bankart repair for traumatic anterior shoulder instability were enrolled for this study. Preoperatively, CT with 3D reconstruction was performed on all patients to evaluate the size (width and depth measured on axial and coronal images), orientation (Hill-Sachs angle), and location (bicipital and vertical angles) of the Hill-Sachs lesion. Dynamic arthroscopic examination was made to confirm engagement of the Hill-Sachs lesion. Then the correlation between the results and measurements on CT images was statistically analyzed.

RESULTS

In cases of engaging lesions, the mean width was 52% (range, 27%-66%) and the mean depth was 14% (range, 8%-20%) of the humeral head diameter on axial images. The corresponding measurements on coronal images were 42% (range, 16%-67%) and 13% (range, 5%-24%), respectively. In cases of nonengaging lesions, the corresponding measurements were 40% (range, 0%-71%) and 10% (range, 0%-21%) on axial images and 31% (range, 0%-62%) and 11% (range, 0%-46%) on coronal images. The size of engaging Hill-Sachs lesions was significantly larger than that of nonengaging lesions on both axial and coronal images (P = .001, < .001, .012, .007). The Hill-Sachs angle was 25.6° ± 7.4° in engaging lesions, which was significantly larger than 13.8° ± 6.2° in nonengaging lesions (P < .001). The bicipital and vertical angles did not demonstrate significant correlation with engagement of the Hill-Sachs lesion (P = .850, .584).

CONCLUSION

On CT with 3D reconstruction images, the engaging Hill-Sachs lesions were larger in size and more horizontally oriented to the humeral shaft than nonengaging lesions. The authors concluded that preoperative prediction of the engagement of the Hill-Sachs lesion, based on these findings, would be useful in planning additional procedures to treat a significant bone defect on the humeral head.

Recurrent anterior shoulder instability: accuracy of estimations of glenoid bone loss with computed tomography is insufficient for therapeutic decision-making

OBJECTIVE

To evaluate the reliability of glenoid bone loss estimations based on either axial computed tomography (CT) series or single sagittal ("en face" to glenoid) CT reconstructions, and to assess their accuracy by comparing with actual CT-based bone loss measurements, in patients with anterior glenohumeral instability.

MATERIALS AND METHODS

In two separate series of patients diagnosed with recurrent anterior glenohumeral instability, glenoid bone loss was estimated on axial CT series and on the most lateral sagittal (en face) glenoid view by two blinded radiologists. Additionally, in the second series of patients, glenoid defects were measured on sagittal CT reconstructions by an independent observer.

RESULTS

In both series, larger defects were estimated when based on sagittal CT images compared to axial views. In the second series, mean measured bone loss was 11.5% (SD = 6.0) of the total original glenoid area, with estimations of 9.6% (SD = 7.2) and 7.8% (SD = 4.2) for sagittal and axial views, respectively. Correlations of defect estimations with actual measurements were fair to poor; glenoid defects tended to be underestimated, especially when based on axial views.

CONCLUSION

CT-based estimations of glenoid bone defects are inaccurate. Especially for axial views, there is a high chance of glenoid defect underestimation. When using glenoid bone loss quantification in therapeutic decision-making, measuring the defect instead of estimating is strongly advised.

Arthroscopic capsular shift technique and volume reduction

Multidirectional instability is very complex pathology. Excessively redundant capsule is one of the important reasons causing symptomatic laxity in multiple planes. Arthroscopic techniques are not able to reproduce the potential of open methods to reduce the joint volume. Most of the studies based their measurements on cadaver model. The aim of the study was to develop simple and reproducible technique to perform arthroscopic capsular shift and measure its volume reduction potential in both cadaveric and clinical setting. Technique is described in the paper. Capsular shift was applied both in cadaver and clinical scenario. Based on group of 5 cadaver shoulder specimen, glenohumeral joint volume was reduced from average of 19.4 ± 7.8 ml to 11.9 ± 4.5 ml following arthroscopic capsular shift (37.9% volume reduction). Clinical material consisted of 12 consecutive patients shoulder with instability and joint laxity undergoing the arthroscopic capsular shift. Average glenohumeral volume before capsular shift was 43.5 ± 10 ml and was reduced to 17.5 ± 4.3 ml (58.8% volume reduction). Arthroscopic capsular shift presented in this paper seems to be relatively easy to perform and safe procedure. The technique provides significant decrease in joint volume in both cadaveric and clinical parts of the study.

Analysis of risk factors for glenoid bone defect in anterior shoulder instability

BACKGROUND

Glenoid bone defect is frequently associated with anterior shoulder instability and is considered one of the major causes of recurrence of instability after shoulder stabilization.

HYPOTHESIS

Some risk factors are significantly associated with the presence, size, and type of glenoid bone defect.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

One hundred sixty-one patients affected by anterior shoulder instability underwent morphologic evaluation of the glenoid by computed tomography scans to assess the presence, size, and type of glenoid bone defect (erosion or bony Bankart lesion). Bone loss greater than 20% of the area of the inferior glenoid was considered "critical" bone defect (at risk of recurrence). Outcomes were correlated with the following predictors: age, gender, arm dominance, frequency of dislocation, age at first dislocation, timing from first dislocation, number of dislocations, cause of first dislocation, generalized ligamentous laxity, type of sport, and manual work.

RESULTS

Glenoid bone defect was observed in 72% of the cases. Presence of the defect was significantly associated with recurrence of dislocation compared with a single episode of dislocation, increasing number of dislocations, male gender, and type of sport. Size of the defect was significantly associated with recurrent dislocation, increasing number of dislocations, timing from first dislocation, and manual work. Presence of a critical defect was significantly associated with number of dislocations and age at first dislocation. Bony Bankart lesion was significantly associated with male gender and age at first dislocation.

CONCLUSION

The number of dislocations and age at first dislocation are the most significant predictors of glenoid bone loss in anterior shoulder instability.

Comparison between 2D and 3D computed tomography evaluation of glenoid bone defect in unilateral anterior gleno-humeral instability

PURPOSE

This study evaluated the agreement between 2D and 3D computed tomography (CT) measurements in identifying the size and type of glenoid-bone defect in anterior glenohumeral instability.

MATERIALS AND METHODS

One hundred patients affected by unilateral anterior glenohumeral instability underwent a CT of both shoulders. Images were processed with both 2D [multiplanar reconstruction (MPR)] and 3D [volumerendering (VR)] methods. The area of the missing glenoid was calculated in comparison with the healthy glenoid and expressed as a percentage. Agreement between the two measurements was assessed according to the Bland-Altman method; a 5% mean difference was considered as clinically relevant.

RESULTS

Analysis of agreement between MPR and VR measurements of the percentage of missing glenoid showed a mean difference equal to 0.62%±1.96%. Percent agreement between the two measurements in detecting the presence of bone defect was 97% (p<0.0001). Percent agreement between the two measurements in discriminating the type of bone defect was 97% (p<0.0001).

CONCLUSIONS

Agreement between 2D (MPR) and 3D (VR) CT measurements to identify the size and type of glenoid-bone defect in anterior glenohumeral instability was so high that the two measurements can be considered interchangeable.

Development and reliability testing of the frequency, etiology, direction, and severity (FEDS) system for classifying glenohumeral instability

HYPOTHESIS

Classification systems for glenohumeral instability (GHI) are opinion based, not validated, and poorly defined. The hypothesis driving this investigation is that a classification system with content validity will have high inter-observer and intra-observer agreement.

MATERIALS AND METHODS

The classification system was developed by first conducting systematic literature review that identified 18 systems for classifying GHI. The frequency of characteristics used was recorded. Additionally, 31 members of the American Shoulder and Elbow Surgeons responded to a survey to identify features important to characterize GHI. Frequency, etiology, direction, and severity (FEDS) were most important. Frequency was defined as solitary (1 episode), occasional (2 to 5 times/y), or frequent (>5 times/year). Etiology was defined as traumatic or atraumatic. Direction referred to the primary direction of instability (anterior, posterior, or inferior). Severity was subluxation or dislocation. For reliability testing, 50 GHI patients completed a questionnaire at their initial visit. One of 6 sports medicine fellowship-trained physicians completed a similar questionnaire after examining the patient. Patients returned after 2 weeks and were examined by the original physician and 2 other physicians. Interrater and intrarater agreement for the FEDS classification system was calculated.

RESULTS

Agreement between patients and physicians was lowest for frequency (39%; κ = 0.130) and highest for direction (82%; κ = 0.636). Physician intrarater agreement was 84% to 97% for the individual FEDS characteristics (κ = 0.69-0.87), and interrater agreement was 82% to 90% (κ = 0.44-0.76).

CONCLUSIONS

The FEDS system has content validity and is highly reliable for classifying GHI. Physical examination using provocative testing to determine the primary direction of instability produces very high levels of interrater and intrarater agreement.

Evaluation of the Clinical Significance of Classification of Traumatic Anterior Shoulder Instability Using Double-Contrast Computed Tomography Arthrography

This study evaluated the clinical significance of traumatic anterior shoulder instability (TASI) classification using double-contrast computed tomography (CT) arthrography. Patient were randomly assigned to two groups: group 1 ( n = 62); and group 2 ( n = 63). TASI symptom severity in group 1 was assessed using physical signs of shoulder trauma and conventional X-ray, CT and magnetic resonance imaging; these patients received either conservative management (with physical rehabilitation) or standard surgery. Group 2 underwent double-contrast CT arthrography to classify TASI; its findings formed the basis of subsequent management. At 24 months post-therapy, significant improvements in clinical outcomes were observed in group 2: Constant scores were higher and Western Ontario Shoulder Instability Index scores were lower. At 24 months, recurrence rates were 21.0% (13/62) in group 1 and 7.9% (5/63) in group 2. Findings suggested that TASI classification using double-contrast CT arthrography provided meaningful information thereby improving treatment efficacy.

Subjective and objective outcome after revision arthroscopic stabilization for recurrent anterior instability versus initial shoulder stabilization

BACKGROUND

The value of arthroscopic revision shoulder stabilization after failed instability repair is still a matter of debate.

HYPOTHESIS

Arthroscopic revision shoulder stabilization using suture anchors provides equivalent subjective and objective results compared with initial arthroscopic instability repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty consecutive patients who underwent arthroscopic revision shoulder stabilization using suture anchors (group 2) were matched for age, gender, and handedness (dominant or nondominant) with 20 patients who had initial arthroscopic instability repair using the same technique (group 1). At the time of follow-up, a complete physical examination of both shoulders and evaluation with the Rowe score, Walch-Duplay score, Melbourne Instability Shoulder Score, Western Ontario Shoulder Instability Index, and the Subjective Shoulder Value were performed. In addition, standard radiographs (true AP and axillary views) were taken to evaluate signs of osteoarthritis.

RESULTS

After a minimum follow-up of 24 months, no recurrent dislocations were observed in either group. The apprehension sign was positive in 2 cases of revision surgery (0 vs 2; P > .05). No significant differences in the Rowe score (89 vs 81.8 points) were found between groups 1 and 2 (P > .05). However, group 2 revealed significantly lower scores in the Walch-Duplay score (85.3 vs 75.5 points), Melbourne Instability Shoulder Score (90.2 vs 73.7 points), Western Ontario Shoulder Instability Index (89.8% vs 68.9%), and Subjective Shoulder Value (91.8% vs 69.2%) (P < .05). Signs of instability arthropathy were found more often in patients with arthroscopic revision surgery (2 vs 5; P > .05).

CONCLUSION

Arthroscopic revision shoulder stabilization is associated with a lower subjective outcome compared with initial arthroscopic stabilization. The objective results found in this study may overestimate the clinical outcome in this patient population.

Management of glenoid and humeral bone loss

Glenoid and humeral head bone deficiency is a common reason for recurrent anterior shoulder instability and failure of capsulolabral reconstruction. There is a strong association between the severity of the bone defects and the number and ease of recurrent instability. Clinical evaluation, advanced imaging, examination under anesthesia, and diagnostic arthroscopy are important in decision making. Glenoid bone loss greater than 20%, an engaging Hill-Sachs lesion, or Instability Severity Index Score greater than 6 are indications for an open bony procedure to restore the glenoid articular arc. Hill-Sachs lesions greater than 30% should be directly addressed with either an arthroscopic remplissage technique or open bone grafting procedure.

[Conservative therapy of antero-inferior glenoid fractures]

The adequate treatment of antero-inferior glenoid rim fractures is a controversial issue. Marginal knowledge exists about the results of non-operative treatment. Therefore, the aim of this study was to evaluate the results of conservative treatment of acute fragment type lesions (type Ib) of the antero-inferior glenoid.A total of 10 patients (5 female and 5 male, mean age 56.5 years) were included in this retrospective study. A complete clinical examination of the shoulders and four functional scores, the Constant Score (CS), Rowe Score (RS), Western Ontario Shoulder Instability Index (WOSI) and Subjective Shoulder Value (SSV) as well as a radiologic evaluation using true a/p and axillary radiographs were performed.After a mean follow-up of 26.4 months no clinical signs of subjective instability or redislocation were found. The median CS reached 80.5 points (range 52-88) versus 84 points (range 73-90) on the healthy contralateral side (p >0.05). The RS, WOSI and SSV achieved 95 points (range 70-100), 86.7% (range 51-99.6%) and 85 % (range 50-100%), respectively. The radiologic evaluation showed a consolidated fragment in all patients. The anterior subchondral sclerosis zone was reformed completely in seven patients. The mean intra-articular step-off was 2 mm (range 0-6 mm). Osteoarthritis was seen in two cases (one grade I and one grade II according to Samilson and Prieto) none of which was symptomatic and the one grade II was present at the time of trauma.The conservative treatment of acute fragment type lesions (type Ib) of the antero-inferior glenoid can lead to excellent and satisfactory clinical results and therefore represents a suitable treatment alternative in the middle aged patient population. Nevertheless, future studies have to explicitly define the exact indications for a conservative versus surgical treatment approach.

Arthroscopic rotator interval closure in shoulder instability repair: a retrospective study

BACKGROUND

Arthroscopic Bankart repair (ABR) is a standard treatment for recurrent anterior shoulder instability. Young age, hyperlaxity, loss of bone stock and multidirectional or voluntary type of instability are all associated with failure of this procedure. Rotator interval laxity is associated with shoulder instability, whereas rotator interval closure increases humeral head stability and reduces shoulder range of motion.

METHODS

The records of patients with recurrent anterior shoulder dislocations who underwent ABR with or without arthroscopic rotator interval closure (ARIC) in our department between 1999 and 2007 were reviewed. Rates of recurrent dislocation or symptomatic subluxation as well as functional outcome were evaluated using Walch-Dupley score.

RESULTS

Three (8.1%) of the 37 ABR+ARIC patients (age 19-44 years, 32 males) had re-dislocated their shoulder at 42±16 months following the procedure, all of which had systemic joint hyperlaxity. Six (13%) of the 46 ABR patients (age 19-39 years, 42 males) had re-dislocated their shoulder at 13±14 months, three of which had systemic joint hyperlaxity and dislocated their shoulder within 1 year following the operation. Systemic joint hyperlaxity (28% of ABR and 41% of ABR+ARIC patients) was significantly associated with recurrent dislocation and poor functional outcome. ABR+ARIC patients had slightly more limited range of motion with similar good and excellent functional results (75%) at final follow up time.

CONCLUSIONS

Systemic joint hyperlaxity is a risk factor for failure of ABR. When ARIC is performed in combination with ABR, it may have an additive effect on shoulder stability.

Stabilizing mechanism in bone-grafting of a large glenoid defect

BACKGROUND

Conventional wisdom suggests that the glenoid defect after a shoulder dislocation is anteroinferior. However, recent studies have found that the defect is located anteriorly. The purposes of this study were (1) to clarify the critical size of the anterior defect and (2) to demonstrate the stabilizing mechanism of bone-grafting.

METHODS

Thirteen cadaver shoulders were investigated. With use of a custom testing machine with a 50-N compression force, the peak translational force that was needed to move the humeral head and lateral humeral displacement were measured. The force was used to evaluate the joint stability. An osseous defect was created stepwise in 2-mm increments of the defect width. The bone graft was harvested from the coracoid process. The defect size was expressed as the estimated defect size divided by the measured glenoid length. Testing was performed with (1) the glenoid intact, (2) a simulated Bankart lesion, (3) the Bankart lesion repaired, (4) a 2-mm defect, (5) the Bankart lesion repaired, (6) the defect bone-grafted, (7) a 4-mm defect, (8) the Bankart lesion repaired, (9) the defect bone-grafted, (10) a 6-mm defect, (11) the Bankart lesion repaired, (12) the defect bone-grafted, (13) an 8-mm defect, (14) the Bankart lesion repaired, and (15) the defect bone-grafted.

RESULTS

Force and displacement decreased as the size of the osseous defect increased. The mean force after the formation of a defect of > or =6 mm (19% of the glenoid length) with the Bankart lesion repaired (22 +/- 7 N) was significantly decreased compared with the baseline force (52 +/- 11 N). Both the mean force (and standard deviation) and displacement returned to the levels of the intact condition (68 +/- 3 N and 2.6 +/- 0.4 mm, respectively) after bone-grafting (72 +/- 12 N and 2.7 +/- 0.3 mm, respectively).

CONCLUSIONS

An osseous defect with a width that is > or =19% of the glenoid length remains unstable even after Bankart lesion repair. The stabilizing mechanism of bone-grafting was the restoration of the glenoid concavity.

Repair of an anteroinferior glenoid defect by the latarjet procedure: quantitative assessment of the repair by computed tomography

PURPOSE

The purpose of this study was to determine quantitatively whether the Latarjet procedure (coracoid transfer to the glenoid) is sufficient to restore a significant defect area of the glenoid.

METHODS

Fourteen cadaveric shoulders were used (mean age, 76 years; range, 72 to 87 years). An anteroinferior glenoid defect was created and then the coracoid osteotomized to its angle and transferred to the defect. A 3-dimensional computed tomography scan was used to calculate the surface area of (1) the intact glenoid, (2) the osteotomized glenoid, and (3) the reconstructed glenoid.

RESULTS

The mean area of the intact inferior glenoid was 734 +/- 89 mm(2). After creation of the defect, the surface area of the glenoid was reduced significantly to 523 +/- 55 mm(2) (P = .011). The mean defect area was 28.7% +/- 6% of the intact glenoid. After coracoid transfer, the mean surface area of the reconstructed glenoid was 708 +/- 71 mm(2) but it was not significantly smaller than that of the intact glenoid (P = .274). The mean surface area of the coracoid that was used to repair the defect was 198 +/- 34 mm(2), or 27% +/- 5% of the intact glenoid.

CONCLUSIONS

In our cadaveric model, a mean 29% defect size of the inferior glenoid was restored to normal after coracoid transfer by use of the Latarjet procedure.

CLINICAL RELEVANCE

In the clinical scenario, the existence of a glenoid bone defect of more than 25% to 30% is very rare in patients with anterior shoulder instability. Therefore, when clinically indicated, large bony defects of the anterior glenoid can be adequately treated by the Latarjet procedure.

Management of failed instability surgery: how to get it right the next time

Traumatic anterior shoulder dislocations are the most frequent type of joint dislocation and affect approximately 1.7% of the general population. The literature supports the consideration of primary stabilization in high-risk patients because of reported recurrences as high as 80% to 90% with nonoperative treatment regimens. Successful stabilization of anterior glenohumeral instability relies on not only good surgical techniques but also careful patient selection. Failure rates after open and arthroscopic stabilization have been reported to range from 2% to 8% and 4% to 13%, respectively. Recurrent shoulder instability leads to increased morbidity to the patient, increased pain, decreased activity level, prolonged time away from work and sports, and a general decrease in quality of life. This article reviews the potential pitfalls in anterior shoulder stabilization and discusses appropriate methods of addressing them in revision surgery.

Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review

OBJECTIVE

The purpose is to systematically evaluate the literature regarding treatment of chronic glenoid bone defects in the setting of recurrent anterior shoulder instability to determine if, from an evidence-based outcomes approach, one technique may be recommended over the other.

METHODS

PubMed 1966-2009, Embase 1980-2009, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials databases were searched for human studies in English. Keywords were osseous glenoid defects, glenoid bone grafting, Latarjet procedure, iliac crest and glenoid defects, and glenoid rim fractures. Inclusion criteria were all articles evaluating chronic glenoid deficiency in the setting of recurrent anterior glenohumeral instability. Exclusion criteria were surgical techniques not reporting follow-up, glenoid rim fractures treated by open reduction internal fixation, and investigations not quantifying glenoid deficiency assessments.

RESULTS

Six articles met all inclusion and exclusion criteria. All articles were level IV (case series), most (5/6) were retrospective. Multiple techniques involving coracoid transfer and allograft or autograft reconstruction have been described for management of chronic glenoid deficiency. Lack of high level evidence in the form of prospective randomized trials limits our ability to recommend one technique over another. The 6 techniques reviewed here were all effective at preventing recurrent instability.

CONCLUSIONS

Chronic glenoid deficiency in the setting of recurrent anterior instability is an extremely challenging problem. There remains a lack of strong evidence guiding the surgeon in the decision-making process. Additional research is needed to optimize the preoperative glenoid defect assessment, further evaluate the reconstruction techniques, and follow the long-term effects of reconstruction on the development of glenohumeral arthrosis.

Shoulder instability in patients with joint hyperlaxity

Generalized ligamentous hyperlaxity and glenohumeral joint instability are common conditions that exhibit a spectrum of diverse clinical forms and may coexist in the same patient. No single diagnostic test can confirm the presence of these disorders, and a careful clinical assessment is important. Unlike patients with traumatic shoulder instability, patients with hyperlaxity and instability are more likely to experience episodes of recurrent subluxation than they are to have recurrent dislocation. They are more likely to have instability in more than one anatomic plane, and they usually do not have the soft-tissue and osseous lesions associated with traumatic instability. Shoulder symptoms in a patient with hyperlaxity are not always due to instability; other pathological conditions may coexist, with rotator cuff impingement being the most common. Most patients with hyperlaxity have a reduction in instability symptoms after nonoperative treatment, including physical therapy, activity modification, and additional psychological support when necessary. Operative treatment provides reproducibly good results for patients with hyperlaxity who do not respond to a prolonged program of nonoperative measures. Open inferior capsular shift remains the gold standard of operative treatment, although arthroscopic capsular shift and plication procedures are now producing comparable results. Thermal capsulorrhaphy is associated with unacceptably high failure rates and postoperative complications and cannot be recommended as a treatment.

Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: a diagnostic sign for an osseous defect of the anterior glenoid rim

BACKGROUND

The integrity of the glenoid defines the surgical treatment in anterior shoulder instabilities. The reliability of plain radiographs to detect anterior glenoid rim deficiencies was determined.

MATERIALS AND METHODS

The anterior sclerotic glenoid line (SGL) was assessed on anteroposterior radiographs of 86 shoulders (34 anterior instabilities, 15 posterior instabilities, 37 stable) and compared with computed tomography (CT) scans (gold standard). A loss of the SGL (LSGL) was defined as a positive LSGL sign.

RESULTS

On CT scans, 25 of 34 shoulders (74%) with anterior instabilities showed a defect of the anterior glenoid rim. No defects were found in shoulders without anterior instabilities. LSGL correctly predicted an anterior glenoid rim lesion in 16 (examiner A) or 14 (examiner B) of the 25 anterior instabilities (sensitivity, 64% and 56%), without a false-positive diagnosis (specificity, 100%).

CONCLUSION

The LSGL on anteroposterior radiographs is a moderately sensitive but highly specific finding for anterior glenoid rim defects.

LEVEL OF EVIDENCE

Level 4; Diagnostic study, case control study.

Arthroscopic treatment of multidirectional glenohumeral instability in young overhead athletes

Purpose:

This prospective case series evaluates the outcome, and the return to sports of young overhead athletes with a persistent, symptomatic multidirectional instability (MDI) with hyperlaxity type Gerber B5 treated with an arthroscopic anteroposteroinferior capsular plication and rotator interval closure.

Methods:

9 young overhead athletes (10 shoulders) with the rare diagnosis of MDI (Gerber B5) and an indication for operative treatment, after a failed physiotherapy program were physically examined 3, 6 and 12 months postoperatively by a physical examination, and got a final phone interview after median 39 months.

Results:

At the final follow-up all patients were satisfied; Rowe Score showed 7 “excellent” and “good” results; Constant Score was “excellent” and “good” in 6, and “fair” in 1 patient. 7/9 returned to their previous sports, 3/9 at a reduced level.

Conclusion:

Symptomatic MDI requires an individual indication for surgical treatment after a primary conservative treatment. The described arthroscopic technique stabilizes glenohumeral joint. A return to overhead sports is possible but often at a reduced level; returning to high-performance sports cannot be recommended because of the high risk of reinstability.

Intra-observer and interobserver reliability of the 'Pico' computed tomography method for quantification of glenoid bone defect in anterior shoulder instability

OBJECTIVE

To evaluate the intra-observer and interobserver reliability of the 'Pico' computed tomography (CT) method of quantifying glenoid bone defects in anterior glenohumeral instability.

MATERIALS AND METHODS

Forty patients with unilateral anterior shoulder instability underwent CT scanning of both shoulders. Images were processed in multiplanar reconstruction (MPR) to provide an en face view of the glenoid. In accordance with the Pico method, a circle was drawn on the inferior part of the healthy glenoid and transferred to the injured glenoid. The surface of the missing part of the circle was measured, and the size of the glenoid bone defect was expressed as a percentage of the entire circle. Each measurement was performed three times by one observer and once by a second observer. Intra-observer and interobserver reliability were analyzed using intraclass correlation coefficients (ICCs), 95% confidence intervals (CIs), and standard errors of measurement (SEMs).

RESULTS

Analysis of intra-observer reliability showed ICC values of 0.94 (95% CI = 0.89-0.96; SEM = 1.1%) for single measurement, and 0.98 (95% CI = 0.96-0.99; SEM = 1.0%) for average measurement. Analysis of interobserver reliability showed ICC values of 0.90 (95% CI = 0.82-0.95; SEM = 1.0%) for single measurement, and 0.95 (95% CI = 0.90-0.97; SEM = 1.0%) for average measurement.

CONCLUSION

Measurement of glenoid bone defect in anterior shoulder instability can be assessed with the Pico method, based on en face images of the glenoid processed in MPR, with a very good intra-observer and interobserver reliability.

Arthroscopic treatment of multidirectional shoulder instability in athletes: a retrospective analysis of 2- to 5-year clinical outcomes

BACKGROUND

There are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the shoulder.

HYPOTHESIS

Arthroscopic management of symptomatic multidirectional instability in an athletic population can successfully return athletes to sports with a high rate of success as determined by patient-reported outcome measures.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty patients (43 shoulders) with multidirectional instability of the shoulder were treated via arthroscopic means and were evaluated at a mean of 33.5 months postoperatively. The mean patient age was 19.1 years (range, 14-39). There were 24 male patients and 16 female patients. Patients were evaluated with the American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability scoring systems. Stability, strength, and range of motion were also evaluated with patient-reported scales.

RESULTS

The mean American Shoulder and Elbow Surgeons score postoperatively was 91.4 of 100 (range, 59.9-100). The mean Western Ontario Shoulder Instability postoperative percentage score was 91.1 of 100 (range, 72.9-100). Ninety-one percent of patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% were able to return to their sport with little or no limitation.

CONCLUSION

Arthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic population.

Open reconstruction of large bony glenoid erosion with allogeneic bone graft for recurrent anterior shoulder dislocation

BACKGROUND

Severe glenoid bone loss in recurrent anterior glenohumeral instability is rare and difficult to treat.

PURPOSE

The authors present a surgical technique using allogeneic bone grafting for open anatomic glenoid reconstruction in addition to the capsular shift procedure.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Nine consecutive patients with a history of recurrent anterior shoulder instability underwent reconstruction of large bony glenoid erosion with a femoral head allograft combined with an anteroinferior capsular shift procedure. Preoperative computed tomographic and arthroscopic evaluation was performed to confirm a > or =120 degrees osseous defect of the anteroinferior quadrant of the glenoid cavity, which had an "inverted-pear" appearance. Patients were followed for at least 4.5 years (range, 4.5-14). Serial postoperative radiographs were evaluated. Functional outcomes were assessed using Rowe scores.

RESULTS

All grafts showed bony union within 6 months after surgery. The mean Rowe score improved to 84 from a preoperative score of 24. The mean loss of external rotation was 7 degrees compared with the normal shoulder. One subluxation and 1 dislocation occurred after grand mal seizures during follow-up. These 2 patients regained shoulder stability after closed reduction. The remaining patients did not report recurrent instability. All patients resumed daily activities without restricted motion.

CONCLUSION

This technique for open reconstruction is viable for the treatment of recurrent anterior glenohumeral instability with large bony glenoid erosion.

[Multidirectional shoulder instability. Nonoperative and operative treatment strategies]

Multidirectional shoulder instability (MDI) is characterized by symptomatic instability in at least two directions, often with a global hyperlaxity. The etiology is mostly atraumatic, with an acquired or congenital enlarged capsular volume or redundancy. Muscular imbalances and pathologic patterns of muscle recruitment and motion are also common findings. Traumatic onset of MDI is rare, although capsulolabral lesions can be found during surgery. Therapy aims at a normalization of muscle balance/weakness and motion patterns. If conservative treatment fails, arthroscopic capsular plication techniques, in combination with repair of labral and interval lesions, can accomplish results similar to those of classic open techniques but with reduced morbidity and invasiveness.