[Multidirectional shoulder instability. Nonoperative and operative treatment strategies]

Traumatische posteriore Luxation als seltene Ursache einer multidirektionalen Schulterinstabilität im Profisport

Die multidirektionale Instabilität der Schulter als Folge einer traumatischen posterioren Luxation ist selten und in der Literatur nur unzureichend beschrieben. Hier präsentiert wird der Fall eines 28-jährigen Anschiebers aus dem deutschen Bob-Olympia-Kader, der eine weichteilige multidirektionale Instabilität in Folge einer traumatischen posterioren Luxation beim Mountainbiken erlitt. Die Stabilisierung des Schultergelenks erfolgte arthroskopisch mittels kombinierter anteriorer und posteriorer Labrumrefixation.

Coracohumeral Ligament Reconstruction for Patients With Multidirectional Shoulder Instability

Coracohumeral ligament pathology arises from acute trauma, capsular thickening, or congenital connective tissue disorders within the glenohumeral joint. Recent studies have highlighted the significance of this pathology in multidirectional shoulder instability because insufficiency of the rotator interval has become increasingly recognized and attributed to failed shoulder stabilization procedures. The diagnosis and subsequent treatment of coracohumeral ligament pathology can be challenging, however, because patients usually present with a history of failed surgical stabilization and persistent laxity. At the time of presentation, most patients have undergone failed nonoperative treatments and are indicated for surgical intervention. One of the options for the treatment of coracohumeral ligament pathology is reconstruction. The purpose of this Technical Note is to describe our preferred surgical technique for the reconstruction of the coracohumeral ligament. Research was performed at the Steadman Philippon Research Institute.

History of shoulder instability surgery

PURPOSE

The surgical management of shoulder instability is an expanding and increasingly complex area of study within orthopaedics. This article describes the history and evolution of shoulder instability surgery, examining the development of its key principles, the currently accepted concepts and available surgical interventions.

METHODS

A comprehensive review of the available literature was performed using PubMed. The reference lists of reviewed articles were also scrutinised to ensure relevant information was included.

RESULTS

The various types of shoulder instability including anterior, posterior and multidirectional instability are discussed, focussing on the history of surgical management of these topics, the current concepts and the results of available surgical interventions.

CONCLUSIONS

The last century has seen important advancements in the understanding and treatment of shoulder instability. The transition from open to arthroscopic surgery has allowed the discovery of previously unrecognised pathologic entities and facilitated techniques to treat these. Nevertheless, open surgery still produces comparable results in the treatment of many instability-related conditions and is often required in complex or revision cases, particularly in the presence of bone loss. More high-quality research is required to better understand and characterise this spectrum of conditions so that successful evidence-based management algorithms can be developed.

LEVEL OF EVIDENCE

IV.

Multidirectional Instability of the Shoulder: A Systematic Review

PURPOSE

To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI).

METHODS

A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed.

RESULTS

Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy.

CONCLUSIONS

Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.