Effect of arthroscopic techniques on joint volume in shoulder instability: Bankart repair versus capsular shift

Current Concepts on the Management of Shoulder Instability in Throwing Athletes

PURPOSE OF REVIEW

The management of shoulder instability in throwing athletes remains a challenge given the delicate balance between physiologic shoulder laxity facilitating performance and the inherent need for shoulder stability. This review will discuss the evaluation and management of a throwing athlete with suspected instability with a focus on recent findings and developments.

RECENT FINDINGS

The vast majority of throwing athletes with shoulder instability experience subtle microinstability as a result of repetitive microtrauma rather than episodes of gross instability. These athletes may present with arm pain, dead arms or reduced throwing velocity. Recent literature reinforces the fact that there is no "silver bullet" for the management of these athletes and an individualized, tailored approach to treatment is required. While initial nonoperative management remains the hallmark for treatment, the results of rehabilitation protocols are mixed, and some patients will ultimately undergo surgical stabilization. In these cases, it is imperative that the surgeon be judicious with the extent of surgical stabilization as overtightening of the glenohumeral joint is possible, which can adversely affect athlete performance. Managing shoulder instability in throwing athletes requires a thorough understanding of its physiologic and biomechanical underpinnings. Inconsistent results seen with surgical stabilization has led to a focus on nonoperative management for these athletes with surgery reserved for cases that fail to improve non-surgically. Overall, more high quality studies into the management of this challenging condition are warranted.

The value of combined ultrasound contrast arthrography and subacromial-subdeltoid bursography for detecting and differentiating the rotator cuff tear subtypes in patients with the uncertain rotator cuff tear

OBJECTIVES

In this study, ultrasound (US) contrast arthrography and subacromial-subdeltoid bursography with the contrast agent of SonoVue were performed to evaluate their value for detecting and differentiating the rotator cuff tear (RCT) subtypes in patients with the uncertain RCT.

METHODS

A total of 102 patients with the clinically suspected RCTs in the orthopedic clinic were prospectively recruited and underwent conventional high-frequency US for the category of undoubted full-thickness RCT, uncertain RCT, and intact rotator cuff. Among these patients, the patients with uncertain RCT underwent the subsequent US contrast arthrography and subacromial-subdeltoid bursography. The arthroscopic findings were used as the gold standard in this study.

RESULTS

After the conventional US screening, 62 patients with uncertain RCT underwent the subsequent US contrast arthrography and subacromial-subdeltoid bursography. All the US contrast arthrography and subacromial-subdeltoid bursography were successfully performed and no severe side effects were observed in all the patients. For full-thickness tears, the sensitivity and specificity of the combined US contrast arthrography and subacromial-subdeltoid bursography were 94.7% (CI: 0.72-1.0) and 81.4% (CI: 0.66-0.91), respectively, and for articular-side tears 100% (CI: 0.51-1) and 100% (CI: 0.92-1), respectively, and for the bursal-side tears 84.6% (CI: 0.54-0.97) and 97.9% (CI: 0.88-1.0), respectively. The main inconsistency between the contrast-enhanced US and arthroscopy was that 7 patients with arthroscopic proved concurrent articular- and bursal-side tears were indicated as full-thickness RCTs on contrast-enhanced US.

CONCLUSIONS

Combined US contrast arthrography and subacromial-subdeltoid bursography are useful for detecting the RCT subtypes in patients with the uncertain RCTs.

CLINICAL RELEVANCE STATEMENT

When conventional high-frequency US has some difficulty in differentiating the full-thickness from partial-thickness RCTs, combined US contrast arthrography and subacromial-subdeltoid bursography could be used to improve the detection accuracy of RCT subtypes.

KEY POINTS

• This is the first study by injection of the US contrast agent SonoVue into the shoulder joint cavity and subacromial-subdeltoid bursa for the detection and differentiation of the RCT subtypes among the people with the uncertain RCT by conventional US screening. • The SonoVue was injected into the glenohumeral joint cavity under US guidance to differentiate the full-thickness RCTs from partial-thickness RCTs. • Combined US contrast arthrography and subacromial-subdeltoid bursography are useful for detecting the RCT subtypes in patients with the uncertain RCTs.

Multidirectional instability of the shoulder: surgical techniques and clinical outcome

Multidirectional instability of the shoulder has a complex pathoanatomy. It is characterized by a redundant glenohumeral capsule and increased joint volume. Subtle clinical presentation, unclear trauma history and multifactorial etiology poseses a great challenge for orthopedic surgeons in terms of diagnosis. Generally accepted therapeutic approach is conservative and the majority of patients achieve good results with rehabilitation. In patients who are symptomatic despite appropriate rehabilitation, surgical intervention may be considered. Good results have been obtained with open inferior capsular surgery, which has historically been performed in these patients. In recent years, advanced arthroscopic techniques have taken place in this field, and similar results compared to open surgery have been obtained with the less-invasive arthroscopic capsular plication procedure.

Clinical Outcomes of Revision Arthroscopic Capsulolabral Repair for Recurrent Anterior Shoulder Instability With Moderate Glenoid Bone Defects: A Comparison With Primary Surgery

Background:

The optimal revision surgery for failed primary arthroscopic capsulolabral repair (ACR) has yet to be determined. Revision ACR has shown promising results.

Purpose:

To compare the functional, strength, and radiological outcomes of revision ACR and primary ACR for anterior shoulder instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between March 2007 and April 2017, a total of 85 patients underwent ACR (revision: n = 23; primary: n = 62). Functional outcome scores and positive apprehension signs were evaluated preoperatively, at 1 year, and then annually. Isokinetic internal and external rotation strengths were evaluated preoperatively and at 1 year after surgery.

Results:

The mean follow-up was 36.5 ± 10.2 months (range, 24-105 months). There was no significant difference between the revision and primary groups in the glenoid bone defect size at the time of surgery (17.3% ± 4.8% vs 15.4% ± 5.1%, respectively; P = .197). At the final follow-up, no significant differences were found in the American Shoulder and Elbow Surgeons score (97.6 ± 3.1 vs 98.0 ± 6.2, respectively; P = .573), Western Ontario Shoulder Instability Index score (636.7 ± 278.1 vs 551.1 ± 305.4, respectively; P = .584), or patients with a positive apprehension sign (17.4% [4/23] vs 11.3% [7/62], respectively; P = .479) between the revision and primary groups. There was no significant difference between the revision and primary groups for returning to sports at the same preoperative level (65.2% vs 80.6%, respectively; P = .136) and anatomic healing failure at 1 year after surgery (13.0% vs 3.2%, respectively; P = .120). Both groups recovered external rotation strength at 1 year after surgery (vs before surgery), although the strength was weaker than in the uninvolved shoulder. In the revision group, a larger glenoid bone defect was significantly related to a positive apprehension sign (22.0% ± 3.8%) vs a negative apprehension sign (16.0% ± 3.2%; cutoff = 20.5%; P = .003).

Conclusion:

In patients with moderate glenoid bone defect sizes (10%-25%), clinical outcomes after revision ACR were comparable to those after primary ACR. However, significant glenoid bone loss was related to a positive remaining apprehension sign in the revision group. Surgeons should consider these findings when selecting their revision strategy for patients with failed anterior shoulder stabilization.

Arthroscopic Bankart repair with an individualized capsular shift restores physiological capsular volume in patients with anterior shoulder instability

PURPOSE

Capsular volume reduction in the context of anterior arthroscopic shoulder stabilization represents an important but uncontrolled parameter. The aim of this study was to analyse capsular volume reduction by arthroscopic Bankart repair with an individualized capsular shift in patients with and without ligamentous hyperlaxity compared to a control group.

METHODS

In the context of a prospective controlled study, intraoperative capsular volume measurements were performed in 32 patients with anterior shoulder instability before and after arthroscopic Bankart repair with an individualized capsular shift. The results were compared to those of a control group of 50 patients without instability. Physiological shoulder joint volumes were calculated and correlated with biometric parameters (sex, age, height, weight and BMI).

RESULTS

Patients with anterior shoulder instability showed a mean preinterventional capsular volume of 35.6 ± 10.6 mL, which was found to be significantly reduced to 19.3 ± 5.4 mL following arthroscopic Bankart repair with an individualized capsular shift (relative capsular volume reduction: 45.9 ± 21.9%; P < 0.01). Pre-interventional volumes were significantly greater in hyperlax than in non-hyperlax patients, while post-interventional volumes did not differ significantly. The average shoulder joint volume of the control group was 21.1 ± 7.0 mL, which was significantly correlated with sex, height and weight (P < 0.01). Postinterventional capsular volumes did not significantly differ from those of the controls (n.s.).

CONCLUSION

Arthroscopic Bankart repair with an individualized capsular shift enabled the restoration of physiological capsular volume conditions in hyperlax and non-hyperlax patients with anterior shoulder instability. Current findings allow for individual adjustment and intraoperative control of capsular volume reduction to avoid over- or under correction of the shoulder joint volume. Future clinical studies should evaluate, whether individualized approaches to arthroscopic shoulder stabilization are associated with superior clinical outcome.

Arthroscopic Bankart repair: A matched cohort comparison of the modified Mason Allen method and the simple stitch method

INTRODUCTION

Arthroscopic Bankart repair (ABR) has become a standard treatment for recurrent anterior shoulder dislocation in cases with minimal bone loss. Using the standard Bankart repair technique, the failure rate has been reported to be approximately between 4 and 35%. In addition to the original injury, multiple pathologies can occur after a dislocation including a Bankart lesion, capsular redundancy and bone defects. In cases with no significant bone loss, soft tissue plays a major role in stabilizing the shoulder joint. We hypothesized that effective repair of soft tissue with good inferior capsular shifting and proper capsulolabral restoration can create a proper level of soft tissue tension so the horizontal mattress suture method should improve outcomes.

MATERIALS AND METHODS

A retrospective cohort study was conducted by reviewing the records of patients with recurrent anterior instability who underwent ABR at a single institution between January 2009 and December 2017. Demographic information, preoperative radiographic data including glenoid bone loss, Hill-Sachs width, glenoid track and other surgical details were retrieved from the medical records. The patients identified were divided into 2 groups. Group 1 had one modified Mason Allen stitch plus simple stitches, while Group 2 had only simple stitches. Data obtained from the patient included failure rate, patient satisfaction, the ROWE score and Walch-Duplay score at a minimum of 2 years after surgery. Risk factors for failure were also identified.

RESULTS

Group 1 included 50 patients (mean age 27.2 ± 9.4 years) who underwent modified Mason Allen stitch ABR (median follow-up, 59.2 months; range, 26.2-128.6 months). Group 2 included 30 patients (mean age 26.9 ± 8.5 years) who underwent simple stitch repair ABR (median follow-up, 68.0 months; range, 24.0-127.9 months). All patients met the inclusion criteria. Evaluation at the final follow-up compared Group 1 and Group 2: ROWE score (86.8 vs 76.3, P = 0.001), Walch-Duplay score (87.2 vs 82.0, P = 0.035), respectively. Failure rates were 6% in group 1 compared to 10% in group 2 (P = 0.511).

CONCLUSIONS

The modified Mason Allen stitch technique and the simple stitches technique ABR both result in excellent patient satisfaction at a minimum 2-year follow-up. Both techniques successfully restore shoulder stability, but the modified Mason Allen stitch technique results in better functional outcomes.

STUDY DESIGN

Cohort study; level of evidence, 3.

Efficacy of the Rotational Traction Method in the Assessment of Glenohumeral Cartilage Surface Area in Computed Tomography Arthrography

OBJECTIVE

We aimed to investigate the efficacy of the rotational traction method in expanding the joint space and enabling the assessment of an extended surface area.

METHODS

Sixty patients who underwent computed tomography arthrography were evaluated in the study: 30 with and 30 without the help of rotational traction. The subgroups consisted of patients with adhesive capsulitis, habitual luxation, or labral tears. Areas of obscured joint surface by coalescent cartilages were calculated using computer software, and those belonging to the traction and nontraction groups along with subgroups were compared statistically.

RESULTS

There was a significant difference between the traction and nontraction group regarding the contact surface area (P < 0.001 for both observers). In patients with adhesive capsulitis, the contact surface area was larger compared with the other subgroups (P = 0.002 for observer 1 and P = 0.002 for observer 2). In patients with habitual luxation, the contact surface area was smaller compared with the other subgroups (P = 0.002 for observer 1 and P = 0.001 for observer 2).

CONCLUSIONS

Expansion of joint distance is important for assessing the joint cartilage. The rotational traction method provides effective separation of the joint space. For this reason, rotational traction can be used effectively in patients in whom the joint cartilage is to be evaluated.