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

Assessing the use of the frequency, etiology, direction, and severity classification system for shoulder instability in physical therapy research - A scoping review

OBJECTIVE

The aim of this study is to review the implementation of the Frequency, Etiology, Direction, and Severity (FEDS) classification for shoulder instability by the physical therapy scientific community since its publication in 2011.

METHODS

A systematic search was conducted on January 10, 2024 in the MEDLINE, EMBASE, SPORTDiscus, Scopus, Web of Science, Cochrane, and SciELO databases, as well as Google Scholar. Studies investigating physical therapy interventions in people with shoulder instability, and reporting selection criteria for shoulder instability were considered eligible. A narrative synthesis was conducted.

RESULTS

Twenty-six studies were included. None reported using the FEDS classification as eligibility criteria for shoulder instability. Only 42% of the studies provided data of all four criteria of the FEDS classification. The most reported criterion was direction (92%), followed by etiology (85%), severity (65%), and frequency (58%). The most common reported descriptor for profiling shoulder instability was "dislocation" (83.3%), followed by "first-time" (66.7%), "anterior" (62.5%), and "traumatic" (59.1%). Regarding other instability classifications, only one study (4%) used the Thomas & Matsen classification, and two (8%) the Stanmore classification.

CONCLUSIONS

The FEDS classification system has not been embraced enough by the physical therapy scientific community since its publication in 2011.

Rehabilitation for atraumatic shoulder instability in circus arts performers: delivery via telehealth

BACKGROUND

The Watson Instability Program (WIP1) is current best evidence for conservative management of atraumatic shoulder instability, but it is unknown if this program can be effectively delivered via tele-consultation. The purpose of this longitudinal pre-post intervention study was to determine the effects of the WIP1 on patient-reported outcome measures, scapular position, shoulder strength, and handstand stability in student circus performers with atraumatic shoulder instability when delivered via tele-consultation.

METHODS

Student circus performers aged between 15 and 35 years from the National Institute of Circus Arts were recruited. A 12-week shoulder exercise program was delivered via tele-consultation during the Melbourne, Australia COVID-19 (coronavirus disease 2019) lockdown. The primary outcome measures were the Western Ontario Shoulder Instability Index score and the Melbourne Instability Shoulder Scale score. Secondary outcomes measures included the Orebro Musculoskeletal Pain Questionnaire, the Tampa Scale for Kinesiophobia, and physical assessment measures including strength via handheld dynamometry, scapular position using an inclinometer, and handstand stability via center-of-pressure fluctuation. Patient-reported outcomes were collected at baseline and 6-week, 12-week, 6-month, and 9-month time points, and physical outcomes were measured at baseline and 9-month time points. A repeated-measures mixed model (with effect sizes [ESs] and 95% confidence intervals [CIs]) was used to analyze patient-reported outcomes, handstand data, strength, and scapular measures. Significance was set at P < .05.

RESULTS

Twenty-three student circus arts performers completed the study. Significant improvements were found in both Western Ontario Shoulder Instability Index scores (effect size [ES], 0.79 [95% CI, 0.31-1.33] at 6 weeks; ES, 1.08 [95% CI, 0.55-1.6] at 12 weeks; ES, 1.17 [95% CI, 0.62-1.78] at 6 months; and ES, 1.31 [95% CI, 0.74-1.95] at 9 months; P < .001) and Melbourne Instability Shoulder Scale scores (ES, 0.70 [95% CI, 0.22-1.22] at 6 weeks; ES, 0.83 [95% CI, 0.34-1.37] at 3 months; ES, 0.98 [95% CI, 0.46-1.54] at 6 months; and ES, 0.98 [95% CI, 0.43-1.50] at 9 months; P < .001), as well as Orebro Musculoskeletal Pain Questionnaire scores at all follow-up time points. The Tampa Scale for Kinesiophobia scores reached significance at 6 weeks and 12 weeks. Following rehabilitation, we found statistically significant increases in shoulder strength in all positions tested and increased scapular upward rotation measured at end-of-range abduction, as well as during loaded external rotation. The affected arm showed greater instability than the unaffected arm with a significant intervention effect on the affected arm showing a greater consistent anterior-posterior movement pattern.

CONCLUSION

In a group of circus performers with atraumatic shoulder instability, treatment with the WIP1 via telehealth resulted in clinically and statistically significant improvements in shoulder symptoms and function.

Implications for the design of a Diagnostic Decision Support System (DDSS) to reduce time and cost to diagnosis in paediatric shoulder instability

Background

Currently the diagnosis of shoulder instability, particularly in children, is difficult and can take time. These diagnostic delays can lead to poorer outcome and long-term complications. A Diagnostic Decision Support System (DDSS) has the potential to reduce time to diagnosis and improve outcomes for patients. The aim of this study was to develop a concept map for a future DDSS in shoulder instability.

Methods

A modified nominal focus group technique, involving three clinical vignettes, was used to elicit physiotherapists decision-making processes.

Results

Twenty-five physiotherapists, (18F:7 M) from four separate clinical sites participated. The themes identified related to ‘Variability in diagnostic processes and lack of standardised practice’ and ‘Knowledge and attitudes towards novel technologies for facilitating assessment and clinical decision making’.

Conclusion

No common structured approach towards assessment and diagnosis was identified. Lack of knowledge, perceived usefulness, access and cost were identified as barriers to adoption of new technology. Based on the information elicited a conceptual design of a future DDSS has been proposed. Work to develop a systematic approach to assessment, classification and diagnosis is now proposed.

Trial Registraty This was not a clinical trial and so no clinical trial registry is needed.

Surgical outcomes in the Frequency, Etiology, Direction, and Severity (FEDS) classification system for shoulder instability

BACKGROUND

The Frequency, Etiology, Direction, and Severity (FEDS) system was developed as a simple but reliable method for classifying shoulder instability based on 4 factors attainable by history and physical examination: frequency (solitary, occasional, or frequent); etiology (traumatic or atraumatic); direction (anterior, posterior, or inferior); and severity (subluxation or dislocation). This study investigated the epidemiology and 2-year surgical outcomes for the FEDS categories in the prospective Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort.

METHODS

At the time of surgery, 1204 patients were assigned to the FEDS categories. Follow-up data were available for 636 of 734 patients (86.6%) who had undergone surgery at least 2 years prior to analysis. The most common categories were further analyzed by patient-reported outcomes (PROs) (American Shoulder and Elbow Surgeons, Western Ontario Shoulder Instability index, Single Assessment Numeric Evaluation scores) and rates of recurrent subluxation, recurrent dislocation, and revision surgery.

RESULTS

Of the 36 FEDS categories, 16 represented at least 1% of patients. Occasional traumatic anterior dislocation (OTAD) was the most common category, with 16.4% of patients. Five other anterior categories (solitary traumatic anterior subluxation, occasional traumatic anterior subluxation [OTAS], frequent traumatic anterior subluxation [FTAS], solitary traumatic anterior dislocation, and frequent traumatic anterior dislocation) and one posterior category (solitary traumatic posterior subluxation [STPS]) represented at least 5% of patients. PROs improved significantly for each category. The highest rates of recurrent subluxation occurred in FTAS, OTAS, and OTAD cases; dislocation, OTAS and FTAS cases; and further surgery, OTAD cases. The lowest rates of failure occurred in STPS cases. Downward trends in PROs and higher failure rates were noted with an increasing number of preoperative dislocations.

CONCLUSION

Different FEDS categories showed varying degrees of improvement and failure rates, indicating that the system can be used to provide prognostic insight for presurgical education. Overall, outcomes decreased with a higher number of preoperative dislocations.

Subacromial space outlet in female patients with multidirectional instability based on hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder measured by ultrasound

OBJECTIVE

The objective of the study was to compare the acromiohumeral distance (AHD) between patients diagnosed with hypermobility type of the Ehlers-Danlos syndrome (hEDS) or hypermobility spectrum disorder (HSD) and healthy controls by evaluating the relative amount the tendon occupies in the subacromial area. Furthermore, the aim was to evaluate if there was a change in AHD with arm elevation within and between groups.

METHODS

Twenty-nine female patients with hEDS/HSD (aged 34 ± 12.9 years) and 20 healthy controls (aged 33 ± 10.8 years) participated in the study. The supraspinatus tendon (SST) thickness and AHD were measured using ultrasound. The interplay between the SST and the AHD was expressed as the occupation ratio (OcAHD), calculated as the SST thickness as a percentage of AHD. The measures were performed in the resting position and in subsequently 45° and 60° of active arm elevation in the scapular plane.

RESULTS

The main finding is that patients with hEDS/HSD have a larger subacromial space outlet compared with the controls when measured by ultrasound. Furthermore, in both groups, we found an increased OcAHD during active arm elevation compared with the resting position, which indicates that similar mechanisms occur for patients with hEDS/HSD and healthy controls.

CONCLUSION

Patients with hEDS/HSD have a larger available subacromial space outlet compared with healthy individuals. OcAHD increased during active arm elevation compared with the resting position in both groups. This knowledge is important when designing rehabilitation exercise programs for shoulder instability patients with abnormal glenohumeral biomechanics.

Epidemiology of Glenohumeral Instability Related to Sporting Activities Using the FEDS (Frequency, Etiology, Direction, and Severity) Classification System: A Multicenter Analysis

Background:

Glenohumeral instability is common in athletes. There are an estimated 0.12 episodes of instability per 1000 sporting exposures. Instability can lead to time away from sport and an increased risk of shoulder arthritis.

Purpose:

To determine the prevalence, demographic data, anatomic features, and likelihood of surgery for the different types of instability as defined by the FEDS (frequency, etiology, direction, and severity) classification system for different sports.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Databases at 3 institutions (University of Iowa, Vanderbilt University, and University of Pennsylvania) were searched for International Classification of Diseases--Ninth Revision codes related to shoulder instability in 2010. Demographic data, symptoms, causes, imaging findings, and operative reports were obtained. Data were entered into a custom-designed REDCap online survey. Patients with subjective instability related to sporting activities were included for analysis.

Results:

A total of 184 athletes had glenohumeral instability; 20.1% were female. The mean age at the time of the first instability episode was 19.0 years for both male and female patients. The most common sports were football (29.3%), basketball (19.0%), and wrestling (9.8%). The most common type of instability based on the FEDS system was occasional, traumatic, anterior dislocation. Surgery was performed on 69.6% of athletes, and 14.1% had a recurrence of instability after surgery overall. Football had the highest rate of recurrence postoperatively at 23.8%. There was no difference in surgery rates between athletes with subluxations versus dislocations (P = .8458). Surgery was significantly more likely in those with frequent dislocations (P < .0001) and posterior instability (P = .027). There was a 10.7% recurrence rate overall with conservative treatment.

Conclusion:

Glenohumeral instability most commonly occurs in contact sports, affects male more than female patients, and is most frequently in the anterior direction. Recurrent instability is most common in football players. Attention should be turned to the specific characteristics of each type of instability to determine the best treatment for each athlete.

Epidemiology of the Frequency, Etiology, Direction, and Severity (FEDS) system for classifying glenohumeral instability

HYPOTHESIS

The purpose of this multicenter epidemiologic study was to determine the distribution of patients within the Frequency, Etiology, Direction, and Severity (FEDS) classification system to determine which categories are of clinical importance.

METHODS

Shoulder instability patients were identified using International Classification of Diseases, Ninth Revision coding data from 3 separate institutions from 2005-2010. Data were collected retrospectively. Details of instability were recorded in accordance with the FEDS classification system. Each patient was assigned a classification within the FEDS system. After all patients were assigned to a group, each group was individually analyzed and compared with the other groups.

RESULTS

There are a total of 36 possible combinations within the FEDS system. Only 16 categories were represented by at least 1% of our patient population. Six categories captured at least 5% of all patients with shoulder instability. Only 2 categories represented greater than 10% of the population: solitary, traumatic, anterior dislocation, with 95 patients (24.8%), and occasional, traumatic, anterior dislocation, with 63 patients (16.4%).

CONCLUSIONS

There are 16 categories within the FEDS classification that are clinically significant. Solitary, traumatic, anterior dislocation and occasional, traumatic, anterior dislocation were the most frequently observed in our cohort.

Scapular muscles weakness in subjects with traumatic anterior glenohumeral instability

OBJECTIVE

To investigate possible alterations on scapular muscle strength in subjects with traumatic anterior glenohumeral instability.

DESIGN

Cross-sectional study.

SETTING

Laboratory setting.

PARTICIPANTS

Fifty-two subjects of both sexes: 26 healthy and 26 with traumatic anterior glenohumeral instability.

MAIN OUTCOME MEASURES

Subjects performed maximal isometric and concentric isokinetic contractions of shoulder protraction and retraction in scapular and sagittal planes, at slow (12.2 cm/s) and fast (36.6 cm/s) speeds.

RESULTS

Subjects with glenohumeral instability presented lower peak force of protraction and retraction during isometric and fast speed tests in the scapular plane; and of isometric protraction in the sagittal plane.

CONCLUSIONS

People with traumatic anterior glenohumeral instability present muscle weakness of scapular protractors and retractors. Considering the importance of the scapulothoracic muscles for the dynamic stability of the glenohumeral joint, strengthening of these muscles is recommended for rehabilitation of traumatic anterior glenohumeral instability.

Multidirectional instability of the glenohumeral joint: Etiology, classification, assessment, and management

Multidirectional instability of the shoulder is a type of glenohumeral joint shoulder instability. There are discrepancies in the definition and classification of this condition, which can make diagnosis and treatment selection challenging. Knowledge of contributing factors, the typical clinical presentation, and current best evidence for treatment options can assist in the diagnosis and appropriate treatment selection for this pathology. The purpose of this article is to present an overview of the current literature regarding the etiology, classification, assessment, and management of multidirectional instability of the glenohumeral joint.

Current Concepts in the Diagnosis and Management of Traumatic, Anterior Glenohumeral Subluxations

Traumatic anterior glenohumeral subluxations comprise the majority of glenohumeral instability events and are endemic in young athletes. Unlike the definitive complete dislocation event, subluxation events may often be more subtle in presentation and, therefore, may be overlooked by clinicians. Glenohumeral subluxation events are associated with a high rate of labral tears as well as humeral head defects. While less is known of the natural history of these injuries, young athletes are at risk for recurrent instability events if not properly diagnosed and treated. While reports of surgical treatment outcomes isolated to subluxation events are limited, arthroscopic and open Bankart repair have been shown to result in excellent outcomes. The purpose of this paper is to review the etiology and pathoanatomy of traumatic anterior glenohumeral subluxations as well as to review the appropriate evaluation and management of patients with this injury.

Value on the Front End: Making the Effective Diagnosis for Optimal Treatment

Much effort is being made to quantitate and improve the outcomes associated with medical treatment. These outcomes are defined as how the patient did after an intervention and may be termed "value on the back end" of the treatment process. The diagnosis guides the content and timing of the treatment, and may be considered the "value on the front end" that optimizes the treatment process. The diagnosis can be defined as "that body of information, collected through the process of evaluating the patient's health problem, that determines the content and timing of the treatment of the health problem." An Institute of Medicine monograph has documented "troubling" deficiencies in the diagnostic process and has suggested guidelines to establish a comprehensive and effective diagnosis, which should include anatomic and patient-derived factors, have multidisciplinary input, have implications for treatment content and timing, and relate to outcomes. The monograph establishes a linear relationship and direct linkage between the diagnosis and treatment. There is much evidence in orthopaedics that these deficiencies exist and often limit the implementation of the most beneficial treatments. Efforts should be made to improve the effectiveness of the diagnostic process to optimize the entire treatment process. The 5 A's framework can be used as a template for the accumulation of information that can guide the treatment process.

Outcomes After Arthroscopic Pancapsular Capsulorrhaphy With Suture Anchors for the Treatment of Multidirectional Glenohumeral Instability in Athletes

BACKGROUND

Outcomes after arthroscopic pancapsular capsulorrhaphy (APC) with suture anchors for multidirectional instability (MDI) of the shoulder are not widely reported.

PURPOSE

To compare intraoperative findings and midterm outcomes of APC with suture anchors for MDI between female and male athletes and between a classic, atraumatic onset versus clinical onset of MDI after a traumatic event.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent APC with suture anchors for MDI and were at least 2 years out from surgery were included. Data were prospectively collected and retrospectively reviewed and included the onset of MDI, intraoperative pathoanatomic findings, level of sports participation, and patient satisfaction as well as the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Short Form-12 Physical Component Summary (SF-12 PCS) scores. Information regarding shoulder instability and return to sport was collected, and Kaplan-Meier survivorship analysis was performed.

RESULTS

Forty-one patients (45 shoulders; 25 male, 20 female), consecutively treated between October 2006 and January 2013, were included. The onset of MDI was atraumatic in 22 shoulders and traumatic in 23 shoulders. At surgery, 29 of 45 (64.4%) had labral detachment. Seven shoulders (16.7%) experienced instability episodes postoperatively, and 3 of these underwent revision surgery. The mean follow-up was 3.3 years (range, 2.0-6.6 years). All subjective outcome scores improved significantly from preoperative levels (P < .005). At final follow-up, the mean ASES score was 92.0, and 76.7% (23/30) indicated that they had returned to sports participation equal to or slightly below their preinjury level. Kaplan-Meier analysis showed a survivorship rate of 87% at 3 years. Male patients were 2.3 times more likely to have a traumatic onset of instability (68% vs 30%, respectively; P = .017) and were 2.1 times more likely to have concomitant lesions (84% vs 40%, respectively; P = .004) than female patients. Furthermore, male patients demonstrated a higher mean postoperative ASES score than female patients (97.0 ± 4.7 vs 85.5 ± 16.4, respectively; P = .023). Female patients were 6.9 times more likely to undergo an additional rotator interval closure (RIC) procedure (58% vs 4.7%, respectively; P < .001) and to experience postoperative subluxations (40% vs 22%, respectively; P = .035) than male patients. A traumatic onset of MDI was associated with a higher mean postoperative ASES score (96.4 ± 6.9 vs 87.0 ± 15.7, respectively; P = .048), higher median satisfaction score (10 vs 9, respectively; P = .029), and higher return-to-sport rate (83% vs 44%, respectively; P = .030) than an atraumatic onset.

CONCLUSION

APC with suture anchors can be an effective and safe treatment for patients with MDI. Labral tears were commonly found, even in patients with a classic, atraumatic onset. Male patients and patients with a traumatic onset of MDI had more favorable outcomes. Female patients may be more challenging to treat as they were more likely to undergo an additional RIC procedure and experience postoperative subluxations.

Effect of exercise-based management on multidirectional instability of the glenohumeral joint: a pilot randomised controlled trial protocol

INTRODUCTION

The most commonly recommended treatment for multidirectional instability (MDI) of the shoulder is exercise. Despite this recommendation, there is limited evidence to support the effectiveness of exercise. The aim of this paper is to describe a pilot randomised controlled trial comparing the effectiveness of 2 exercise programmes on outcomes of participants with MDI.

METHODS AND ANALYSIS

Consenting participants between 12 and 35 years, with non-traumatic MDI will be randomly allocated to participate in either the Rockwood Instability programme or the Watson MDI programme. Both programmes involve 1 consultation per week for 12 weeks with a physiotherapist to prescribe and progress a home exercise programme. Outcomes will be assessed at baseline, 6, 12, 24 and 52 weeks. Primary outcome measures include the Melbourne Instability Shoulder Score and Western Ontario Shoulder Index. Secondary outcomes include scapular coordinates, scapular upward rotation angles, muscle strength, symptomatic onset, limiting factor and angle of limiting factor in abduction range, incidence of complete glenohumeral joint dislocation, global rating of change, satisfaction scores, the Orebro Musculoskeletal Pain Questionnaire, adverse events and compliance with the home exercise programme. Data will be analysed on intention-to-treat principles and a per protocol basis.

DISCUSSION

This trial will evaluate whether there are differences in outcomes between the Rockwood and the Watson MDI programmes for participants with MDI.

ETHICS AND DISSEMINATION

Participant confidentiality will be maintained with publication of results. Ethics approval: Faculty of Health Sciences (FHEC12/201).

TRIAL REGISTRATION NUMBER

ACTRN12613001240730; Pre-results.

Development and initial validation of the Classification of Early-Onset Scoliosis (C-EOS)

BACKGROUND

Early-onset scoliosis is a heterogeneous condition, with highly variable manifestations and natural history. No standardized classification system exists to describe and group patients, to guide optimal care, or to prognosticate outcomes within this population. A classification system for early-onset scoliosis is thus a necessary prerequisite to the timely evolution of care of these patients.

METHODS

Fifteen experienced surgeons participated in a nominal group technique designed to achieve a consensus-based classification system for early-onset scoliosis. A comprehensive list of factors important in managing early-onset scoliosis was generated using a standardized literature review, semi-structured interviews, and open forum discussion. Three group meetings and two rounds of surveying guided the selection of classification components, subgroupings, and cut-points. Initial validation of the system was conducted using an interobserver reliability assessment based on the classification of a series of thirty cases.

RESULTS

Nominal group technique was used to identify three core variables (major curve angle, etiology, and kyphosis) with high group content validity scores. Age and curve progression ranked slightly lower. Participants evaluated the cases of thirty patients with early-onset scoliosis for reliability testing. The mean kappa value for etiology (0.64) was substantial, while the mean kappa values for major curve angle (0.95) and kyphosis (0.93) indicated almost perfect agreement. The final classification consisted of a continuous age prefix, etiology (congenital or structural, neuromuscular, syndromic, and idiopathic), major curve angle (1, 2, 3, or 4), and kyphosis (-, N, or +) variables, and an optional progression modifier (P0, P1, or P2).

CONCLUSIONS

Utilizing formal consensus-building methods in a large group of surgeons experienced in treating early-onset scoliosis, a novel classification system for early-onset scoliosis was developed with all core components demonstrating substantial to excellent interobserver reliability. This classification system will serve as a foundation to guide ongoing research efforts and standardize communication in the clinical setting.

Accuracy and reliability of the Mayo Elbow Performance Score

PURPOSE

To test the reliability of the Mayo Elbow Performance Score (MEPS) and compare it with a validated outcomes instrument, the American Shoulder and Elbow Surgeons (ASES) score.

METHODS

A total of 42 patients with the chief problem of elbow dysfunction formed the study cohort. Patients with an immediate surgical indication or treatment at the index visit were excluded. The others completed an MEPS questionnaire; at a second visit 2 to 3 weeks later, they completed another MEPS questionnaire and were evaluated with the ASES elbow assessment. Reliability and accuracy were calculated using 2-tailed Pearson correlation coefficients with 95% confidence intervals. Pearson coefficients greater than 0.8 indicated strong agreement.

RESULTS

The average MEPS score at the initial visit was 58. At the second visit, the average MEPS score was 69 and the average ASES score was 78. The Pearson coefficient for MEPS scores at the 2 time points averaged 0.82, and between the MEPS and ASES scores averaged 0.83. Both coefficients indicated strong agreement.

CONCLUSIONS

The MEPS has strong reliability when assessed at different times and when compared with a validated elbow outcomes instrument. Differences in compared scores of approximately 10 points indicate some patient improvement between time points; however, 95% confidence intervals, standard deviations, and ranges were essentially equivalent between and among tests, indicating similar accuracy.

CLINICAL RELEVANCE

The MEPS is a reliable outcomes instrument for clinical studies of elbow function that is used to assess nonsurgical treatment.

Surgical treatment of significant glenoid bone defects and associated humeral avulsions of glenohumeral ligament (HAGL) lesions in anterior shoulder instability

PURPOSE

Combined occurrence of humeral avulsion of glenohumeral ligament (HAGL) lesion and a significant glenoid bone defect is an unusual and previously undescribed association in traumatic anterior shoulder instability. The purpose of this study was (1) to report a retrospective case series of seven anterior bony instability patients who were diagnosed with this unusual association and (2) to evaluate the results of a modified Latarjet procedure and simultaneous HAGL repair using a new subscapularis-sparing approach.

METHODS

A retrospective review of the records of 64 anterior shoulder instability patients who underwent bony stabilization surgery was performed, and patients who underwent a combined reconstruction for significant glenohumeral bone defects (glenoid loss >20 %) and an associated HAGL lesion were identified. Pre- and postoperative follow-up clinical parameters and functional scores were documented (Oxford shoulder instability score [OSIS], Western Ontario shoulder instability index [WOSI]), Rowe score). Radiological assessment included measurement of the glenoid bone defect (CT scan) and evaluation of soft tissue lesions (MR arthrogram).

RESULTS

Radiological and arthroscopic evaluation confirmed the combined lesion complex in 7 (11 %) patients. Follow-up evaluation (mean 20.6 months) suggested an excellent outcome (Rowe score: median 95, range 95-100); a statistically significant improvement was seen in the follow-up OSIS (median 12, range 12-14, p = 0.018) and WOSI score (median 28, range 17-102, p = 0.018) as compared to the preoperative score (median OSIS 50, range 32-53; median WOSI 1,084, range 919-1,195). Clinical tests for subscapularis function revealed a functional subscapularis muscle; no significant differences were detected in pre- versus postoperative internal rotation strength and in the operated versus normal contralateral shoulder (ns). The dual-window subscapularis-sparing approach provided adequate exposure for combined reconstruction of the humeral and glenoid lesions, and no complications were encountered.

CONCLUSIONS

Significant glenoid defects are associated with HAGL lesions in approximately 1/10th of patients with bony instability. Combined reconstruction of these lesions via a subscapularis-sparing approach results in an excellent outcome and significant improvement in functional scores at a medium-term follow-up.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Open capsular shift and arthroscopic capsular plication for treatment of multidirectional instability

PURPOSE

To compare the results of open inferior capsular shift with arthroscopic capsular plication for multidirectional instability in patients without a Bankart lesion. We hypothesized that there is no difference with regard to the specific clinical outcomes evaluated, including recurrent instability, range of motion, return to sport, and complications.

METHODS

We conducted a comprehensive literature search. Databases searched included PubMed from 1966 to 2010, the Cochrane Database of Systematic Reviews and Controlled Trials, CINAHL (Cumulative Index to Nursing and Allied Health Literature) from 1982 to 2010, and SPORTDiscus from 1975 to 2010. Limits included English language, human subjects, and title.

RESULTS

We found 7 articles with a total of 197 patients (219 shoulders) that met our inclusion criteria. The data did not clearly show open treatment to be superior to arthroscopic treatment. No study reported a consistent loss of greater than 40° of external rotation. No technique showed significantly less external rotation loss over the other. Whereas there was a slight trend toward increased return to sport for patients treated arthroscopically, no clear conclusion can be drawn given the variability of reporting in the reviewed studies. Analysis of complications shows that both procedures are reliably safe with minimal complications.

CONCLUSIONS

When one is evaluating patients with traumatic or atraumatic onset of shoulder instability in 2 directions and no structural lesions, arthroscopic capsular plication yields comparable results to open capsular shift with regard to recurrent instability, return to sport, loss of external rotation, and overall complications.

Magnetic resonance imaging in glenohumeral instability

The glenohumeral joint enables tremendous range of motion at the expense of stability. Functional stability is maintained by the synchronous coordination of complex static and dynamic structures. Symptomatic glenohumeral instability most often results from injury to the inferior labral-ligamentous complex, the primary passive stabilizer of the shoulder. This article reviews the structures important in glenohumeral stabilization and illustrates their normal appearances and the abnormalities associated with anterior, posterior, and multidirectional instability. These lesions are discussed in the context of therapeutic decision making.