Intraarticular pathology in acute, first-time anterior shoulder dislocation: an arthroscopic study

Anterior mid-portion capsular tear with Bankart lesion in recurrent anterior shoulder dislocation: outcome report and bone defect evaluation

INTRODUCTION

This study aimed to report the incidence of anterior mid-portion capsular tears identified during arthroscopic Bankart repair (ABR), the clinical outcomes of repairing this combined lesion, and to evaluate the associated bone defects.

METHODS

We retrospectively reviewed the records of patients undergoing ABR between January 2014 and December 2017. Data from patients with capsular tears identified during ABR were included and analyzed. Age, number of dislocations, repair technique, follow-up results, and X-rays were reviewed. The size of the glenoid defect and Hill-Sachs lesion were reviewed via magnetic resonance imaging or magnetic resonance arthrography (MRA).

RESULTS

Records of 95 patients undergoing ABR during the study period were reviewed, and nine were included. The overall incidence of capsular tears was 9.5% and the mean age at surgery was 45.3 ± 14.3 years. All cases had > 3 dislocations before treatment. All patients had labral lesions, and one had a glenoid defect. Hill-Sachs lesions were observed in eight patients. Seven patients underwent MRA examination, and all seven showed axillary pouch disruption. Over 3.9 ± 1.1 years of follow-up, there was no instability recurrence, and Rowe scores improved from 42.2 to 96.7 (p < 0.001).

CONCLUSIONS

There was no recurrent shoulder instability after combined arthroscopic repair of capsular and Bankart lesions. There were Rowe score improvements over at least three years of follow-up. Although our case number was small, we found that mid-portion capsular tear occurred in patients over 30 years with multiple recurrent dislocations, with or without small glenoid bone defects, and with axillary pouch disruption on MRA images.

Management of shoulder instability in in-season athletes

Although shoulder instability is common in young athletes, there are limited prospective data to guide treatment for competitive athletes who sustain a dislocation mid-season. The management of athletes during their competitive season requires an understanding of the natural history of shoulder instability, the specific needs of the injured athlete (eg, specific sport, player position), and the duration of treatment. Rehabilitation can enable an athlete with a shoulder dislocation to return to play within 3 weeks of injury. Bracing is an option, but it can result in restricted glenohumeral motion and thereby possibly affect performance. Surgical stabilization should be considered for the athlete with recurrent instability or inability to perform; however, this frequently results in the termination of the player's season. In this article, we review the available literature to help guide physicians treating athletes with shoulder instability.

64-slice MDCT arthrography in shoulder instability: our experience

PURPOSE

This study was performed to assess the diagnostic accuracy of air-contrast 64-slice multidetector computed tomography (MDCT) arthrography in the evaluation of glenohumeral joint instability by comparison with conventional arthroscopy.

MATERIALS AND METHODS

Fifty patients with a history of shoulder instability underwent MDCT arthrography with thin collimation scans. The raw data were transferred to a workstation and processed using multiplanar reformation (MPR) and volume rendering (VR) algorithms. All patients subsequently underwent conventional arthroscopy. The results of the two techniques were compared and their sensitivity and specificity calculated.

RESULTS

We diagnosed eight anterosuperior labrum lesions (group 1), 32 anteroinferior labrum lesions (group 2) and two posterior labrum lesions (group 3). Overall sensitivity and specificity (groups 1, 2, 3) were 88% and 100%, respectively. In group 1, sensitivity was only 66% (four false negatives), whereas in groups 2 and 3, it was 94% (two false negatives) and 100%, respectively. The labrum lesions were also found to be associated, with 100% sensitivity and specificity, with 20 lax capsules, 17 Hill-Sachs lesions, five Bankart lesions, two Perthes lesions and three complete rotator-cuff tears.

CONCLUSIONS

Air-contrast MDCT arthrography is fast, reproducible, well tolerated and very accurate in the evaluation of lesions causing shoulder instability.

Primary repair versus conservative treatment of first-time traumatic anterior dislocation of the shoulder: a randomized study with 10-year follow-up

PURPOSE

The purpose of this study was to compare long-term results after surgical and conservative primary treatment of first-time traumatic anterior shoulder dislocation.

METHODS

Arthroscopic diagnosis after first-time traumatic anterior shoulder dislocation was performed, and in cases of a Baker type 1, 2, or 3 lesion, patients were randomized either to conservative treatment with a fixed sling for 1 week followed by a rehabilitation program or to open repair with a similar rehabilitation program.

RESULTS

In this study 76 patients (14 female and 62 male patients), aged 15 to 39 years, were randomized to surgical repair (n = 37) or conservative treatment (n = 39). Of the patients, 6.6% had Baker type 1 lesions, 13.2% had type 2 lesions, and 80.3% had type 3 lesions. After a minimum of 2 years' follow-up, 56% had recurrence after conservative treatment and 3% after open repair (P < .005). Among nondislocators, 39% in the conservative group and 7% in the repair group had a positive apprehension test. When evaluated after 10 years by use of the Oxford self-assessment score, 72% of patients in the surgical group had good or excellent results. Of the conservatively treated patients, 75% had unsatisfactory results because of recurrence, instability, and pain or stiffness.

CONCLUSIONS

Arthroscopic evaluation after first-time anterior shoulder dislocation revealed a Baker type 2 or 3 lesion in 93.5% of patients. At 2 years' follow-up, 21 (54%) of the conservatively treated patients had recurrence, as compared with 1 patient with recurrence (3%) after open surgical repair. After 8 years, a further 3 patients in the conservatively treated group had redislocations, 1 had subjective instability, and 4 had pain or stiffness, resulting in 74% having unsatisfactory results according to the Oxford score. Of the patients who had surgical repair, 72% had good or excellent results after 10 years. Because open repair produces superior results compared with conservative treatment, we recommend that the surgeon consider performing primary repair in active patients to reduce the risk of recurrence.

LEVEL OF EVIDENCE

Level I, high-quality prospective, randomized controlled trial.

Clinical outcome of anterior shoulder instability with capsular midsubstance tear: a comparison of isolated midsubstance tear and midsubstance tear with Bankart lesion

To analyze the clinical outcomes of patients with a midsubstance capsular tear for anterior shoulder instability, 21 shoulders with a midsubstance tear were reviewed. There were 7 isolated midsubstance tears (group I) and 14 combined midsubstance tears with Bankart lesions (group II). The Rowe score averaged 92.3 points with 6 excellent and 1 good one in group I. Group II scored 86.3 points with 8 excellent, 3 good, 2 fair, and 1 poor (P = .184). The Rowe score averaged 89.8 points for the cases with an arthroscopic procedure and 86.9 points with an open repair (P = .542). At the last follow-up, forward elevation increased by 6 degrees in group I and 8 degrees in group II (P = .432). External rotation decreased by 8 degrees and 16 degrees , respectively (P = .150). The clinical outcomes of anterior instability with a midsubstance tear were good in both groups. The loss of external rotation was greater in the cases with combined midsubstance tears and Bankart lesions than in those with an isolated midsubstance tear.

Shoulder instability: return to play

Shoulder instability in the competitive athlete is a relatively common problem. The etiology of glenohumeral instability that can affect the athlete runs a wide spectrum, from an isolated traumatic dislocation to repeated microtrauma or congenital laxity. Although many athletes are able to adapt to a mild laxity that might only occasionally affect them, it can be much more difficult to adapt or return to play after a dislocation or repeated subluxation episodes. This article focuses on the return to play for competitive individuals after a glenohumeral dislocation or reconstructive surgery for shoulder instability.