Glenohumeral osteoarthrosis after Putti-Platt repair

Characterization of articular lesions associated with glenohumeral instability using arthroscopy

Aims

The prevalence of osteoarthritis (OA) associated with instability of the shoulder ranges between 4% and 60%. Articular cartilage is, however, routinely assessed in these patients using radiographs or scans (2D or 3D), with little opportunity to record early signs of cartilage damage. The aim of this study was to assess the prevalence and localization of chondral lesions and synovial damage in patients undergoing arthroscopic surgery for instablility of the shoulder, in order to classify them and to identify risk factors for the development of glenohumeral OA.

Methods

A total of 140 shoulders in 140 patients with a mean age of 28.5 years (15 to 55), who underwent arthroscopic treatment for recurrent glenohumeral instability, were included. The prevalence and distribution of chondral lesions and synovial damage were analyzed and graded into stages according to the division of the humeral head and glenoid into quadrants. The following factors that might affect the prevalence and severity of chondral damage were recorded: sex, dominance, age, age at the time of the first dislocation, number of dislocations, time between the first dislocation and surgery, preoperative sporting activity, Beighton score, type of instability, and joint laxity.

Results

A total of 133 patients (95%) had synovial or chondral lesions. At the time of surgery, shoulders were graded as having mild, moderate, and severe OA in 55 (39.2%), 72 (51.4%), and six (4.2%) patients, respectively. A Hill-Sachs lesion and fibrillation affecting the anteroinferior glenoid cartilage were the most common findings. There was a significant positive correlation between the the severity of the development of glenohumeral OA and the patient's age, their age at the time of the first dislocation, and the number of dislocations (p = 0.004, p = 0.011, and p = 0.031, respectively).

Conclusion

Synovial inflammation and chondral damage associated with instability of the shoulder are more prevalent than previously reported. The classification using quadrants gives surgeons more information about the chondral damage, and could explain the pattern of development of glenohumeral OA after stabilization of the shoulder. As the number of dislocations showed a positive correlation with the development of OA, this might be an argument for early stabilization.

Unexpected complication after reverse shoulder arthroplasty: Brachial artery pseudoaneurysm: A case report

Pseudoaneurysm should be acknowledged as a possible but infrequent postoperative complication after shoulder arthroplasty which could be easily misdiagnosed. It is important that the upper-extremity surgeon suspects this problem in the follow-up assessment for appropriate management. In this paper, we present an unusual case of brachial artery pseudoaneurysm in the early postoperative period after reverse shoulder arthroplasty.

The role of the anterior shoulder joint capsule in primary glenohumeral osteoarthritis

The pathogenesis of primary glenohumeral arthritis (GHOA) is mediated by a complex interaction between osseous anatomy and the surrounding soft tissues. Recently, there has been growing interest in characterizing the association between the anterior shoulder joint capsule and primary GHOA because of the potential for targeted treatment interventions. Emerging evidence has shown substantial synovitis, fibrosis, and mixed inflammatory cell infiltrate in the anterior capsule of osteoarthritic shoulders. In addition, increased thickening of the anterior shoulder joint capsule has been associated with greater posterior glenoid wear and humeral head subluxation. While these findings suggest that anterior capsular disease may play a causative role in the etiology and progression of eccentric GHOA, further studies are needed to support this association. The purpose of this article is to review the pathogenesis of primary GHOA, contextualize current hypotheses regarding the role of the anterior capsule in the disease process, and provide directions for future research.

Effect of Anterior Glenoid Chondrolabral Defects on Anterior Glenohumeral Stability: A Biomechanical Study

Background:

It is well known that glenoid osseous defects >13.5% of the glenoid width critically destabilize the shoulder, as do labral tears. Chondrolabral defects often occur with anterior dislocation of the shoulder. It is unclear whether glenoid chondrolabral defects contribute to shoulder stability and, if so, at what size they become critical.

Purpose/Hypothesis:

The purpose of this study was to determine the effect of incremental chondrolabral defect sizes on anterior shoulder stability in the setting of labral deficiency. The hypothesis was that chondrolabral defects ≥13.5% of the glenoid width will decrease anterior shoulder stability.

Study Design:

Controlled laboratory study.

Methods:

This controlled laboratory study tested 12 fresh-frozen shoulders. Specimens were attached to a custom testing device in abduction and neutral rotation with 50-N compression applied to the glenoid. The humeral head was translated 10 mm anterior, anteroinferior, and anterosuperior with the conditions of intact cartilage and labrum and anterior full-thickness chondrolabral defects of 3-, 6-, and 9-mm width. Translation force was measured continuously. Peak translation force divided by 50-N compressive force defined the stability ratio. Data were analyzed using analysis of variance.

Results:

The anterior stability ratio decreased between the intact state (36% ± 7%) and all defects ≥3 mm (≤32% ± 8%; P ≤ .023). The anteroinferior stability ratio decreased between the intact state (52% ± 7%) and all defects ≥3 mm (≤47% ± 7%; P ≤ .006). The anterosuperior stability ratio decreased between the intact state (36% ± 4%) and all defects ≥6 mm (≤33% ± 4%; P ≤ .006). A 3-mm defect equated to 10% of the glenoid width. There were moderate to strong negative correlations between chondrolabral defect size and stability ratio in the anterior, anteroinferior, and anterosuperior directions (r = –0.79, –0.63, and –0.58, respectively; P ≤ .001). There were moderate to strong negative correlations between the percentage of glenoid chondrolabral defect size to the glenoid width and the stability percentage in all directions (r = –0.81, –0.63, and –0.61; P ≤ .001).

Conclusion:

An anterior glenoid chondrolabral defect ≥3 mm (>10% of the glenoid width) significantly decreased anterior and anteroinferior stability. Chondrolabral defect size negatively correlated with stability.

Clinical Relevance:

To fully restore glenohumeral stability, in addition to labral repair, it may be necessary to reconstruct chondrolabral defects as small as 3 mm (10% of the glenoid width).

Morphology of Glenoid Cartilage Defects in Anteroinferior Glenohumeral Instability

Background:

Glenoid cartilage defects may contribute to anterior shoulder instability recurrence and progression to osteoarthritis, but their morphology remains unknown.

Purpose/Hypothesis:

The purpose was to determine the shape, size, and location of glenoid cartilage defects and the prevalence and risk factors for cartilage defects in the setting of anterior glenohumeral instability. It was hypothesized that glenoid cartilage defects would be common, would be associated with recurrence of dislocation, and would share similar morphology with glenoid osseous defects.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

In this retrospective study, all patients who underwent arthroscopic surgical treatment for anterior glenohumeral instability between January 2012 and May 2019 were included; excluded were patients with documented posterior or multidirectional instability or previous glenohumeral surgery. For each patient, the operative report, arthroscopic images, and preoperative magnetic resonance imaging (MRI) scans were reviewed to determine the prevalence of cartilage injury. For those patients with an Outerbridge grade 3 or 4 defect, the cartilage surfaces on the MRI scans were segmented to make 3-dimensional (3-D) segmentations. From these 3-D segmentations, we measured length, width, and surface area of the glenoid and defect, and the orientation of the defect relative to the superior and inferior poles of the glenoid. A multivariable analysis was conducted to determine correlates with cartilage damage.

Results:

In 322 patients treated operatively for anterior glenohumeral instability, 38% had a concomitant cartilage defect. The mean cartilage defect was located directly anteriorly at the 3:07 clockface position (range, 2:10-4:05) and encompassed 6.5% ± 3.5% of the glenoid surface area. However, defects ranged up to >56% of glenoid length and up to 27% of glenoid width, and the largest defect encompassed 19.5% of the glenoid cartilage surface area. Patients with a cartilage defect were more likely to be male (P = .031) and to have undergone a concomitant posterior labral repair (P = .018).

Conclusion:

Cartilage defects were common in patients with operatively treated anterior glenohumeral instability, occurring in 38% of patients. These defects were located directly anteriorly at 3:07, similar to osseous glenoid defects. Future prospective studies with cartilage-specific MRI sequences should be conducted.

Treatment type may influence degree of post-dislocation shoulder osteoarthritis: a systematic review and meta-analysis

PURPOSE

Age at primary dislocation, recurrence, and glenoid bone loss are associated with development of osteoarthritis (OA). However, an overview of OA following traumatic anterior shoulder instability is lacking and it is unclear to what degree type of surgery is associated with development of OA in comparison to non-operative treatment. The aim of this study was to determine the degree of OA at long-term follow-up after non-operative and operative treatments for patients with anterior shoulder instability. Surgery is indicated when patients experience recurrence and this is associated with OA; therefore, it was hypothesized that shoulders show a higher proportion or degree of OA following operative treatment compared to non-operative treatment.

METHODS

A literature search was performed in the PubMed/Medline, EMBASE, and Cochrane databases. Articles reporting the degree of OA that was assessed with the Samilson-Prieto or Buscayret OA classification method after non-operative and operative treatment for anterior shoulder instability with a minimum of 5 years follow-up were included.

RESULTS

Thirty-six articles met the eligibility criteria of which 1 reported the degree of OA for non-operative treatment and 35 reported the degree of OA for 9 different operative procedures. A total of 1832 patients (1854 shoulders) were included. OA proportions of non-operative and operative treatments are similar at any point of follow-up. The Latarjet procedure showed a lower degree of OA compared to non-operative treatment and the other operative procedures, except for the Bristow procedure and Rockwood capsular shift. The meta-analyses showed comparable development of OA over time among the treatment options. An increase in OA proportion was observed when comparing the injured to the contralateral shoulder. However, a difference between the operative subgroups was observed in neither analysis.

CONCLUSION

Non-operative and operative treatments show similar OA proportions at any point of follow-up. The hypothesis that shoulders showed a higher proportion or degree of OA following operative treatment compared to non-operative treatment is not supported by the data. Operative treatment according to the Latarjet procedure results in a lower degree of OA compared to other treatments, including non-operative treatment.

LEVEL OF EVIDENCE

IV.

Shoulder arthroplasty to address the sequelae of anterior instability arthropathy and stabilization procedures: systematic review and meta-analysis

PURPOSE

Chronic anterior glenohumeral joint instability is a common situation and can lead to progressive cartilage deterioration and ultimately instability arthopathy. Progressive cartilage deterioration can occur despite conservative or surgical treatment and the sequelae of these conditions are often addressed with total shoulder arthroplasty. Aims of the present study were to analyze the available literature to describe the technical aspects of this particular operation and to report outcomes and complication rates. The hypothesis was that shoulder arthropalsty in the sequelae of instability had lower outcomes and higher complication rates than arthroplasties for primary arthritis.

METHODS

A systematic review of the literature was performed, in accordance with the PRISMA guidelines. PubMed, Ovid, Cochrane Reviews, and Google Scholar were comprehensively searched using a combination of the following keywords: shoulder arthroplasty, reverse shoulder arthroplasty, dislocation arthropathy, capsulorrhaphy arthropathy and stabilization procedures.

RESULTS

Thirteen studies with 365 patients met inclusion criteria. Since 13 patients were lost to follow-up, 352 were reviewed at an average follow-up of 53.4 months. The average Constant-Murley (CM) and American Shoulder and Elbow Society (ASES) scores improved from 35.6 and 35.7 to 72.7 and 77, respectively. The overall complication rate was 25.7% and the reoperation rate was 18.5%. Radiographs at follow-up revealed radiolucent lines on the humerus in 12.4% of cases and radiolucent lines or notching on the glenoid side in 22.7% of cases. The average Methodological Index for Non-randomized Studies Score (MINORS) was 12.9 for non-comparative studies and 21.3 for comparative studies.

CONCLUSION

Shoulder arthroplasty to address the sequelae of instability arthropathy and stabilization procedures can be a challenging procedure as a consequence of the distorted anatomy and severe glenohumeral joint pathology. Complication and reoperation rates are higher compared to shoulder arthroplasty for primary glenohumeral joint arthritis; however, the difference is not statistically significant. When reverse shoulder arthroplasties (RSA) were considered as a subgroup and compared to anatomic shoulder replacements (total shoulders and hemiarthroplasties), they showed a lower revision rate.

Glenohumeral Osteoarthritis: An Overview of Etiology and Diagnostics

BACKGROUND AND AIMS

Osteoarthritis (OA) is the world's most common joint disease and there is currently no cure. Glenohumeral osteoarthritis (GHOA) accounts for an estimated 5% -17% of patients with shoulder complaints. The etiology of GHOA is multifactorial, and we review the various non-specific and specific risk factors and further sub-classify them into local and systemic factors.

MATERIALS AND METHODS

Data for this review article were identified by searches of MEDLINE, PubMed, and references from relevant articles using search terms such as "glenohumeral," "osteoarthritis," "epidemiology," "etiology," "imaging," and "pathophysiology." Only articles published in English, German, and Finnish between 1957 and 2017 were included.

RESULTS

The prevalence of radiological shoulder OA has been estimated to be as high as 16% -20% in the middle-aged and elderly population, but the concordance between structural findings and symptoms seems to be weak, as many of these individuals are asymptomatic. The vast majority of GHOA is related to non-specific factors, namely advancing age, while specific risk factors are commonly found in young patients. Diagnosis of GHOA is made when typical clinical features and defined radiological findings overlap in an individual.

CONCLUSION

Ultimately the determinants of shoulder pain in GHOA remain incompletely understood. Improved understanding of the etiology and diagnosis of GHOA will enable clinicians to better determine which patients will benefit from different treatment modalities, as well as provide new avenues to potential treatments.

Clinical and Radiographic Evaluation of Patients Operated by the Bristow-Latarjet Technique with a Minimum Follow-Up of 20 Years

Objective  To verify the results of 27 patients submitted to surgery from 1990 to 1997 by the Bristow-Latarjet technique for the treatment of anterior traumatic instability of the shoulder. The analysis included the possible complications, especially the appearance of arthropathy. Methods  The subjective clinical evaluation was performed through a questionnaire answered by the patients, and the objective evaluation was performed using the Rowe et al score. The radiographic evaluation was performed using the anteroposterior (true) incidence to detect signs of shoulder arthrosis, according to the classification of Samilson and Prieto, as well as the apical oblique and the Bernageau and Patte incidences to verify the consolidation of the bone graft, the position of the screw and of the graft, and signs of the release of the synthesis material. These evaluations were performed by two examiners at different times without interference between them. Results  In the subjective assessment of the patients, 93% were fully recovered, and, in the objective evaluation, the average was 95 points on the Rowe et al score. Complications related to coracoid placement were not found. The degree of arthropathy of the shoulders, according to the Samilson and Prieto classification, presented an average of seven mild cases, two moderate cases and one severe case. In total, 17 patients did not present arthropathy. Conclusion  Between the first and second evaluations, there was no change in the efficacy of the Bristow-Latarjet technique. The careful observation of the criteria of the technique was fundamental to avoid complications. The occurrence of arthropathy in the long term was not relevant in our evaluation. Based on the evidences of the present study, the surgical procedure alone is not the cause of the onset of the arthropathy, but the failure in its execution.

Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older

BACKGROUND

The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization.

METHODS

A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations.

RESULTS

Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients.

CONCLUSIONS

The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury.

Glenoid morphology is associated with the development of instability arthropathy

BACKGROUND

Instability arthropathy (IA) is a major long-term concern in patients with anterior shoulder instability. This study investigated the association of glenoid morphology with the development of IA.

METHODS

The study included 118 patients with unilateral anterior shoulder instability and available bilateral computed tomography scans. Instability-specific information was obtained from all patients. The glenoid morphology of the affected shoulder was compared with the nonaffected contralateral side resembling the constitutional preinjury glenoid shape. Both shoulders were evaluated independently by 3 observers to assess the grade of IA according to a Comprehensive Arthropathy Rating (CAR) system. Associations between IA and the glenoid morphology parameters were investigated.

RESULTS

The average glenoid retroversion (P < .001), glenoid depth (P < .001), glenoid diameter (P < .001), and the bony shoulder stability ratio (P < .001) of the affected shoulder were significantly reduced compared with the contralateral side due to bony defects in 79.6% of the patients. The CAR of the affected side was significantly higher (P < .001), with more osteophytes (P = .001) and more sclerosis and cysts (P < .001). Differences in CAR (Δ-CAR) correlated positively with the age at the time of the computed tomography scan (P < .001), age at the initial dislocation (P = .001), size of the glenoid defect (P = .005), and the contralateral glenoid depth (P = .011), glenoid diameter (P = .016), and bony shoulder stability (P = .029), and negatively with glenoid retroversion of the affected side (P = .027).

CONCLUSION

Development of IA arthropathy is associated not only with the age of the patients but also with morphologic parameters of the glenoid, including glenoid defect size and the constitutional glenoid concavity shape.

Glenohumeral Dislocation Arthropathy: Etiology, Diagnosis, and Management

Dislocation arthropathy describes the development of progressive degenerative changes of the glenohumeral joint in the setting of instability. Although the specific etiology remains unclear, the trauma of a single dislocation, repetitive injury associated with recurrent dislocations, changes in shoulder biomechanics, and complications associated with instability surgery have all been implicated in its development. Pain and restricted range of motion are the most common patient complaints. Conservative management, consisting of pain control, activity modification, and physical therapy, is the first-line treatment after the development of arthropathy. If conservative management fails, multiple surgical options exist. Arthroscopic débridement can be attempted in young, active patients and in those patients with mild-to-moderate arthropathy. Open subscapularis lengthening and capsular release can be done in patients with prior instability repairs that are overly tight. In young patients with minimal bone loss and glenoid wear, surface replacement arthroplasty and hemiarthroplasty are surgical options. In older patients with moderate-to-severe arthropathy, total shoulder or reverse shoulder arthroplasty is the preferred treatment option. Further study is needed to better predict which patients will develop dislocation arthropathy and will thus benefit from early surgical intervention.

Contraindications and complications of the Latarjet procedure

The Latarjet procedure is a well-known, safe and reliable technique to treat primary or recurrent anterior dislocations or subluxations, with or without hyperlaxity, with or without glenoid bone loss. Both the open and the arthroscopic methods produce excellent clinical results, with a low rate of recurrent instability. There have been concerns of a higher surgical complication rate associated with this procedure, however, large reviews reported an overall complication rate in the open Latarjet procedure of 15%. Meticulous surgical technique and a good understanding of the local anatomy can help to avoid the complications but postoperative shoulder arthritis and frequent bone block osteolysis remain unsolved additional challenges, which require further research. There are 2 main factors to further improve the clinical outcome and patient satisfaction: careful patient selection with good surgical indication, and reducing complications with adequate surgical techniques. The aim of this study is to provide the current overview of the contraindications and complications of the Latarjet procedure.

Long-term outcomes of the Bankart and Latarjet repairs: a systematic review

The most common surgical techniques for the treatment of recurrent anterior shoulder instability include the arthroscopic Bankart repair, the open Bankart repair and the open Latarjet procedure. The purpose of this study was to evaluate and compare the long-term outcomes following these procedures. A systematic review of modern procedures with a minimum follow-up of 5 years was completed. The objective outcome measures evaluated were post-operative dislocation and instability rate, the Rowe score, radiographic arthritis and complications. Twenty-eight studies with a total of 1652 repairs were analyzed. The estimated re-dislocation rate was 15.1% following arthroscopic Bankart repair, 7.7% following open Bankart repair and 2.7% following Latarjet repair, with the comparison between arthroscopic Bankart and open Latarjet reaching statistical significance (p<0.001). The rates of subjective instability and radiographic arthritis were consistently high across groups, with no statistical difference between groups. Estimated complication rates were statistically higher in the open Latarjet repair (9.4%) than in the arthroscopic Bankart (0%; p=0.002). The open Latarjet procedure yields the most reliable method of stabilization but the highest complication rate. There are uniformly high rates of post-operative subjective instability symptoms and radiographic arthritis at 5 years regardless of procedure choice.

Surgical options for the young patient with glenohumeral arthritis

Young patients with glenohumeral arthritis are an ongoing treatment challenge. They typically have high demands of their shoulders, require long-term durability due to their young age, and often have altered local anatomy, through their disease process (instability arthropathy, juvenile rheumatoid arthritis, etc.) or from previous surgery (capsulorraphy arthropathy, chondrolysis, etc.). Workup to evaluate underlying causes of early arthritis, and to exclude infectious causes are necessary. When nonoperative management fails, arthroscopic debridement, hemiarthroplasty (isolated, with glenoid reaming, or with biological interposition), and total shoulder arthroplasty are treatment options available to the treating surgeon. Debridement or hemiarthroplasty can provide pain relief for a subset of patients, but results have not been reproducible across the literature and have not been durable over time. Total shoulder arthroplasty provides the most reliable pain relief, but long-term glenoid loosening and wear continue to lead to high revision rates in this patient population.

Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Long-term Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13-Year Follow-up

BACKGROUND

Glenohumeral osteoarthritis is a well-documented, long-term complication of open stabilization procedures. However, there is a lack of knowledge about long-term radiographic outcome after arthroscopic Bankart procedures.

HYPOTHESIS

Glenohumeral osteoarthritis will develop less frequently in arthroscopic Bankart repair compared with open repairs reported in the literature.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The inclusion criteria for this study were (1) all-arthroscopic Bankart repair for a (2) symptomatic anteroinferior shoulder instability and (3) a minimum follow-up of 10 years. True anteroposterior and lateral radiographs were obtained to evaluate the prevalence and grade of osteoarthritis according to the Samilson classification. Patients were assessed by the Constant score and examined for passive external rotation deficits.

RESULTS

Of 165 shoulders that fulfilled the inclusion criteria, 100 were available for evaluation. The median Constant score at an average±SD 156.2±18.5 months after Bankart repair was 94 (range, 46-100). Twenty-one shoulders (21%) sustained a recurrent dislocation. Overall, 31% of shoulders showed no evidence of glenohumeral osteoarthritis; 41% showed mild, 16% moderate, and 12% severe degenerative changes. Osteoarthritis did not correlate with Constant score results (P=.427). The grade of osteoarthritis was significantly associated with the number of preoperative dislocations (P=.016), age at initial dislocation (P=.005) and at surgery (P=.002), and the number of anchors used (P=.001), whereas time from initial dislocation to surgery (P=.854) and external rotation deficit at 0° and 90° of abduction (P=.104 and .348, respectively) showed no significant correlation. Recurrent dislocation did not affect the presence or grade of osteoarthritis (P=.796 and .665, respectively).

CONCLUSION

At an average 13 years after arthroscopic Bankart repair, osteoarthritic changes are a common finding and, overall, are comparable with reports in the literature regarding open procedures as well as nonoperative treatment. The extent of trauma sustained during preoperative dislocations and the age of the patient seem to be more relevant for long-term dislocation arthropathy than the kind of treatment. Accordingly, the study hypothesis must be rejected. Avoiding preoperative dislocations is more important for the prevention of osteoarthritis than short-term treatment. The number of anchors used was found to be a predictor for long-term development of osteoarthritis.

Risk of arthropathy after the Bristow-Latarjet repair: a radiologic and clinical thirty-three to thirty-five years of follow-up of thirty-one shoulders

BACKGROUND

Transfer of the coracoid (Bristow-Latarjet [B-L]) is used to stabilize anterior shoulder instability. We report the long-term results of our first 31 operations with this method.

MATERIALS AND METHODS

Thirty-six patients (mean age, 26.7 years) had a B-L repair from 1977 to 1979. Five patients died, and during 2012 to 2013, the remaining 31 shoulders had a follow-up with questionnaire, physical examination, Western Ontario Shoulder Instability Index, Subjective Shoulder Value, Subjective Assessment of Shoulder Function, subjective assessment of loss of motion, and radiologic imaging.

RESULTS

One patient required revision surgery because of recurrence and another because of repeat dislocation. Six patients reported subluxations. Eighteen patients (58%) were very satisfied, and 13 (42%) were satisfied. The mean Western Ontario Shoulder Instability Index score (100 possible) was 85, and the median score was 93. According to Samilson-Prieto classification of arthropathy of the shoulder, 39% were classified as normal, 27% as mild, 23% as moderate, and 11% as severe. The classification of arthropathy varied with observers and radiologic views. Age younger than 22 years at the primary dislocation meant less arthropathy at follow-up (P = .045).

CONCLUSION

The degree of arthropathy 33 to 35 years after the B-L repair seems to follow the natural history of shoulder dislocation with respect to arthropathic joint degeneration. Postoperative restriction of external rotation does not increase later arthropathy.

"8 plate": an alternative device to fix highly recurrent traumatic anterior gleno-humeral instability in patients with severe impairment of the anterior capsule

Background:

There is still debate about the best treatment option for highly recurrent anterior shoulder dislocation in patients with severe impairment of the anterior capsule and/or recurrence after either arthroscopic or open capsulorrhaphy. Materials and

Methods:

The clinical and radiological findings of 7 patients treated with an open capsulorrhaphy stabilized with an “8 plate” for a highly recurrent traumatic anterior shoulder dislocation with severe impairment of the anterior capsule and a large Bankart lesion were retrospectively reviewed. Follow-up evaluation included VAS for pain, Constant-Murley, Simple Shoulder Test, ASES, UCLA, Quick DASH, Rowe, Walsch-Duplay scores, as well as X-rays of the operated shoulder.

Results:

At follow-up none of the patients reported subsequent dislocations. Range of motion of the shoulder was complete in all cases, but one. Results of the functional scoring systems were satisfactory. X-rays showed no osteolysis and good position of the plate.

Conclusion:

To our knowledge, this is the first report in the literature about an open capsular tensioning and Bankart lesion repair performed with an “8 plate”. We believe that this is a reliable and effective procedure to address traumatic anterior re-dislocation of the gleno-humeral joint when the capsule is extensively torn and frayed or in revision cases. Moreover the “8 plate” is ideal to be applied in such a narrow space on the slant surface of the scapular neck close to the glenoid rim.

Survey on the management of acute first-time anterior shoulder dislocation amongst Dutch public hospitals

INTRODUCTION

The primary aim of this study was to record how orthopaedic surgeons are currently managing acute first-time anterior shoulder dislocation (AFASD) 8 years after introduction of the Dutch national guideline: "acute primary shoulder dislocation, diagnostics and treatment" in 2005. The second aim was to evaluate how these surgeons treat recurrent instability after AFASD.

MATERIALS AND METHODS

An online questionnaire regarding the management of AFASD and recurrent shoulder instability was held amongst orthopaedic surgeons of all 98 Dutch hospitals.

RESULTS

The overall response rate was 60%. Of the respondents, 75% had a local protocol for managing AFASD, of which 28% had made changes in their treatment protocol after the introduction of the national guideline. The current survey showed wide variety in the overall treatment policies for AFASD. Twenty-seven percent of the orthopaedic surgeons were currently unaware of the national guideline. The variability in treatment for AFASD was present throughout the whole treatment from which policy at the emergency department; when to operate for recurrent instability; type of surgical technique for stabilization and type of fixation of the labrum. As for the treatment of recurrent instability, the same variability was seen: 36% of the surgeons perform only arthroscopic procedures, 7% only open and 57% perform both open and arthroscopic procedures.

CONCLUSIONS

Despite the introduction of the national guideline for the initial management of AFASD in 2005, still great variety among orthopaedic surgeons in the Netherlands was present. As for the surgical stabilization technique, the vast majority of the respondents are performing an arthroscopic shoulder stabilization procedure at the expense of the more traditional open procedure as a first treatment option for post-traumatic shoulder instability.

Long-term results of the Latarjet procedure for anterior instability of the shoulder

BACKGROUND

The Latarjet procedure is effective in managing anterior glenohumeral instability in the short term, but there is concern for postoperative arthritis. The purpose of this study was to evaluate the long-term functional outcome after the Latarjet procedure and to assess the prevalence of and risk factors for glenohumeral arthritis after this procedure.

MATERIALS AND METHODS

A retrospective review was conducted of 68 Latarjet procedures at a mean of 20 years postoperatively. The mean age at surgery was 29.4 years. Functional outcome was determined by the Rowe score, subjective shoulder value, and recurrence of instability. Preoperative arthritis and postoperative radiographs were reviewed to evaluate the development or progression of arthritis.

RESULTS

The mean Rowe score increased from 37.9 preoperatively to 89.6 at final follow-up (P < .001). The mean subjective shoulder value was 90.9% at final follow-up. The postoperative rate of recurrence was 5.9%. Of the 60 shoulders without arthritis preoperatively, 12 (20%) had developed arthritis at final follow-up. Among the 8 shoulders with preoperative arthritis (all stage 1), 4 (50%) demonstrated progression of arthritis at final follow-up. Overall, postoperative arthritis was stage 1 in 14.7%, stage 2 in 5.9%, and stage 3 in 8.8% of cases; no stage 4 arthritis was observed. Risk factors for postoperative arthritis were older age, high-demand sports activity, and lateral overhang of coracoid bone graft.

CONCLUSION

The Latarjet procedure provides excellent long-term outcomes in the treatment of recurrent anterior glenohumeral instability. Twenty years after the Latarjet procedure, arthritis may develop or progress in 23.5% of cases, but the majority of arthritis is mild.

Intermediate and long-term follow-up of total shoulder arthroplasty for the management of postcapsulorrhaphy arthropathy

BACKGROUND

The purpose of this study was to evaluate the subjective and objective outcomes in patients undergoing total shoulder arthroplasty for treatment of postcapsulorrhaphy arthropathy (CA) and compare them with outcomes in patients undergoing total shoulder arthroplasty for primary glenohumeral osteoarthritis (OA).

METHODS

Total shoulder arthroplasty was used to treat 25 consecutive CA patients (25 shoulders) at our institution; of these, 22 patients were available for follow-up. An age-matched cohort of 19 consecutive patients (20 shoulders) who were treated with total shoulder arthroplasty for primary glenohumeral OA was compared with the CA group. Patients were evaluated by physical examination and patient outcome measures (American Shoulder and Elbow Surgeons assessment and Simple Shoulder Test). Complications, reoperations, and subscapularis function was also recorded.

RESULTS

Compared with the CA group, the OA group achieved greater forward elevation (165° vs 147°; P = .036) and greater external rotation (56° vs. 45°; P = .04); however, no significant differences were seen in subjective patient scores between the 2 groups for Simple Shoulder Test (P = .90), American Shoulder and Elbow Surgeons assessment (P = .65), and pain scores (P = .80). The difference in the number of revision surgeries in the OA group compared with the CA group (1 vs 4) was not significant (P = .35). A significantly higher number of patients in the CA group had subscapularis insufficiency compared with the OA group (5 CA vs 0 OA; P = .049).

CONCLUSIONS

Our findings suggest that when compared with patients undergoing total shoulder arthroplasty for primary OA, CA patients experience similar outcomes with respect to revision surgery, pain relief, and subjective self-assessment and have a higher incidence of subscapularis insufficiency.

Outcome after modified Putti-Platt procedure for recurrent traumatic anterior shoulder dislocations

Most recent studies on procedures for stabilizing the glenohumeral joint focus on arthroscopic techniques. A relatively simple open procedure is the modified Putti-Platt procedure. The aim of these retrospective case series was to evaluate the functional outcome, patient satisfaction, and quality of life of patients who underwent this procedure. After a median follow-up time of 4.7 (P₂₅–P₇₅ 1.7–6.8) years, fifty-one patients could be enrolled with a mean age of 25 (21–39) years. Five patients (10 %) reported re-dislocations. The median Constant score for the affected side was 84 (P₂₅–P₇₅ 75–91). Median loss of motion in abduction, elevation, external rotation, and external rotation in 90° of abduction did not exceed 10° when compared to the healthy shoulder. A median Rowe score of 92 (P₂₅–P₇₅ 75–95) was measured. The WOSI score and SF-36 showed excellent quality of life. The VAS proved high patient satisfaction with the outcome; 7.9 (6.8–9.5). We concluded that the modified Putti-Platt procedure leads to excellent outcome scores and only marginal restriction in range of motion combined with a high patient satisfaction. Our data prove that excellent results can be obtained with a relatively simple open procedure.

Dislocation arthropathy and drill hole appearance in a mid- to long-term follow-up study after arthroscopic Bankart repair

PURPOSE

The aim of this study was to perform a prospective mid- to long-term clinical and radiographic follow-up after arthroscopic Bankart repair using absorbable tacks with special emphasis on the development of dislocation arthropathy.

METHODS

Thirty-four shoulders in 32 patients with post-traumatic shoulder instability were included in the study. Clinical and radiographic follow-ups took place after approximately 2 and 8 years.

RESULTS

Thirty-four of 34 (100 %) shoulders in 32 patients returned for the follow-up examination after 95 (53-129) months. Pre-operatively, none of the shoulders had any arthropathy changes. At follow-up, 8/34 (24 %) had minor changes, 6/34 (18 %) had moderate changes, and none had severe arthropathy changes, a significant increment compared with the pre-operative figures (p = 0.005). At follow-up, the drill holes in 24 % of the shoulders still had not healed radiographically. The failure rate in terms of stability was 3/34 (9 %) re-dislocations and 3/34 (9 %) subluxations.

CONCLUSION

Eight years after arthroscopic Bankart repair using absorbable tacks, 41 % of the shoulders displayed some degree of radiographic arthropathy changes and in 24 % the drill holes had not yet radiographically healed. There was no correlation between clinical outcome or drill hole appearance and the development of arthropathy changes.

LEVEL OF EVIDENCE

III.

FUNCTIONAL ASSESSMENT OF ARTHROSCOPIC REPAIR FOR RECURRENT ANTERIOR SHOULDER INSTABILITY

Objective: To clinically and radiologically evaluate patients who underwent arthroscopic surgical treatment for anterior shoulder instability by means of the Bankart technique, using metal anchors. Methods: This was a retrospective study on 49 patients who underwent arthroscopic repair of anterior shoulder instability between 2002 and 2007. The patients were evaluated using the Carter-Rowe score and the Samilson and Prieto classification. The mean age at the time of surgery was 30 years. The mean length of follow-up was 42.7 months (ranging from 18 to 74). 85% of the patients were male. Results: The mean Carter-Rowe score was 83 points (ranging from 30 to 100) including 31 excellent results, 7 good, 3 fair and 8 poor. Recurrent dislocation was observed in 16% (8 patients), and 37.5% of them were of traumatic origin. Joint degeneration was present in 32.5% of the cases, including 5 cases of grade 1, 6 cases of grade 2 and 2 cases of grade 3. The average loss of external rotation was 12° and the loss of anterior elevation was 8°. There was a statistically significant relationship (p < 0.05) between arthritis and age at first dislocation, age at surgery and crackling. 92% of the patients reported high degrees of satisfaction after the procedure. Among the complications, there were two cases of stiff shoulder, one patient with prominence of the synthesis material and one case of anchor loosening. Conclusion: Arthroscopic repair of anterior shoulder instability using metal anchors was shown to be effective, with a low complication rate.

Arthrosis of glenohumeral joint after arthroscopic Bankart repair: a long-term follow-up of 13 years

HYPOTHESIS

The purpose of the study was to establish radiologic and clinical occurrence of glenohumeral arthrosis after arthroscopic Bankart repair.

MATERIALS AND METHODS

Between January 1994 and December 1998, an arthroscopic Bankart repair was performed in 187 patients at our institution. We were able to assess clinical and radiologic glenohumeral arthrosis in 72 of the 101 patients who met the inclusion criteria (74 shoulders) (71%) after a 13-year follow-up. An additional 9 patients were interviewed by telephone. Radiologic arthrosis was evaluated with the Samilson-Prieto classification and clinical arthrosis with an arthrosis-specific quality-of-life questionnaire (Western Ontario Osteoarthritis of the Shoulder test). In addition, functional impairment was assessed with the Constant score and subjective satisfaction with a questionnaire.

RESULTS

Radiologic arthrosis was diagnosed in 50 of 74 shoulders (68%), with 40 (80%) of them classified as mild. The mean score on the Western Ontario Osteoarthritis of the Shoulder questionnaire was 280 points (85% of the best possible score), which is considered relatively good. The mean Constant score was 78 points, and 75% of the patients were extremely satisfied or satisfied with the final results of operative treatment.

DISCUSSION

The radiologic evaluation and self-assessment of the patients imply that the incidence of glenohumeral arthrosis after arthroscopic Bankart repair is quite common but the symptoms are generally mild and comparable to nonoperative treatment.

CONCLUSION

Arthrosis rarely causes more than minor subjective symptoms or a minor objectively perceived disadvantage during 13 years' follow-up.

Long-term result after traumatic anterior shoulder dislocation: what works best?

Traumatic anterior shoulder dislocation is a common pathology. To inform the patient, it is therefore important to know the natural history of anterior dislocation and the long-term result of conservative treatment versus the long-term results of operative treatment. In this review article, we compare the effectiveness of various anatomical and non-anatomical interventions and between open and arthroscopic surgery. Evaluating of the result, we focused on the recurrence of instability, return to sport, and prevalence of articular cartilage degeneration in the several treatments.

Glenohumeral osteoarthritis after arthroscopic Bankart repair for anterior instability

BACKGROUND

Few data on shoulder arthropathy in patients undergoing arthroscopic repair for glenohumeral instability are available.

HYPOTHESIS

Arthroscopic stabilization of Bankart lesions does not prevent the development of postoperative glenohumeral osteoarthritis.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Clinical (Rowe and Constant scores) and radiographic preoperative and postoperative data from 60 patients who underwent arthroscopic Bankart repair were compared. Osteoarthritis was graded preoperatively and postoperatively with the Buscayret classification grading system. The average age at surgery was 27.6 years, and follow-up averaged 8.0 years.

RESULTS

The postoperative incidence of osteoarthritis in patients with no preoperative degenerative changes was 21.8% (12 of 55 patients). The incidence of degenerative joint disease of the glenohumeral joint showed evidence of a statistically significant association with older age at first dislocation and at surgery, increased length of time from the first episode to surgery, increased number of preoperative dislocations, increased length of time from the initial dislocation until surgery, increased number of anchors used at surgery, and more degenerated labrum at surgery. A higher number of preoperative dislocations, a greater length of follow-up, and reduced external rotation in abduction influenced Rowe and Constant scores.

CONCLUSION

The number of anchors used and the state of the labrum are the most important factors associated with a higher risk of radiographic degenerative changes. Longer follow-up investigations are needed to draw meaningful conclusions.

Outcome of the open Bankart procedure for shoulder instability and development of osteoarthritis: a 5- to 20-year follow-up study

BACKGROUND

The etiologic factors, time of development, and extent of the progression of postoperative osteoarthritis (OA) in traumatic shoulder instability remain controversial.

HYPOTHESIS

Most OA seen postoperatively occurs before surgery and progresses very slowly.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Review of 167 joints of 163 patients undergoing the open Bankart procedure, who had no history of shoulder surgery and were younger than 45 years at follow-up, was done at a mean follow-up of 8.7 years (range, 5-20 years). The shoulders were directly examined and radiographed. A statistical analysis was performed to examine the correlation between OA development/progression and patients' demographic characteristics and various factors, and to evaluate the correlation between these factors.

RESULTS

Recurrence of instability occurred in 8 of 167 joints (4.8%). Preoperative computed tomography (CT) showed OA in 44 shoulders (26.3%), among which 12 shoulders (7.2%) showed OA on the preoperative radiographs. Consequently, CT-proven OA in the remaining 32 shoulders was incipient OA that was not revealed radiographically. Radiographs taken at follow-up revealed OA in 30 shoulders (18.0%), of which 24 (80%) had had OA proven by preoperative imaging. Preoperative CT-proven OA in 20 shoulders never became visible on postoperative radiographs. The severity of OA slightly increased in 14 joints (32%) during the postoperative period. The number of preoperative subluxations and the total number of preoperative dislocations/subluxations were significantly greater, and the percentages of male patients and glenoid bone defect greater than 20% of the anteroposterior diameter were higher for the 30 shoulders with postoperative OA.

CONCLUSION

Most postoperatively detected OA developed before surgery. The preoperative factors are profoundly involved in the development of OA. The role of surgery in favoring the OA development appears to be inconclusive. The development and progression of OA cannot be prevented by surgical intervention, but the progression of postoperative OA is extremely slow.

The posterior bone block procedure in posterior shoulder instability

We present the long-term outcome, at a median of 18 years (12.8 to 23.5) of open posterior bone block stabilisation for recurrent posterior instability of the shoulder in a heterogenous group of 11 patients previously reported on in 2001 at a median follow-up of six years.

We found that five (45%) would not have chosen the operation again, and that four (36%) had further posterior dislocation. Clinical outcome was significantly worse after 18 years than after six years of follow-up (median Rowe score of 60 versus 90 (p = 0.027)). The median Western Ontario Shoulder Index was 60% (37% to 100%) at 18 years’ follow-up, which is a moderate score. At the time of surgery four (36%) had glenohumeral radiological osteoarthritis, which was present in all after 18 years.

This study showed poor long-term results of the posterior bone block procedure for posterior instability and a high rate of glenohumeral osteoarthritis although three patients with post-traumatic instability were pleased with the result of their operations.

Glenohumeral arthropathy following stabilization for recurrent instability

Little attention has been focused on the most common risk factors for post-operative glenohumeral arthropathy in patients undergoing open and arthroscopic stabilization. We performed a literature search using Medline, Cochrane and Google Scholar using the keywords: 'Shoulder instability surgery' in combination with 'glenohumeral osteoarthrosis', 'recurrent shoulder dislocation' in combination with 'surgery' and 'complications'. We identified 33 published studies. There is evidence of long-term postoperative glenohumeral arthropathy in patients undergoing surgical management for shoulder instability. The Coleman methodology score showed great heterogeneity in terms of study design, patient characteristics, management methods and outcome assessment and generally low methodological quality. Follow-up length, age at first dislocation episode and limited external rotation have been shown to be strongly associated with shoulder arthropathy. There is no univocal outcome assessment available. To define the risk factors responsible for development of postoperative glenohumeral arthropathy, controversial findings have been detected. A common validated scale for clinical and imaging measurements for shoulder arthropathy is needed, so as to allow easier and more reliable comparison of outcomes in different studies. Patients should receive controlled imaging assessment (MR and radiographs) in addition to clinical examination. There is a need to perform appropriately powered randomized clinical trials comparing clinical and imaging related outcomes in patients undergoing open, arthroscopic and conservative management for shoulder instability. Standard diagnostic assessment, common and validated clinical and imaging scoring systems are needed.

Osteochondral autologous transplantation for the treatment of full-thickness cartilage defects of the shoulder

We describe the outcome at a mean follow-up of 8.75 years (7.6 to 9.8) of seven patients who had undergone osteochondral autologous transplantation for full-thickness cartilage defects of the shoulder between 1998 and 2000. These patients have been described previously at a mean of 32.6 months when eight were included. One patient has been lost to follow-up. The outcome was assessed by the Constant shoulder score and the Lysholm knee score to assess any donor-site morbidity. Standard radiographs and MR scores were obtained and compared with the pre-operative findings and the results from the previous review.

No patient required any further surgery on the shoulder. The mean Constant score improved significantly until the final follow-up (p = 0.018). The Lysholm score remained excellent throughout. There was a significant progression of osteoarthritic changes from the initial surgery to the first and final follow-up but this did not appear to be related to the size of the defect, the number of cylinders required or the Constant score (p = 0.016). MRI showed that all except one patient had a congruent joint surface at the defect with full bony integration of all osteochondral cylinders.

The results have remained satisfactory over a longer period with very good objective and subjective findings.

Neer Award 2008: Arthropathy after primary anterior shoulder dislocation--223 shoulders prospectively followed up for twenty-five years

BACKGROUND

Shoulder dislocation may cause arthropathy, but the natural history of this evolution is not well described. We therefore conducted a radiographic follow-up 25 years after the primary shoulder dislocation.

METHODS

A prospective Swedish multicenter study (1978-1979) included 257 shoulders in 255 patients (age, 12-40 years) with a first-time anterior shoulder dislocation. After 25 years, 227 patients (229 shoulders) were alive and had follow-up. Radiographic imaging was performed in 223 shoulders (97%).

RESULTS

Shoulders were normal in 44%. Arthropathy was mild in 29%, moderate in 9%, and severe in 17%. Of the shoulders without a recurrence, 18% had moderate/severe arthropathy. The corresponding figures were 39% for shoulders that recurred once or more (without surgery) and 26% (16 of 62) for surgically stabilized shoulders. Seven of 221 patients (7 of 223 shoulders) were considered alcoholic at 25 years and all had severe arthropathy (P < .001). Other factors that correlated with moderate/severe arthropathy were age older than 25 years at primary dislocation (P = .01) and primary dislocation caused by high-energy sports activity (P = .009). Shoulders that had not recurred had less arthropathy than shoulders classified as recurrent (P = .047) or stabilized over time (P = .007). Sixty-two surgically stabilized shoulders had less arthropathy than those that became stable over time (P = .047). Mild arthropathy at 10 years was associated with moderate/severe arthropathy at 25 years in 19 of 30 shoulders (63%) compared with 13 of 146 (9%) classified as normal at 10 years (P < .001). Joint incongruence at 10 years was associated with moderate/severe arthropathy at 25 years (P = .001).

CONCLUSION

Age at primary dislocation, recurrence, high-energy sports, and alcohol abuse were factors associated with the development of arthropathy. Also shoulders without a recurrence were associated with arthropathy.

Shoulder stiffness

Shoulder stiffness is commonly encountered in clinical practice but varies greatly in severity and etiology. Loss of shoulder range of motion can be a patient's primary complaint or may be a secondary finding. Possible causes of stiffness include guarding due to pain or secondary gain issues (nonanatomic), true mechanical blockage due to acute or chronic trauma, adhesive capsulitis, rotator cuff disease, or surgery on or near the shoulder. This review includes a more detailed discussion of these causes as well as the appropriate history and physical and diagnostic testing recommended for each. Finally, treatment strategies for each group of patients will be presented.

In vivo comparison of changes in glenohumeral translation after arthroscopic capsulolabral reconstructions

BACKGROUND

The objective of this study was to quantify anteroposterior glenohumeral translation of patients undergoing arthroscopic capsulolabral repairs using cutaneous electromagnetic position sensors.

HYPOTHESIS

Anteroposterior translation will be restored after arthroscopic capsulolabral repairs to values similar to the contralateral or uninjured shoulder.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

With use of an electromagnetic tracking system, preoperative anteroposterior translation was measured in the injured and uninvolved shoulders of 32 patients with a diagnosis of glenohumeral labral tears. Testing was done with patients placed in the supine position with the arm suspended in 90 degrees of abduction and neutral rotation. The American Shoulder and Elbow Society index and range of motion were also measured. Patients with capsulolabral injuries requiring arthroscopic repair were reexamined at 3 and 6 months postoperatively.

RESULTS

In patients with anteroinferior/posteroinferior capsulolabral repairs, glenohumeral translation at 3 and 6 months postoperative (P < .0001) was significantly decreased compared with preoperative values (P = .0007) and the uninvolved side (pre-operative, P = .04; postoperative, P = .002). In patients with superior capsulolabral (superior labral anterior-posterior) repairs, the mean glenohumeral translation at 3 and 6 months postoperative was decreased significantly compared with the preoperative value; however, no significant differences were found between the uninvolved side (preoperative, P = .5) and the operative shoulder (postoperative, P = .2). By 6-month follow-up, no significant difference existed in external rotation when compared with pre-operative values for either repair group.

CONCLUSION

Arthroscopic superior capsulolabral reconstructions successfully restored anteroposterior translation. However, arthroscopic capsulolabral techniques for treating recurrent anterior or posterior instability resulted in decreased anteroposterior translation compared to the uninvolved side while restoring external rotation.

Humeral resurfacing hemiarthroplasty with meniscal allograft in a young patient with glenohumeral osteoarthritis

STUDY DESIGN

Case report.

BACKGROUND

Management of glenohumeral joint osteoarthritis in young, active patients is challenging due to the significant functional limitations and progression of the disease, coupled with the limited lifespan of prosthetic implants presently in use. The purpose of this report is to present the detailed rehabilitation program and outcome of a patient who suffered an initial glenohumeral dislocation and, following multiple surgical interventions, required shoulder hemiarthroplasty and biologic glenoid resurfacing to return to function.

CASE DESCRIPTION

An objectively based rehabilitation protocol was used for this patient following shoulder hemiarthroplasty. Data collected included passive and active range of motion, isometric rotational strength, and functional outcome scores to include the Single Assessment Numeric Evaluation (SANE) and American Shoulder Elbow Surgeons (ASES) outcome measures.

OUTCOMES

Progressive improvements in active and passive range of motion were documented at numerous points during postoperative rehabilitation, including 1 and 2 years postoperatively. The patient's initial functional outcome scores improved from 2/100 to 90/100 in the SANE and from 17/100 to 85/100 for the ASES rating scales. At 2 years postsurgery the SANE score was 60/100 and ASES 68/100.

DISCUSSION

Early postoperative range of motion exercises performed in a range protecting the subscapularis, coupled with a progressive program of rotator cuff and scapular strengthening exercises, resulted in decreased pain, improved range of motion, and return to work in a limited capacity following hemiarthroplasty with biologic glenoid resurfacing. Further research in series of patients following this procedure will help to establish optimal treatment guidelines and prognosis for young active patients with severe glenohumeral joint osteoarthritis.

LEVEL OF EVIDENCE

Therapy, level 4.

The J-bone graft for anatomical glenoid reconstruction in recurrent posttraumatic anterior shoulder dislocation

BACKGROUND

Posttraumatic shoulder dislocations with glenoid rim fractures show high rates of dislocation recurrence. For glenoid rim defects exceeding a certain size, several investigators recommend bone grafting. Few reports on anatomical glenoid reconstruction addressing this problem are published.

HYPOTHESIS

Anatomical glenoid reconstruction by the J-bone graft creates permanent joint stability without a clinically relevant loss of motion.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty-seven shoulders with glenoid rim fractures after recurrent anterior dislocation were stabilized by a J-bone graft. For clinical outcome, motion and strength compared with the uninjured shoulder, as well as sports activity, were recorded. The Rowe score and the Constant-Murley score were used for scoring. In cases of follow-up exceeding 6 years, computed tomography scans were obtained and compared to preoperative radiographs.

RESULTS

The mean Rowe score was 94.3 for the affected shoulder and 96.8 for the uninjured side. The Constant score reached 93.5 and 95 points, respectively. Loss of external rotation was 4.36 degrees in adduction and 3.19 degrees at 90 degrees of abduction. The computed tomography evaluation included 24 shoulders at a mean follow-up of 106.2 months. There were no recurrences of instability and 1 traumatic graft fracture. Of the 19 patients in whom arthropathy was present at follow-up, 11 had arthrosis before surgery.

CONCLUSION

The J-bone graft is capable of creating a stable shoulder joint without causing extensive loss of motion on the long term in patients with traumatic glenoid rim fractures after shoulder dislocation. In some patients, mild to moderate arthropathy develops despite anatomical glenoid reconstruction.

Does Weber's rotation osteotomy induce degenerative joint disease at the shoulder in the long term?

Weber's internal rotation osteotomy of the humeral head is recommended for the treatment of anteroinferior shoulder instability with a large Hill-Sachs defect. The observation of severe joint degeneration in the course of long-term follow-up provided the motivation for this study. An osteotomy was performed in 42 patients from 1984 to 1990. Thirty-four patients were available for clinical and radiological follow-up after 14.5 years. Our own CT-based classification was applied to categorize the degree of osteoarthritis. A shoulder prosthesis was implanted in 9 patients (26%). Only 3 patients (9%) did not show any signs of degeneration. A statistically significant relationship was found between increased internal rotation of the humeral head and disease severity (P = .03). A lower incidence of joint degeneration (P = .02) was found for patients with generalized ligamentous laxity. We therefore recommend this osteotomy only as a salvage procedure whereby the internal rotation of the humeral head should not exceed 20 degrees .

The open modified Bankart procedure

We report the outcome of a modified Bankart procedure using suture anchors in 31 patients (31 shoulders) with a mean follow-up of 11 years (10 to 15). The mean age of the patients was 28 years (16 to 39). At follow-up, the mean Rowe score was 90 points (66 to 98) and the Constant score was 96 points (85 to 100). A total of 26 shoulders (84%) had a good or excellent result. The rate of recurrence varied between 6.7% and 9.7% and depended on how recurrence was defined. Two patients had a significant new injury at one and nine years, respectively after operation. The overall rate of instability (including subluxations) varied between 12.9% and 22.6%. All patients returned to work, with 29 (94%) resuming their pre-operative occupation and level of activity. Mild radiological osteoarthritis was seen in nine shoulders (29%) and severe osteoarthritis in one.

We conclude that the open modified Bankart procedure is a reliable surgical technique with good long-term results.

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.

The effect of total shoulder arthroplasty on self-assessed deficits in shoulder function in patients with capsulorrhaphy arthropathy

The objective of this study was to characterize self-assessed functional deficits before and after total shoulder arthroplasty (TSA) in a consecutive series of 24 patients treated for capsulorrhaphy arthropathy. Deficits were determined by use of the Simple Shoulder Test. The effects of age, type of original stabilization surgery, duration of time since the initial repair, and pattern of glenoid erosion were analyzed. Deficits were significantly reduced from 8.5 to 4 of 12 SST items after TSA (P = .003). Items related to motion and function had the largest effect on improvement. Age did not affect results. There was a trend toward greater improvement in patients whose original stabilization was less than 20 years previously (P = .06) and in those with concentric glenoid erosion (P = .06). A prior Bristow procedure was associated with the least improvement. Overall, TSA was an effective treatment for capsulorrhaphy arthropathy at midterm follow-up. Restoring range of motion appears to have the largest impact on improvement in function.

One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study II-the evolution of dislocation arthropathy

Dislocation arthropathy after surgical treatment of recurrent anterior dislocation of the shoulder has been a subject of discussion over the years. The objective of this prospective study was to evaluate the Bristow-Latarjet repair at 2 and 15 years after surgery with respect to arthropathy and to evaluate factors responsible for this development. At 2 and 15 years after a Bristow-Latarjet repair for recurrent anterior dislocation, we prospectively analyzed the radiographs of 115 of 118 shoulders. The majority of the patients also had radiography of the nonindex shoulder (111/118). Dislocation arthropathy was found on ordinary anteroposterior views in 46 of 115 shoulders (mild in 39, moderate in 5, and severe in 2). The anteroposterior view angulated 45 degrees from above gave the best visualization of the humeral osteophyte and, together with the axial view, doubled the incidence of moderate and severe arthropathy at follow-up (mild in 40, moderate in 11, and severe in 5). Of 38 shoulders with a postoperative position of the transferred coracoid process 2 to 4 mm medial to the glenoid rim and the screw and transplant parallel to the glenoid, 3 had moderate arthropathy (8%) compared with 8 shoulders with moderate arthropathy and 5 with severe arthropathy out of 77 shoulders with a nonoptimal position of the coracoid (17%) (P = not significant). The degree of restriction of outward rotation at 2 years did not influence the degree of arthropathy after 15 years. Global assessment of the operative result was not related to arthropathy at follow-up. When the first dislocation occurred before age 23 years, the incidence of arthropathy was significantly lower than when it occurred in age 23 years or older (P = .006). When all views were included, moderate or severe dislocation arthropathy was found in 14% of the shoulders, and a further 35% had mild arthropathy. When follow-up studies of operated series of shoulder dislocations with the Bristow-Latarjet method are done, it is important to have the same radiologic views to compare the incidence of dislocation arthropathy correctly.

Bankart repair for recurrent anterior glenohumeral instability: results at twenty-nine years' follow-up

The aim of the study was to evaluate the long-term results of the open surgical technique of Bankart repair for glenohumeral instability, a procedure that is still widely used. Thirty-nine patients were operated on at our institution by use of the Bankart technique for traumatic anterior glenohumeral instability. Thirty patients were reviewed, with a mean follow-up of 29.0 years (range, 20.3-41.0 years). After surgery, all patients recovered the pretraumatic level of sporting and professional activities. Three (ten percent) had recurrence of dislocation, one of whom underwent reoperation. Between surgery and review, 5 patients needed a total shoulder arthroplasty because of symptomatic osteoarthritis. Among the 25 remaining patients, 20 had a good subjective result, 4 had a fair result, and 1 had a poor result. The mean loss of external rotation was 24 degrees, and the mean loss of internal rotation was 19 degrees. Compared with the contralateral intact shoulder, the scores measured in the operative shoulder were significantly lower (13 points less for the Constant score, 19.8 points less for the Rowe score, and 1.4 points less for the American Shoulder and Elbow Surgeons score). As seen on the radiographs, there were some signs of osteoarthritis in 7 patients. Including the 5 patients who needed shoulder prosthetic replacement, the global rate of osteoarthritis of the study was 40%. All of the patients said that they would recommend this surgery. The Bankart technique, when used for traumatic anterior glenohumeral instability, gives reliable long-term results. However, it does not prevent the development of shoulder osteoarthritis.

A prospective, randomized, clinical and radiographic study after arthroscopic Bankart reconstruction using 2 different types of absorbable tacks

PURPOSE

The aim of the study was to compare the clinical and radiographic results after arthroscopic Bankart reconstruction using 2 different types of absorbable implant.

TYPE OF STUDY

Randomized controlled trial.

METHODS

A randomized series of 40 patients who had recurrent, unidirectional, post-traumatic shoulder instability were included in the study. All patients underwent an arthroscopic Bankart reconstruction involving either polygluconate co-polymer (PGACP group, n = 20) or self-reinforced poly-L-lactic acid polymer (PLLA group, n = 20) tack implants. The patients underwent clinical and radiographic assessments preoperatively and at 2 years. Additional radiographic assessments were performed at 6 months.

RESULTS

Preoperatively, the study groups were comparable in terms of demographics as well as clinical parameters. One patient in each group had a redislocation (5%) during the follow-up period of 2 years. No subluxations were registered. No statistically significant differences were found between the study groups in terms of strength in abduction, range of motion, and Rowe or Constant scores. There was a significant increase in degenerative changes during the follow-up period in both study groups (P = .004). However, no significant differences in degenerative changes were registered between the study groups either preoperatively or at the 2-year follow-up. There were no significant differences in the radiographic visibility of the drill holes used for the absorbable implants between the study groups at the 6-month assessment. However, at the 2-year assessment, the radiographic visibility of the drill holes was significantly greater (P = .004) in the patients in the PLLA group than those in the PGACP group. At the 2-year assessment, no correlation was found between the appearance of the drill holes and the degenerative findings (PGACP group, rho = 0.44; PLLA group, rho = 0.42).

CONCLUSIONS

Two years after arthroscopic Bankart reconstruction using either PGA polymer or PLA polymer implants, the overall clinical results were comparable. Radiographic assessments revealed that the degenerative changes increased in both study groups during the follow-up period. Furthermore, the visibility of the drill holes on the 2-year radiographs was greater after using PLLA implants than after using PGACP implants.

LEVEL OF EVIDENCE

Level I.

Medicolegal aspects of the orthopaedic care for shoulder injuries

The medicolegal aspects of orthopaedic care increasingly are becoming an important focus of physicians. Because of the rarity of publications on the subject, I will examine medical litigation in orthopaedics, specifically in regards to shoulder injuries. There are several reasons for recent increases in malpractice litigation. Increased orthopaedic specialization and advanced technologies have raised patient expectations while the media have informed patients of the potential financial rewards of litigation. I will discuss three cases of litigation regarding shoulder injuries including reasons for malpractice and what can be done to avoid it. In Case 1 I examine an implant failure of a rotator cuff repair. The failure was caused by a manufacturing error; therefore, the importance of being familiar with the equipment and the companies that a physician deals with is emphasized in this case. Case 2 is another failed rotator cuff repair; this litigation stemmed from poor patient selection and a lack of preoperative patient-physician communication. Finally, Case 3 involved retained hardware, a surgical mistake that often results in a substantial settlement because it is considered indefensible. These cases highlight the potential for malpractice and can be applied more broadly to all branches of orthopaedics. Most litigation, however, can be avoided with careful diagnostic procedures, greater experience with equipment, and better communication.

Glenohumeral arthritis and its management

Glenohumeral arthritis has many different etiologies, including osteo-arthritis, secondary degenerative joint disease, rheumatoid arthritis,avascular necrosis, cuff tear arthropathy, and capsulorrhaphy arthropathy. Each of these diagnoses may have different underlying pathoanatomy and pathomechanics. The treating physician must recognize how these characteristics impair shoulder function so that the prescribed course of treatment addresses the root causes of shoulder dysfunction. The patient's age. level of physical activity, and comorbidities should be taken into account, and the intended management should be weighed against how these factors may interfere with treatment efficacy over the long-term. The goal of treatment is to restore comfort, motion, strength, and stability to the shoulder in a safe and reliable manner. Conservative treatments should aim to optimize shoulder flexibility, maintain muscle function, and reduce inflammation. Activity modification is crucial but often unreasonable to the active patient. Temporary surgical approaches include arthroscopic debridement and synovectomy. These approaches may be appropriate for a younger patient with some remaining joint space and a functional rotator cuff. Definitive surgical treatment typically involves either a proximal humerus replace mentor a total shoulder replacement. The decision to resurface the glenoid should be based on the patient's age, diagnosis, available bone stock, and physical demands. The surgeon must be familiar with the options provided by the given implant system so that the proper balance of motion and stability can be restored with a close approximation of the native anatomy. Inexperienced hands, good-to-excellent results can be achieved in greater than 90% of properly selected patients. Glenoid component failure is one of the most common complications of shoulder arthroplasty, highlighting the need to select carefully patients in whom glenoid resurfacing is warranted.

Glenohumeral arthrosis in anterior instability before and after surgical treatment: incidence and contributing factors

BACKGROUND

Few large series of arthropathy related to anterior glenohumeral instability are available in the orthopaedic literature, preventing analysis of the incidence and the risk factors of preoperative and postoperative glenohumeral arthritis.

HYPOTHESIS

Anterior stabilization surgery influences the risk factors of glenohumeral arthritis.

STUDY DESIGN

Retrospective review.

METHODS

There were 570 patients who underwent an instability procedure. Clinical and radiographic preoperative data were collected for these patients. Arthritis was evaluated preoperatively and postoperatively with the Samilson classification. The mean age at surgery was 31.9 years. Follow-up averaged 6.5 years.

RESULTS

The preoperative incidence of arthritis was 9.2%. Arthritic risk factors were older age at the initial dislocation and at surgery, increased length of time from the initial dislocation until surgery, and the presence of osseous glenoid rim lesions. Postoperative arthritis in patients without any preoperative arthritis occurred in 19.7% and was correlated with older age at the initial dislocation and at surgery, increased number of dislocations, and longer follow-up. Decreased external rotation at latest follow-up correlated with arthritis, although whether this was the cause or the effect was unclear.

CONCLUSIONS

Similar factors contribute to preoperative and postoperative arthritis in patients with anterior glenohumeral instability, suggesting that surgery does not influence the risk factors of arthritis. Although decreased external rotation with the arm at side statistically correlated with arthritis in this study, the authors were unable to establish this as an effectual relationship because nearly all patients with glenohumeral osteoarthritis, whether instability related or not, have decreased external rotation.

Shoulder arthroplasty in patients with a prior anterior shoulder dislocation. Results of a multicenter study

BACKGROUND

Prior reports of shoulder arthroplasty performed for dislocation-induced arthropathy have included only patients who had had a prior stabilizing procedure. The purpose of this study was to report the results of shoulder arthroplasty in all patients with a prior anterior shoulder dislocation, including both those previously treated operatively and those previously treated nonoperatively.

METHODS

Fifty-five shoulders undergoing arthroplasty for arthritis following a prior anterior shoulder dislocation were evaluated. Twenty-seven of the shoulders had undergone a prior anterior stabilization procedure. The measures used to evaluate the shoulders included the Constant score, adjusted Constant score, active mobility, subjective satisfaction, radiographic result, and complications.

RESULTS

The shoulders were evaluated at a mean of 45.0 months. The Constant score improved from a mean of 30.8 points preoperatively to a mean of 65.8 points at the time of follow-up. The adjusted Constant score improved from a mean of 38.2% to a mean of 79.8%. Active forward flexion improved from a mean of 82.1 degrees to a mean of 138.9 degrees. Active external rotation improved from a mean of 4.0 degrees to a mean of 38.6 degrees. Fifty patients rated the result as good or excellent. Negative prognosticators included an older age at the time of the initial dislocation and a rotator cuff tear. No significant differences in demographic factors, pre-arthroplasty function, post-arthroplasty function, pre-arthroplasty radiographic findings, post-arthroplasty radiographic findings, complication rate, or reoperation rate were noted between the patients treated with a prior operation for the anterior instability and those treated nonoperatively.

CONCLUSIONS

This investigation documented the good results obtainable with shoulder arthroplasty for the treatment of arthritis following anterior shoulder instability. In addition, our findings suggest that capsulorrhaphy-induced arthropathy may be indistinguishable from arthritis following nonoperatively treated anterior shoulder instability.