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Housset V, Ho SWL, Lädermann A, Phua SKA, Hui SJ, Nourissat G. Multidirectional instability of the shoulder: a systematic review with a novel classification. EFORT Open Rev 2024; 9:285-296. [PMID: 38579775 PMCID: PMC11044084 DOI: 10.1530/eor-23-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
Purpose A variety of instabilities are grouped under multidirectional instability (MDI) of the shoulder. This makes understanding its diagnostic process, presentation and treatment difficult due to lack of evidence-based consensus. This review aims to propose a novel classification for subtypes of MDI. Methods A systematic search was performed on PubMed Medline and Embase. A combination of the following 'MeSH' and 'non-MesH' search terms were used: (1) Glenohumeral joint[tiab] OR Glenohumeral[tiab] OR Shoulder[tiab] OR Shoulder joint[tiab] OR Shoulder[MeSH] OR Shoulder joint[MeSH], (2) Multidirectional[tiab], (3) Instability[tiab] OR Joint instability[MeSH]. Sixty-eight publications which met our criteria were included. Results There was a high degree of heterogeneity in the definition of MDI. Thirty-one studies (46%) included a trauma etiology in the definition, while 23 studies (34%) did not. Twenty-five studies (37%) excluded patients with labral or bony injuries. Only 15 (22%) studies defined MDI as a global instability (instability in all directions), while 28 (41%) studies considered MDI to be instability in two directions, of which one had to include the inferior direction. Six (9%) studies included the presence of global ligamentous laxity as part of the definition. To improve scientific accuracy, the authors propose a novel AB classification which considers traumatic etiology and the presence of hyperlaxity when subdividing MDI. Conclusion MDI is defined as symptomatic instability of the shoulder joint in two or more directions. A comprehensive classification system that considers predisposing trauma and the presence of hyperlaxity can provide a more precise assessment of the various existing subtypes of MDI. Level of Evidence III.
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Affiliation(s)
- Victor Housset
- Clinique de l'épaule, Clinique Maussins-Nollet, Paris, France
| | | | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, Hôpital de La Tour, Meyrin, Switzerland
- FORE (Foundation for Research and Teaching in Orthopedics, Sports Medicine, Trauma, and Imaging in the Musculoskeletal System), Meyrin, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | | | - Si Jian Hui
- Department of Orthopaedic Surgery, National University Health System, Singapore
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Gruskay JA, Rakowski DR, Woolson TE, Horan MP, Millett PJ. Clinical Outcomes After Arthroscopic Pancapsular Shift for the Treatment of Multidirectional Glenohumeral Instability at a Mean Follow-up of 9 Years. Am J Sports Med 2022; 50:3897-3906. [PMID: 36322393 DOI: 10.1177/03635465221127293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Arthroscopic treatment of multidirectional instability (MDI) of the shoulder is being increasingly performed, but there is a paucity of studies with minimum 5-year follow-up. PURPOSE To report on survivorship and patient-reported outcomes (PROs) after arthroscopic pancapsulorraphy (APC) for MDI with a minimum 5-year follow-up. STUDY DESIGN Case series; Level of evidence, 4. METHODS Institutional review board approval was obtained before initiation of this retrospective review of prospectively collected data. Patients were included if they had a minimum of follow-up 5 years after APC for MDI. PROs included the 12-Item Short Form Health Survey Physical Component Summary; American Shoulder and Elbow Surgeons; Single Assessment Numeric Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; and patient satisfaction. Preoperative, short-term (1-2 years), and final follow-up PROs were compared. Recurrent instability, dislocation, and reoperation were collected, and survivorship analysis was performed. RESULTS A total of 49 shoulders in 44 patients (15 male, 29 female) treated between October 2005 and November 2015 were included in the study. MDI onset was atraumatic in 27 shoulders and traumatic in 22. Rotator interval closure was performed in 17 patients. Overall, 14 of 49 (29%) patients reported feelings of instability in the shoulder, of whom 5 (10.2%) underwent revision surgery at a mean of 1.5 years. Kaplan-Meier analysis demonstrated a survivorship rate of 88% at 5 years and 82% at 8 years, with failure defined as requiring revision surgery or postoperative feelings of instability with ASES score <65. Final outcome analysis was performed on 41 shoulders with a mean follow-up of 9.0 years (range, 5.1-14.6 years). All PROs demonstrated significant improvement from preoperative baseline (P < .05) and remained significantly improved at both short-term and long-term final follow-up. There was no difference in PROs based on \\ atraumatic versus traumatic onset, or patients treated with a rotator interval closure. There was a significant difference in PROs between patients who had continued instability. CONCLUSION APC for the treatment of MDI provided reasonable, durable long-term PROs that persisted from short-term follow-up. Although 29% of patients experienced feelings of instability at final follow-up, most of these patients still had high postoperative satisfaction and acceptable PROs.
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Affiliation(s)
- Jordan A Gruskay
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
| | | | | | | | - Peter J Millett
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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3
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Mitchell BC, Siow MY, Carroll AN, Pennock AT, Edmonds EW. Clinical Outcomes, Survivorship, and Return to Sport After Arthroscopic Capsular Repair With Suture Anchors for Adolescent Multidirectional Shoulder Instability: Results at 6-Year Follow-up. Orthop J Sports Med 2021; 9:2325967121993879. [PMID: 33748302 PMCID: PMC7903833 DOI: 10.1177/2325967121993879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Multidirectional shoulder instability (MDI) refractory to rehabilitation can be treated with arthroscopic capsulolabral reconstruction with suture anchors. To the best of our knowledge, no studies have reported on outcomes or examined the risk factors that contribute to poor outcomes in adolescent athletes. Purpose: To identify risk factors for surgical failure by comparing anatomic, clinical, and demographic variables in adolescents who underwent intervention for MDI. Study Design: Case series; Level of evidence, 4. Methods: All patients 20 years or younger who underwent arthroscopic shoulder surgery at a single institution between January 2009 and April 2017 were evaluated. MDI was defined by positive drive-through sign on arthroscopy plus positive sulcus sign and/or multidirectional laxity on anterior and posterior drawer tests while under anesthesia. A 2-year minimum follow-up was required, but those whose treatment failed earlier were also included. Demographic characteristics and intraoperative findings were recorded, as were scores on the Single Assessment Numeric Evaluation (SANE), Pediatric and Adolescent Shoulder Survey (PASS), and short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH). Results: Overall, 42 adolescents (50 shoulders; 31 female, 19 male) were identified as having undergone surgical treatment for MDI with minimum 2-year follow-up or failure. The mean follow-up period was 6.3 years (range, 2.8-10.2 years). Surgical failure, defined as recurrence of subluxation and instability, was noted in 13 (26.0%) shoulders; all underwent reoperation at a mean of 1.9 years (range, 0.8-3.2 years). None of the anatomic, clinical, or demographic variables tested, or the presence of generalized ligamentous laxity, was associated with subjective outcomes or reoperation. Number of anchors used was not different between shoulders that failed and those that did not fail. Patients reported a mean SANE score of 83.3, PASS score of 85.0, and QuickDASH score of 6.8. Return to prior level of sport occurred in 56% of patients. Conclusion: Adolescent MDI refractory to nonsurgical management appeared to have long-term outcomes after surgical intervention that were comparable with outcomes of adolescent patients with unidirectional instability. In patients who experienced failure of capsulorrhaphy, results showed that failure most likely occurred within 3 years of the index surgical treatment.
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Affiliation(s)
- Brendon C Mitchell
- Department of Orthopaedic Surgery, University of California, San Diego, San Diego, California, USA
| | - Matthew Y Siow
- Department of Orthopaedic Surgery, University of California, San Diego, San Diego, California, USA
| | - Alyssa N Carroll
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Andrew T Pennock
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Eric W Edmonds
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
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4
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Fanning E, Maher N, Cools A, Falvey EC. Outcome Measures After Shoulder Stabilization in the Athletic Population: A Systematic Review of Clinical and Patient-Reported Metrics. Orthop J Sports Med 2020; 8:2325967120950040. [PMID: 32984424 PMCID: PMC7498977 DOI: 10.1177/2325967120950040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/07/2020] [Indexed: 01/02/2023] Open
Abstract
Background: Athletic endeavor can require the “athletic shoulder” to tolerate significant
load through supraphysiological range and often under considerable
repetition. Outcome measures are valuable when determining an athlete’s safe
return to sport. Few data are available to guide a clinician’s choice from
the variety of measures available. Purpose: To describe the use of quantifiable objective outcome measures and
patient-reported outcome tools after glenohumeral joint stabilization,
specifically in an athletic population. The secondary aim of our study was
to assess whether the method of measurement used was clearly described and
standardized to aid clinical interpretation. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic search of MEDLINE, Scopus, SPORTDiscus, and Web of Science
databases was performed in December 2018 based on the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. After
the application of selection criteria, a full review of identified papers,
and screening of reference lists, a total of 62 studies were included in the
review. All studies were independently appraised for quality, predefined
data fields were populated and cross-checked for accuracy, and results were
then summarized from these data fields. Results: Of the 62 included studies, 94% used a quantifiable objective clinical
outcome. A majority (85%) of the studies measured range of motion, 21%
recorded muscle strength, 5% measured electromyographic activity, 5%
examined shoulder kinematics, and 3% assessed joint proprioception after
surgery. However, only 18% of the studies clearly described a standardized
method of measuring the outcome. Nearly all (95%) of the studies used at
least 1 patient-reported outcome measure. The Rowe score was most commonly
used (35%). Conclusion: We must standardize and clearly describe the use of quantifiable objective
outcome measures to aid clinical interpretation. A concerted effort should
also be made to standardize the use of patient-reported outcome tools after
shoulder stabilization in the athletic population.
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Affiliation(s)
- Edel Fanning
- Sports Surgery Clinic, Sports Medicine, Dublin, Ireland.,University College Cork, Cork, Ireland
| | - Natasha Maher
- Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, West Yorkshire, UK
| | - Ann Cools
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Gent, Belgium
| | - Eanna C Falvey
- Sports Surgery Clinic, Sports Medicine, Dublin, Ireland.,University College Cork, Cork, Ireland
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Noorani A, Goldring M, Jaggi A, Gibson J, Rees J, Bateman M, Falworth M, Brownson P. BESS/BOA patient care pathways: Atraumatic shoulder instability. Shoulder Elbow 2019; 11:60-70. [PMID: 30719099 PMCID: PMC6348586 DOI: 10.1177/1758573218815002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ali Noorani
- St Bartholomew's and the Royal London Hospital, London, UK
| | | | - Anju Jaggi
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Jo Gibson
- Royal Liverpool University Hospital, Liverpool, UK
| | - Jonathan Rees
- Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marcus Bateman
- Derby Shoulder Unit, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | - Mark Falworth
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
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Coughlin RP, Bullock GS, Shanmugaraj A, Sell TC, Garrigues GE, Ledbetter L, Taylor DC. Outcomes After Arthroscopic Rotator Interval Closure for Shoulder Instability: A Systematic Review. Arthroscopy 2018; 34:3098-3108.e1. [PMID: 30297156 DOI: 10.1016/j.arthro.2018.05.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/25/2018] [Accepted: 05/01/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE (1) To systematically assess the clinical outcomes of arthroscopic rotator interval closure (RIC) procedures for shoulder instability and (2) to report the different technical descriptions and surgical indications for this procedure. METHODS Two independent reviewers searched 4 databases (PubMed, Embase, Web of Science, and Cochrane) from database inception until October 15, 2017. The inclusion criteria were studies that reported outcomes of shoulder stabilization using arthroscopic RIC as an isolated or adjunctive surgical procedure. The methodologic quality of studies was assessed with the Methodological Index for Non-Randomized Studies tool and Grading of Recommendations Assessment, Development and Evaluation system for randomized controlled trials. RESULTS Fifteen studies met our search criteria (524 patients). Of the studies, 12 were graded Level IV evidence; 2, Level III; and 1, Level II. Six different RIC technique descriptions were reported, with 2 studies not defining the details of the procedure. The most common method of RIC was arthroscopic plication of the superior glenohumeral ligament to the middle glenohumeral ligament (8 of 15 studies). The most commonly used patient-reported outcome measure was the Rowe score, with all studies reporting a minimum postoperative score of 80 points. The rate of return to preinjury level of sport ranged from 22% to 100%, and the postoperative redislocation rate ranged from 0% to 16%. CONCLUSIONS The indications for RIC were poorly reported, and the surgical techniques were inconsistent. Although most studies reported positive clinical results, the heterogeneity of outcome measures limited our ability to make definitive statements about which types of rotator interval capsular closure are warranted for select subgroups undergoing arthroscopic shoulder stabilization. LEVEL OF EVIDENCE Level IV, systematic review of Level II through IV studies.
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Affiliation(s)
- Ryan P Coughlin
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Garrett S Bullock
- Division of Physical Therapy, Duke University, Durham, North Carolina, U.S.A
| | - Ajaykumar Shanmugaraj
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Timothy C Sell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Leila Ledbetter
- Medical Center Library, Duke University, Durham, North Carolina, U.S.A
| | - Dean C Taylor
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A..
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7
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Kraeutler MJ, Aberle NS, Brown CC, Ptasinski JJ, McCarty EC. Clinical Outcomes and Return to Sport After Arthroscopic Anterior, Posterior, and Combined Shoulder Stabilization. Orthop J Sports Med 2018; 6:2325967118763754. [PMID: 29637085 PMCID: PMC5888826 DOI: 10.1177/2325967118763754] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Glenohumeral instability is a common abnormality, especially among athletes. Previous studies have evaluated outcomes after arthroscopic stabilization in patients with anterior or posterior shoulder instability but have not compared outcomes between groups. Purpose: To compare return-to-sport and other patient-reported outcomes in patients after primary arthroscopic anterior, posterior, and combined anterior and posterior shoulder stabilization. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent primary arthroscopic anterior, posterior, or combined anterior and posterior shoulder stabilization were contacted at a minimum 2-year follow-up. Patients completed a survey that consisted of return-to-sport outcomes as well as the Western Ontario Shoulder Instability Index (WOSI), Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Sur’geons (ASES) score, and Shoulder Activity Scale. Results: A total of 151 patients were successfully contacted (anterior: n = 81; posterior: n = 22; combined: n = 48) at a mean follow-up of 3.6 years. No significant differences were found between the groups with regard to age at the time of surgery or time to follow-up. No significant differences were found between the groups in terms of WOSI (anterior: 76; posterior: 70; combined: 78; P = .28), SANE (anterior: 87; posterior: 85; combined: 87; P = .79), ASES (anterior: 88; posterior: 83; combined: 91; P = .083), or Shoulder Activity Scale (anterior: 12.0; posterior: 12.5; combined: 12.5; P = .74) scores. No significant difference was found between the groups in terms of the rate of return to sport (anterior: 73%; posterior: 68%; combined: 75%; P = .84). Conclusion: Athletes undergoing arthroscopic stabilization of anterior, posterior, or combined shoulder instability can be expected to share a similar prognosis. High patient-reported outcome scores and moderate to high rates of return to sport were achieved by all groups.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, Seton Hall-Hackensack Meridian School of Medicine, South Orange, New Jersey, USA
| | | | - Colin C Brown
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Joseph J Ptasinski
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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8
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Arthroscopic plication for multidirectional instability: 50 patients with a minimum of 2 years of follow-up. J Shoulder Elbow Surg 2017; 26:e29-e36. [PMID: 27727061 DOI: 10.1016/j.jse.2016.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Treatment of patients who have not improved after physiotherapy for multidirectional instability (MDI) remains challenging, with no agreed best practice. The purpose of this study was to ascertain whether arthroscopic plication is safe and effective for these patients. METHODS Fifty consecutive patients who had not improved after at least 6 months of specialized shoulder physiotherapy for symptomatic MDI and no labral lesion at arthroscopy underwent arthroscopic plication between 2006 and 2013. Outcome measures were preoperative and postoperative Oxford Instability Scores (OIS), recurrence of instability, return to work and sport, surgical complications, and patient satisfaction. RESULTS The study comprised 32 male and 18 female patients, with a mean age of 26 years (range, 16-46 years). Complete OISs were available in 43 of 50 patients, and 41 patients had good or excellent postoperative OIS. The mean OIS was 16.2 preoperatively compared with 42.5 postoperatively (P < .001). There was no difference in OIS improvement between male and female patients (P = .962) or in those aged younger than 25 years vs. older than 25 years (P = .789). Patients with Beighton scores of 4 to 9 showed smaller OIS improvement (P = .030) and were less likely to achieve excellent postoperative OISs (P = .010). There were 2 patients with recurrent instability. All patients successfully returned to work, and 45 of 50 patients returned to the same level of sport. Surgical complications were shoulder stiffness in 1 patient that resolved with physiotherapy and 1 superficial wound infection that was successfully treated with flucloxacillin. Forty-seven of 50 patients were satisfied. CONCLUSION Arthroscopic plication is a safe and effective treatment for MDI in patients without labral lesions who have not improved after 6 months of specialized shoulder physiotherapy.
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9
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Chen D, Goldberg J, Herald J, Critchley I, Barmare A. Effects of surgical management on multidirectional instability of the shoulder: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2016; 24:630-9. [PMID: 26658564 DOI: 10.1007/s00167-015-3901-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/23/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study was to assess the effectiveness of arthroscopic and open surgical techniques on the treatment of shoulder multidirectional instability. METHODS Literature searches were conducted using the databases MEDLINE, Embase, ClinicalTrials.gov, the Cochrane Library, and the Cochrane Central Register of Controlled Trials. Original articles on the surgical management of multidirectional instability were retrieved against selection criteria. Data were extracted and divided into three groups by surgical technique. Proportion and mean meta-analyses were performed for comparison. RESULTS The available evidence was from 35 level IV and 1 level II studies. The recurrent instability rate was 9.9 % (95 % CI 7.3-12.9 %) in open capsular shift (OCS) group and 6.0 % (95 % CI 3.7-8.9 %) in arthroscopic capsular plication (ACP) group, between which no difference was observed. However, thermal capsular shrinkage (TCS) group resulted in a recurrent instability rate of 23.9 % (95 % CI 16.6-32.2 %), significantly higher than the above two groups. OCS and ACP groups revealed low reoperation rates of approximately 5.2 % (95 % CI 2.7-8.5 %) and 4.8 % (95 % CI 2.3-8.0 %), respectively, which are lower than that in TCS group of 16.9 % (95 % CI 12.4-21.8 %). OCS caused more loss of external rotation than ACP, losing 7.0 (95 % CI 3.3-10.6) degrees versus 2 (95 % CI 0.9-2.4) degrees, respectively. CONCLUSIONS ACP and OCS techniques have similar primary outcomes, but the former causes less post-operative stiffness. It is suggestible to avoid TCS in the treatment of MDI. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Dong Chen
- Orthopaedic Department, Goulburn Valley Health, The University of Melbourne, Shepparton, VIC, 3630, Australia.
| | - Jerome Goldberg
- Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Jonathan Herald
- Orthopaedic Department, Bankstown Hospital, University of Western Sydney, Sydney, NSW, Australia
| | - Ian Critchley
- Orthopaedic Department, Goulburn Valley Health, The University of Melbourne, Shepparton, VIC, 3630, Australia
| | - Arshad Barmare
- Orthopaedic Department, Goulburn Valley Health, The University of Melbourne, Shepparton, VIC, 3630, Australia
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Longo UG, Rizzello G, Loppini M, Locher J, Buchmann S, Maffulli N, Denaro V. Multidirectional Instability of the Shoulder: A Systematic Review. Arthroscopy 2015. [PMID: 26208802 DOI: 10.1016/j.arthro.2015.06.006] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI). METHODS A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed. RESULTS Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy. CONCLUSIONS Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift. LEVEL OF EVIDENCE Level IV, systematic review of Level I to IV studies.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy.
| | - Giacomo Rizzello
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Joel Locher
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Stefan Buchmann
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, London, England; Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Surgery, Salerno, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
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11
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Blonna D, Bellato E, Bonasia DE, Canata GL, Rossi R, Marmotti A, Castoldi F. Design and Testing of the Degree of Shoulder Involvement in Sports (DOSIS) Scale. Am J Sports Med 2015; 43:2423-30. [PMID: 26297519 DOI: 10.1177/0363546515597485] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND For athletes affected by shoulder problems, the most important expectation is to resume sporting activities. The ability to return to sport is related to several parameters, including the type and level of sport played. By focusing on these parameters, the Degree of Shoulder Involvement in Sports (DOSIS) scale allows for a better assessment of the involvement of the shoulder in sports. PURPOSE To design the DOSIS scale and test its psychometric features. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The DOSIS scale was developed as a patient self-administered scale by the Sport Committee of SIGASCOT (Società Italiana del Ginocchio Artroscopia Sport Cartilagine Tecnologie Ortopediche) to score sports activity based on 3 parameters: (1) type of sport, (2) frequency with which the sport is played, and (3) level at which the sport is played. In a subsequent phase, the psychometric features of the DOSIS scale were measured in a cohort of 85 patients who were affected by recurrent anterior shoulder instability and who underwent an open Bristow-Latarjet procedure or an arthroscopic Bankart repair. The content validity, criterion validity, construct validity, responsiveness, and test-retest reliability were measured and compared with the psychometric features of the Tegner activity scale. RESULTS Neither the DOSIS nor the Tegner activity scale showed floor or ceiling effects, but the DOSIS scale had a different distribution of scores, with a tendency toward a higher percentage of patients with high scores. The test-retest reliability analysis of the DOSIS scale revealed excellent intraobserver reliability (intraclass correlation coefficient = 0.96). Regarding the construct validity, 3 of the 4 hypotheses that we tested were significant. The DOSIS scale showed good criterion validity when compared with the Tegner activity scale (ρ = 0.3, P = .003), and the effect size between the preoperative and postoperative DOSIS scale was 1.1. CONCLUSION The DOSIS scale showed acceptable psychometric features and seems to be a valid instrument for shoulder assessment in athletes.
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Affiliation(s)
- Davide Blonna
- Department of Orthopaedics and Traumatology, Mauriziano-Umberto I Hospital, University of Turin, Turin, Italy
| | - Enrico Bellato
- Department of Orthopaedics and Traumatology, Cittá della Salute e della Scienza, CTO-Maria Adelaide Hospital, University of Turin, Turin, Italy
| | - Davide Edoardo Bonasia
- Department of Orthopaedics and Traumatology, Cittá della Salute e della Scienza, CTO-Maria Adelaide Hospital, University of Turin, Turin, Italy
| | | | - Roberto Rossi
- Department of Orthopaedics and Traumatology, Mauriziano-Umberto I Hospital, University of Turin, Turin, Italy
| | - Antonio Marmotti
- Department of Orthopaedics and Traumatology, Mauriziano-Umberto I Hospital, University of Turin, Turin, Italy
| | - Filippo Castoldi
- Department of Orthopaedics and Traumatology, Cittá della Salute e della Scienza, CTO-Maria Adelaide Hospital, University of Turin, Turin, Italy
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Merolla G, Cerciello S, Chillemi C, Paladini P, De Santis E, Porcellini G. Multidirectional instability of the shoulder: biomechanics, clinical presentation, and treatment strategies. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:975-85. [PMID: 25638224 DOI: 10.1007/s00590-015-1606-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/14/2015] [Indexed: 12/18/2022]
Abstract
Multidirectional instability (MDI) of the shoulder is a condition where the dislocation occurs in more than one direction with minimal or no causative trauma. Its pathoanatomy is complex and characterized by a redundant capsule, resulting in increased glenohumeral joint volume. The fact that several further factors may contribute to symptom onset complicates the diagnosis and hampers the identification of a therapeutic approach suitable for all cases. There is general agreement that the initial treatment should be conservative and that surgery should be reserved for patients who have not responded to an ad hoc rehabilitation program. We review the biomechanics, clinical presentation, and treatment strategies of shoulder MDI.
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Affiliation(s)
- Giovanni Merolla
- Unit of Shoulder and Elbow Surgery, "D. Cervesi" Hospital, Cattolica, AUSL della Romagna Ambito Territoriale di Rimini, Cattolica, Italy,
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13
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Jaggi A, Alexander S, Herbert R, Funk L, Ginn KA. Does surgery followed by physiotherapy improve short and long term outcome for patients with atraumatic shoulder instability compared with physiotherapy alone? - protocol for a randomized controlled clinical trial. BMC Musculoskelet Disord 2014; 15:439. [PMID: 25515666 PMCID: PMC4300830 DOI: 10.1186/1471-2474-15-439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/19/2014] [Indexed: 11/10/2022] Open
Abstract
Background Shoulder instability is a common problem affecting young adults. Stabilization surgery followed by physiotherapy rehabilitation has been shown to reduce the chance of further episodes of shoulder dislocation and to improve quality of life in patients who sustain a shoulder dislocation as a result of a high collision trauma, but it is unclear if surgical intervention is beneficial for patients with atraumatic shoulder instability who have structural damage at the shoulder. The aim of this randomized controlled clinical trial is to determine if the addition of surgical intervention to physiotherapy rehabilitation improves outcomes for patients with atraumatic shoulder instability who have sustained soft tissue damage at their joint. Methods/Design 140 participants will be recruited. Patients with feelings of insecurity (apprehension) at their shoulder joint, which is not the result of a collision injury, with physical signs of shoulder joint instability will be invited to participate. Consenting participants will undergo arthroscopic investigation of the shoulder joint. Patients with capsulolabral damage will be randomly allocated using a concealed allocation procedure to either stabilization surgery immediately following the arthroscopic examination or no additional surgical procedure. All participants will then receive the same postoperative physiotherapy protocol for up to 6 months. Outcomes (pain, functional impairment and number of shoulder dislocations sustained) will be evaluated prior to surgery and, together with participant-reported improvement, again at 6, 12 and 24 months after randomization. The primary endpoint will be pain and functional impairment at 2 years. Participants, clinical staff (but not surgeons) and assessors will be blind to whether stabilization surgery was performed. Data analysis will be conducted on an intention-to-treat basis with the focus on estimation of the effect. Discussion This trial will have a direct and immediate impact on clinical decision making by establishing if patients presenting with soft tissue shoulder damage associated with atraumatic shoulder instability should be referred for stabilization surgery before commencing physiotherapy rehabilitation in order to ensure optimal outcome. This in turn will ensure effective, efficient use of scarce health resources to manage this common often disabling musculoskeletal condition. Trial registration Study was registered with National Institutes of Health Clinical Trials Protocol Registration System in December 2012. ClinicalTrials.gov Identifier: NCT01751490.
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Affiliation(s)
| | | | | | | | - Karen A Ginn
- Discipline of Biomedical Science, Sydney Medical School, The University of Sydney, Sydney, Australia.
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14
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Porcellini G, Savoie FH, Campi F, Merolla G, Paladini P. Arthroscopically assisted shoulder arthrodesis: is it an effective technique? Arthroscopy 2014; 30:1550-6. [PMID: 25174536 DOI: 10.1016/j.arthro.2014.06.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare clinical and radiographic outcomes of open and mini-open arthroscopic arthrodesis. METHODS Twelve patients underwent arthroscopically assisted glenohumeral arthrodesis over a 5-year period; none were lost to follow-up. Surgery was performed with the patient in the lateral decubitus position, with the arm positioned in 30° each of flexion, internal rotation, and abduction. The articular cartilage was arthroscopically removed from the humerus and glenoid, creating flat opposing surfaces. One to 2 Kirschner wires were inserted percutaneously through the deltoid and across the glenohumeral joint in the center of the articulation; screws were then inserted arthroscopically. The glenohumeral joint was accessed through a mini-open posterior approach beneath the deltoid and was then reassessed before cannulated screws were tightened completely to compress the joint. Two dynamic compression plates were applied to the posterior glenohumeral joint to neutralize rotatory forces. Each patient was immobilized for 6 weeks. Follow-up radiographic imaging was performed at 2, 6, 12, and 24 months after surgery. These patients were then compared with a similar group who underwent a classic open approach. Success of arthrodesis was determined by bone growth across the glenohumeral joint as visualized on axillary radiographs. RESULTS At 2-year follow-up, complete fusion was achieved in 12 (100%) arthroscopically treated patients, with 2 patients (17%) having early bone grafting (within 6 weeks) through a percutaneous approach. Four patients in the classic open approach group ("open group") required additional grafting. Two patients in the group undergoing arthroscopic surgery ("arthroscopic group") had solid fusion but persisting infection from previously failed operations. Comparison of the 2 groups showed no difference in patient satisfaction or infection rates (2 in each group, all of whom had active infection at the time of the index surgery). One patient in the open group sustained a humeral shaft fracture 5 years after arthrodesis, which required additional surgery. No patient who underwent an arthroscopic procedure required additional surgery other than the 2 early bone grafts. CONCLUSIONS Arthroscopically assisted mini-open glenohumeral arthrodesis provides results that are at least equal to those of open arthrodesis, with a much less invasive approach. Success and complication rates are the same as for the completely open procedure. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
| | - Felix H Savoie
- Tulane Institute of Sports Medicine, Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A..
| | - Fabrizio Campi
- Unit of Shoulder Surgery, D. Cervesi Hospital, Cattolica, Italy
| | | | - Paolo Paladini
- Unit of Shoulder Surgery, D. Cervesi Hospital, Cattolica, Italy
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15
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Blonna D, Bellato E, Caranzano F, Bonasia DE, Marmotti A, Rossi R, Castoldi F. Validity and reliability of the SPORTS score for shoulder instability. JOINTS 2014; 2:59-65. [PMID: 25606544 DOI: 10.11138/jts/2014.2.2.059] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE athletes affected by shoulder instability cannot be judged solely according to the criteria used for non-athletes. In order to improve the assessment of shoulder instability surgery outcomes, the SPORTS score was tested in a cohort of athletes. METHODS ninety-eight athletes at an average follow-up of 4.6 years (range 1-9.2) after open or arthroscopic surgery for recurrent anterior shoulder instability were included in this study. The patients were asked to complete the SPORTS score questionnaire twice, with an interval of 2-3 weeks between the two assessments. The Bland-Altman method and the intra-class correlation coefficient were used to measure reliability. Criterion validity was assessed by calculating the Spearman correlation coefficient between the SPORTS score and the Western Ontario Shoulder Instability Index (WOSI) score, the Rowe score, the Oxford Shoulder Instability Score (OSIS), and the Subjective Shoulder Value (SSV). RESULTS the SPORTS score showed excellent test-retest reliability. The systematic error between the first and the second assessment was 0.3 points (95% upper limit of agreement = 2.3 points). The criterion validity was found to be strong for the SPORTS score, which correlated best with the SSV and the "sport, recreation, and work" component of the WOSI score. The SPORTS score had an acceptable floor effect (8%). The ceiling effect was 46%, which was better than the ceiling effects seen with the Rowe, OSIS and WOSI scores. CONCLUSIONS this study suggests that the SPORTS score is a valid score in the assessment of athletes after surgery for shoulder instability and that it adds important information to the currently available scores. LEVEL OF EVIDENCE Level III, diagnostic study of nonconsecutive patients.
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Affiliation(s)
- Davide Blonna
- Mauriziano "Umberto I" Hospital, Department of Orthopaedic and Traumatology, University of Turin, Medical School, Italy
| | - Enrico Bellato
- AO CTO, Maria Adelaide, "Città della salute e della scienza", Orthopaedic Department, University of Turin Medical School, Italy
| | - Francesco Caranzano
- Mauriziano "Umberto I" Hospital, Department of Orthopaedic and Traumatology, University of Turin, Medical School, Italy
| | - Davide E Bonasia
- AO CTO, Maria Adelaide, "Città della salute e della scienza", Orthopaedic Department, University of Turin Medical School, Italy
| | - Antongiulio Marmotti
- Mauriziano "Umberto I" Hospital, Department of Orthopaedic and Traumatology, University of Turin, Medical School, Italy
| | - Roberto Rossi
- Mauriziano "Umberto I" Hospital, Department of Orthopaedic and Traumatology, University of Turin, Medical School, Italy
| | - Filippo Castoldi
- AO CTO, Maria Adelaide, "Città della salute e della scienza", Orthopaedic Department, University of Turin Medical School, Italy
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16
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Open capsular shift and arthroscopic capsular plication for treatment of multidirectional instability. Arthroscopy 2012; 28:1010-7. [PMID: 22365265 DOI: 10.1016/j.arthro.2011.12.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 12/06/2011] [Accepted: 12/06/2011] [Indexed: 02/02/2023]
Abstract
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.
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