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Management of Shoulder Instability in Patients with Underlying Hyperlaxity. Curr Rev Musculoskelet Med 2023; 16:123-144. [PMID: 36821029 PMCID: PMC10043087 DOI: 10.1007/s12178-023-09822-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD). RECENT FINDINGS Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.
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Langlais T, Barret H, Le Hanneur M, Fitoussi F. Dynamic pediatric shoulder instability: Etiology, pathogenesis and treatment. Orthop Traumatol Surg Res 2023; 109:103451. [PMID: 36273504 DOI: 10.1016/j.otsr.2022.103451] [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] [Received: 10/28/2021] [Revised: 04/13/2022] [Accepted: 05/05/2022] [Indexed: 11/05/2022]
Abstract
Dynamic shoulder instability in children or adolescents, whose glenohumeral growth plates are still open, is a rare condition with an etiology that is hard to decipher. Atraumatic and recurrent forms are most common, contrary to adults. Disruptions to capsule and ligament maturation, muscle balance or bone growth can lead to glenohumeral instability. The etiology assessment, which needs to be multidisciplinary in atraumatic forms, aims to collect the medical history, analyze the direction of the instability, determine whether it is voluntary or involuntary, and look for a history of trauma, connective tissue abnormality, psychological disorder, neuromuscular pathology or congenital malformation. The initial treatment is conservative. It requires a multidisciplinary team when the shoulder instability is voluntary. Surgical treatment is reserved for symptomatic forms that do not respond to conservative treatment and have an impact on daily life and/or sports participation after a minimum of 6 months of well-conducted rehabilitation. The results of surgical stabilization mainly depend on the features of the instability, the anatomical structures damaged and the etiology. Episodes of recurrent instability in children/adolescents with open glenohumeral growth plates can fade in adulthood or can get worse with the development of structural damage. Early detection of poor outcomes and suitable treatment will help to limit the occurrence of osteoarthritis in the medium and long term. LEVEL OF EVIDENCE: Expert opinion.
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Affiliation(s)
- Tristan Langlais
- Hôpital des enfants, Purpan, Toulouse université, Toulouse, France; Service orthopédie infantile, Necker-Enfants-Malades, université de Paris, Paris, France.
| | - Hugo Barret
- Département orthopédie adulte, Purpan, Toulouse université, Toulouse, France
| | - Malo Le Hanneur
- Centre main épaule Méditerranée, ELSAN, clinique Bouchard, Marseille, France; Service orthopédie infantile, Armand Trousseau, Sorbonne université, Paris, France
| | - Franck Fitoussi
- Service orthopédie infantile, Armand Trousseau, Sorbonne université, Paris, France
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Amemiya M, Nakamura R, Yoshimura M, Takagi T. Proximal tibiofibular joint (PTFJ) dislocation due to Ehlers-Danlos syndrome: posterolateral open-wedge high tibial osteotomy combined with medial closed-wedge distal femoral osteotomy can correct the severe valgus deformity with a markedly increased tibial posterior slope. BMJ Case Rep 2022; 15:15/11/e250308. [PMID: 36446469 PMCID: PMC9710336 DOI: 10.1136/bcr-2022-250308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Ehlers-Danlos syndrome (EDS) causes joint hypermobility and joint dislocation. Since there are no reports of proximal tibiofibular joint (PTFJ) dislocation caused by EDS, little is known about the long-term course of this disease. A woman in her 40s presented with a posterolaterally depressed tibial condyle and severe valgus deformity caused by a long-standing PTFJ dislocation due to EDS. Considering the pathology, posterolateral open-wedge high tibial osteotomy (PLOWHTO) and medial closed-wedge distal femoral osteotomy were performed according to the deformity analysis. A favourable short-term clinical outcome was obtained and the PTFJ dislocation was reduced over time. Although PLOWHTO has several pitfalls, it is a logical and useful surgical technique that can help treat posterolateral dysplasia of the tibial plateau concomitant with severe valgus deformity, regardless of joint laxity, if performed with attention to pitfalls.
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Affiliation(s)
- Masaki Amemiya
- Joint Preservation and Sports Orthopaedic Center, Harue Hospital, Sakai, Japan,Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryuichi Nakamura
- Joint Preservation and Sports Orthopaedic Center, Harue Hospital, Sakai, Japan
| | | | - Tomoharu Takagi
- Orthopaedic Surgery, Fukui-ken Saiseikai Hospital, Fukui, Japan
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Hishimura R, Kondo E, Matsuoka M, Iwasaki K, Kawaguchi Y, Suzuki Y, Onodera T, Momma D, Iwasaki N. Double-bundle anterior cruciate ligament reconstruction using autologous hamstring tendon hybrid grafts in a patient with hypermobile Ehlers-Danlos Syndrome: A case report. Knee 2022; 35:81-86. [PMID: 35220136 DOI: 10.1016/j.knee.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/29/2021] [Accepted: 02/07/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ehlers-Danlos syndrome (EDS) is a connective tissue disorder characterized by skin hyperextensibility, joint hypermobility, and tissue friability. Hypermobile type Ehlers-Danlos syndrome (hEDS) is considered one of the EDS subtypes characterized by generalized joint hypermobility. Although there have been a few case reports which described surgical considerations for anterior cruciate ligament (ACL) reconstructions in patients with other types of EDS, no reports have described those in patients with hEDS. CASE PRESENTATION We report a case of ACL injury in an 18-year-old male patient with hEDS. The patient was successfully treated with an anatomic double-bundle ACL reconstruction using autologous hamstring tendon hybrid grafts which consist of hamstring tendons connected in a series with commercially available polyester tape. The autogenous tendon portion of the anteromedial and posterolateral bundles were composed of 4 and 2 strands of hamstring tendons, respectively. After 2 weeks of knee joint immobilization, continuous passive motion exercise of the knee joint and partial weight-bearing was allowed. A hinged knee brace was used for a period of 5 months postoperatively. Second-look arthroscopy at 30 months showed that the ACL graft had no laceration and an excellent coverage of the synovium. At 36 months after surgery, the side-to-side differences in the anterior laxity was remarkably improved. The operated knee showed negative Lachman test and had a full range of motion. CONCLUSIONS To the best of our knowledge, this represents the first report of anatomic double-bundle ACL reconstruction in patients with hEDS and demonstrates excellent clinical and functional outcomes.
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Affiliation(s)
- Ryosuke Hishimura
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, North 14 West 5, Kita-ku, Sapporo, Hokkaido 060-8648, Japan.
| | - Masatake Matsuoka
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan
| | - Koji Iwasaki
- Department of Functional Reconstruction for the Knee Joint, Hokkaido University, North 15, West 7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan
| | - Yasuyuki Kawaguchi
- Sports and Arthroscopy Center, Hanna Central Hospital, Ikoma, Nara 630-0243, Japan
| | - Yuki Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan
| | - Daisuke Momma
- Centre for Sports Medicine, Hokkaido University Hospital, North 14 West 5, Kita-ku, Sapporo, Hokkaido 060-8648, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan
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