How does dynamic arthroscopic tracking compare with radiologic glenoid track for identification of on- and off-track lesions in anterior shoulder instability?

BACKGROUND

Current treatment paradigms for anterior shoulder instability are based on radiologic measurements of glenohumeral bone defects, and mathematical calculation of the glenoid track (GT) is used to classify lesions into on-track and off-track morphology. However, radiologic measurements have shown high variability, and GT widths under dynamic conditions have been reported to be significantly smaller than those under static radiologic conditions. The purpose of this study was to assess the reliability, reproducibility, and diagnostic validity of dynamic arthroscopic standardized tracking (DAST) in comparison to the gold-standard radiologic track measurement method for the identification of on- and off-track bony lesions in patients with anteroinferior shoulder instability.

METHODS

Between January 2018 and August 2022, 114 patients with traumatic anterior shoulder instability were evaluated using 3-T magnetic resonance imaging or computed tomography scans; glenoid bone loss, Hill-Sachs interval, GT, and Hill-Sachs occupancy ratio (HSO) were measured, and defects were classified as on-track or off-track defects and peripheral-track defects (based on HSO percentage) by 2 independent researchers. During arthroscopy, a standardized method (DAST method) was used by 2 independent observers to classify defects into on-track defects (central and peripheral) and off-track defects. Interobserver reliability of the DAST and radiologic methods was calculated using the κ statistic and reported as percentage agreement. Diagnostic validity (sensitivity, specificity, positive predictive value, and negative predictive value) of the DAST method was calculated using the radiologic track (HSO percentage) as the gold standard.

RESULTS

The radiologically measured mean glenoid bone loss percentage, Hill-Sachs interval, and HSO in off-track lesions were lower with the arthroscopic method (DAST) as compared with the radiologic method. The DAST method showed nearly perfect agreement between the 2 observers for the on-track/off-track classification (κ = 0.96, P < .001) and the on-track central or peripheral /off-track classification (κ = 0.88, P < .001). The radiologic method showed greater interobserver variability (κ = 0.31 and κ = 0.24, respectively) with only fair agreement for both classifications. Inter-method agreement varied between 71% and 79% (95% confidence interval, 62%-86%) between the 2 observers, and reliability was assessed as slight (κ = 0.16) to fair (κ = 0.38). Overall, for identification of an off-track lesion, the DAST method showed maximum specificity (81% and 78%) when radiologic peripheral-track lesions (HSO percentage of 75%-100%) were considered off-track and showed maximum sensitivity when arthroscopic peripheral-track lesions were classified as off-track.

CONCLUSION

Although inter-method agreement was low, a standardized arthroscopic tracking method (DAST method) showed superior interobserver agreement and reliability for lesion classification in comparison to the radiologic track method. Incorporating DAST into current algorithms may help reduce variability in surgical decision making.

Native Glenoid Depth and Hill-Sachs Lesion Morphology in Traumatic Anterior Shoulder Instability

BACKGROUND

Although Hill-Sachs lesions (HSLs) are assumed to be influenced by glenoid characteristics in the context of bipolar bone loss, little is known about how glenoid concavity influences HSL morphology.

PURPOSE

To investigate the relationship between the native glenoid depth and HSL morphological characteristics.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Computed tomography images of bilateral shoulders from 151 consecutive patients with traumatic unilateral anterior shoulder instability were retrospectively reviewed. Patients were categorized into flat (<1 mm), moderate (1-2 mm), and deep (>2 mm) groups based on the native glenoid depth measured from the contralateral unaffected shoulder. The HSL morphological characteristics included size (depth, width, length, and volume), location (medial, superior, and inferior extent), and orientation (rim and center angle). The glenoid characteristics included diameter, depth, version, and bone loss. The patient, glenoid, and HSL morphological characteristics were compared among the 3 depth groups. Subsequently, the independent predictors of some critical HSL morphological characteristics were determined using multivariate stepwise regression.

RESULTS

After exclusion of 55 patients, a total of 96 patients were enrolled and classified into the flat group (n = 31), moderate group (n = 35), and deep group (n = 30). Compared with those in the flat group, patients in the deep group were more likely to have dislocation (38.7% vs 93.3%; P = .009) at the primary instability and had a significantly larger number of dislocations (1.1 ± 1.0 vs 2.2 ± 1.8; P = .010); moreover, patients in the deep group had significantly deeper, wider, larger volume, more medialized HSLs and higher incidences of off-track HSLs (all P≤ .025). No significant differences were detected among the 3 groups in HSL length, vertical position, and orientation (all P≥ .064). After adjustment for various radiological and patient factors in the multivariate regression model, native glenoid depth remained the strongest independent predictor for HSL depth (β = 0.346; P < .001), width (β = 0.262; P = .009), volume (β = 0.331; P = .001), and medialization (β = -0.297; P = .003).

CONCLUSION

The current study sheds light on the association between native glenoid depth and the morphology of HSLs in traumatic anterior shoulder instability. Native glenoid depth was independently and positively associated with HSL depth, width, volume, and medialization. Patients with deeper native glenoids were more likely to have off-track HSLs and thus require more attention in the process of diagnosis and treatment.

Glenoid Track Assessment at Imaging in Anterior Shoulder Instability: Rationale and Step-by-Step Guide

Anterior shoulder dislocation is the most common form of joint instability in humans, usually resulting in soft-tissue injury to the glenohumeral capsuloligamentous and labral structures. Bipolar bone lesions in the form of fractures of the anterior glenoid rim and posterolateral humeral head are often associated with anterior shoulder dislocation and can be a cause or result of recurrent dislocations. Glenoid track assessment is an evolving concept that incorporates the pathomechanics of anterior shoulder instability into its management. Currently widely endorsed by orthopedic surgeons, this concept has ramifications for prognostication, treatment planning, and outcome assessment of anterior shoulder dislocation. The glenoid track is the contact zone between the humeral head and glenoid during shoulder motion from the neutral position to abduction and external rotation. Two key determinants of on-track or off-track status of a Hill-Sachs lesion (HSL) are the glenoid track width (GTW) and Hill-Sachs interval (HSI). If the GTW is less than the HSI, an HSL is off track. If the GTW is greater than the HSI, an HSL is on track. The authors focus on the rationale behind the glenoid track concept and explain stepwise assessment of the glenoid track at CT or MRI. Off-track to on-track conversion is a primary goal in stabilizing the shoulder with anterior instability. The key role that imaging plays in glenoid track assessment warrants radiologists' recognition of this concept along with its challenges and pitfalls and the production of relevant and actionable radiology reports for orthopedic surgeons-to the ultimate benefit of patients. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Arthroscopic findings of the glenohumeral joint in symptomatic anterior instabilities: comparison between overhead throwing disorders and traumatic shoulder dislocation

BACKGROUND

The term shoulder instability refers to a variety of mechanisms and clinical presentations. One of the common pathologies of throwing disorders is internal impingement with anterior instability. Most throwing athletes with symptomatic internal impingement with anterior instability exhibit positive apprehension and relocation test results, whereas those with recurrent anterior shoulder instability display positive apprehension test results. While the glenoid labrum-inferior glenohumeral ligament complex is a significant critical stabilizer for the prevention of anterior shoulder dislocation, the characteristics of the essential lesion in internal impingement with anterior instability have not been determined yet. This study aimed to compare the intra-articular lesion of athletes with internal impingement related to the overhead throwing motion in athletes with a traumatic shoulder dislocation.

METHODS

Sixty-one athletes (all men; mean age, 25.2 ± 12.6 yr) who underwent an arthroscopic procedure were divided into 2 groups: 25 in the throwing group and 36 in the dislocation group. All shoulders had subtle glenohumeral instability defined by a positive anterior apprehension test and a relocation test. Those with voluntary and multidirectional instability and large glenoid bone loss (more than 25%) were excluded from the current study. All shoulders were evaluated for the following evidence: rotator cuff injury, superior labrum tear anterior and posterior lesions, labral pathologies including Bankart lesions, osteochondral lesions to the humeral head, biceps tendon fraying or rupture, and inferior glenohumeral ligament and middle glenohumeral ligament (MGHL) conditions.

RESULTS

Arthroscopic findings of the throwing group showed more supraspinatus injuries (92% and 25%, P < .001), type II superior labrum tear anterior and posterior lesions (60% and 3%, P < .001), posterosuperior labral lesions (92% and 39%, P < .001), and hypoplastic MGHLs (56% and 6%, P < .001) and lesser Bankart lesions (8% and 92%, P < .05) than those of the dislocation group.

CONCLUSIONS

These results indicate that the characteristic lesions of internal impingement with anterior instability in throwing athletes include partial thickness rotator cuff tears, superior labrum tear anterior and posterior lesions, posterosuperior labral tears, and hypoplastic MGHLs. As expected, the physiopathology of internal impingement with anterior instability in throwing athletes may be related to the dysfunction of the anterosuperior glenohumeral capsular ligament, including the MGHL, rather than the inferior glenohumeral ligament as in traumatic anterior shoulder dislocations. These findings would be useful for defining treatment strategies for internal impingement with anterior instability in overhead throwing athletes.

Acromioclavicular dislocation associated with scapular fractures - pathoanatomy of the injury

INTRODUCTION

No detailed study dealing with an injury to the AC joint in combination with scapular fractures has been published to date. The aim of this study is to describe pathoanatomy of these injuries.

METHODS

In a series of 519 scapular fractures in adult patients from the period of 20022020 we identified a total of 20 (3.9%) cases associated with AC dislocation. The group comprised 17 men and 3 women with the mean age of 49 years (range, 2178). Radiographs of the shoulder joint followed by CT examination, including 3D reconstructions, were performed in all patients. This documentation allowed assessment of the scapular fracture pattern and type of injury to the AC joint.

RESULTS

AC dislocation was associated with a simple scapular fracture in 15 cases (7 fractures of the coracoid base, 4 fractures of the acromion or the lateral spine, 2 fractures of the scapular body, 1 fracture of the superior and 1 fracture of the inferior glenoid). In 5 cases AC dislocation accompanied multiple or complex scapular fractures (once a combination of a coracoid fracture and a fracture of the lateral scapular spine, once a combination of a fracture of the superior glenoid and of the acromion, 2 cases of a complex intraarticular fracture and 1 case of scapulothoracic dissociation).

CONCLUSION

AC dislocation is relatively infrequent injury accompanying scapular fractures. It is most commonly associated with fractures of coracoid, acromion/lateral spine or superior glenoid. No case of AC dislocation was recorded in a fracture of the scapular neck.

Is CT scan a predictor of instability in recurrent dislocation shoulder?

PURPOSE

Glenoid bone defect and the defect on the posterior-superior surface of the humerus "Hill-Sachs lesion" are the commonly seen bony lesions in patients with recurrent dislocation shoulder. Computed tomography (CT) scan is considered as the best option in assessing the bony defects in the recurrent dislocation shoulder. The aim of this study was to assess the clinical and radiological co-relation in the patients with recurrent dislocation shoulder.

METHODS

Forty-four patients of recurrent dislocation shoulder who were evaluated between January 2015 and December 2017 at a tertiary care center, clinically and radiologically using CT scan and meeting the inclusion criteria, were included. The correlation between the clinical history of the number of dislocations and the bone loss using CT scan was evaluated. Two sided statistical tests were performed at a significance level of α = 0.05. The analysis was conducted using IBM SPSS STATISTICS (version 22.0).

RESULTS

All the patients were male with mean age of 25.95 (SD ± 4.2) years were evaluated. Twenty-four patients sustained injury in sporting activities while 20 patients sustained injury in training. There were an average of 4.68 (SD ± 3.1, range 2-15, median 3) episodes of dislocation. Forty-one patients had the glenoid bone loss while 40 had the Hill-Sachs lesions. The mean glenoid width defect was 10.80% (range 0-27%) while the mean Hill-Sachs defect was 14.27 mm (range 0-26.6 mm). The mean area of bone loss of the glenoid surface was 10.81% (range 0-22.4%). The lesions were on track in 34 patients and off track in 10 patients.

CONCLUSIONS

CT scan of the shoulder joint is an effective method for assessing the amount of bone loss. The number of dislocations are correlated significantly with off-track lesions and the amount of bone loss on the glenoid and Hill-Sachs lesion. The glenoid width bone loss of more than 9.80% or Hill-Sachs defect of more than 14.80 mm are the critical defects after which the frequency of dislocations increases.

Partial Resurfacing for Humeral Head Defects Associated With Recurrent Shoulder Instability

Recurrent traumatic shoulder instability is a complex clinical entity that commonly affects young, active patients. Humeral head defects are frequently associated with this condition, but specific treatment to stabilize the shoulder is rarely needed. Management options for defects of the humeral head that do necessitate treatment carry various risks and disadvantages, including the need for bone or soft tissue healing, complications related to hardware, and loss of motion. Partial prosthetic resurfacing has been reported as a treatment option. The current study retrospectively reviewed a cohort of patients with recurrent or locked anterior and posterior instability who underwent partial prosthetic humeral head resurfacing for significant Hill-Sachs and reverse Hill-Sachs lesions. At an average of 36.4 months after the index procedure, 16 patients were contacted by mail and telephone. Of the study group, 13 patients underwent partial resurfacing for anterior instability and 3 patients underwent partial re-surfacing for posterior instability. No patient had a repeat dislocation. In addition, 77% of patients in the anterior instability cohort and all of the patients in the posterior instability cohort returned to their full preinjury activity level. For the anterior instability cohort, significant improvements from preoperatively to final follow-up occurred for mean Musculoskeletal Review of System score (4.54, P<.0001) and Short Form-12 physical component score (9.52, P=.002). For the combined cohort, the Penn Shoulder Score improved by 36.4 points (P=.059). This study showed the effectiveness of partial humeral head resurfacing for preventing redislocation for patients with significant Hill-Sachs and reverse Hill-Sachs lesions. [Orthopedics. 2017; 40(6):e996-e1003.].

The Reduction in Stability From Combined Humeral Head and Glenoid Bony Defects Is Influenced by Arm Position

BACKGROUND

Combined defects of the glenoid and humeral head are often a cause for recurrent shoulder instability.

PURPOSE/HYPOTHESIS

The aim of this study was to evaluate the influence of combined bony lesions on shoulder instability through varying glenohumeral positions. The hypothesis was that instability due to combined defects would be magnified with increasing abduction and external rotation.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen cadaveric shoulders were tested. Experiments were performed at combinations of glenohumeral abduction angles of 20°, 40°, and 60° and external rotations of 0°, 40°, and 80°. The various glenoid defect sizes created were 10%, 20%, and 30% of the glenoid width. Four humeral head defects were created based on humeral head diameter (6%, 19%, 31%, and 44%). Each experiment consisted of translating the glenoid in a posterior direction to simulate an anterior dislocation under a 50-N load. The instability was measured as a percentage of intact translation (ie, loss in translational distance normalized to the no-defect condition).

RESULTS

At 20° of abduction, instability increased from 100% to 85%, 70%, and 43% with increasing glenoid defect sizes of 10%, 20% and 30%, respectively, with a 6% humeral head defect. However, at a functional arm position of apprehension, these values were significantly decreased (P < .05) for humeral head defect sizes of 19%, 31%, and 44%, with translation values of 49%, 27%, and 2%, respectively.

CONCLUSION

A humeral defect leads to rotational instability with the arm rotated into a functional position rather than a resting position. However, a significant glenoid defect can lead to loss of translation independent of changes in arm position. Combined defects as large as 44% of humeral head and 20% glenoid did not show instability at 20° of abduction and neutral position; however, defects as small as 19% humeral defect and 10% glenoid defect led to significant instability in the position of apprehension.

CLINICAL RELEVANCE

Instability at lower levels of abduction and external rotation clinically indicates larger bony defects and may need to be directly addressed, depending on the patient's age and function.

Effect of three remplissage techniques on tendon coverage and shoulder kinematics: a navigated robotic biomechanical study

BACKGROUND

In addition to Bankart repair engaging Hill-Sachs defects in glenohumeral instability have been treated successfully with remplissage procedure. The purpose of this study was to compare three remplissage techniques regarding (I) ability of preventing Hill-Sachs defect from engaging, (II) influence on glenohumeral rotational torque, and (III) resulting tendon coverage over the Hill-Sachs defect.

METHODS

Standardized engaging Hill-Sachs defects and Bankart lesions were created in n = 7 fresh frozen human shoulder specimens. Besides Bankart repair three remplissage techniques (T) with double anchor position in the valley of the defect zone were studied: T1, knots tied over anchors; T2, knots tied between anchors (double-pulley); T3, knotless anchors with a suture tape. A parallel position-orientation and force-moment controlled navigated roboticsystem was used to compare prevention of Hill-Sachs defect engagement and torque [Nm]. Pressure sensitive film was used to study area of infraspinatus tendon coverage over Hill-Sachs defect [%].

RESULTS

All remplissage techniques prevented engagement of the Hill-Sachs defect without showing any construct failures. Regarding humeral torque there were significant impairments observed between intact conditions and the three investigated repair techniques in 60° abduction and ≥30° external rotation (p < .04). There was no significant difference in torque between intervention groups (n.s.). With a mean coverage of 26.8 % over the defect zone the knotless suture tape technique (T3) significantly improved area of soft tissue coverage compared to the other techniques (p = .03).

CONCLUSION

All remplissage techniques prevented engagement of the Hill Sachs defect. With high abduction and external rotation ≥30° all techniques showed significant higher humeral torque compared to the intact specimens, while there was not one technique superior over the others. The suture tape technique conferred the largest and most effective area of tendon coverage over the Hill-Sachs defect zone. Long-term success of the remplissage procedure can possibly be enhanced by increasing the interface area of tendon coverage over the Hill-Sachs defect. Clinical studies will be necessary to proof potential benefits for clinical outcome.

Hill-Sachs lesion location: does it play a role in engagement?

OBJECTIVE

To see if there is an association between engagement on physical examination (PE) and the location of the Hill-Sachs lesion (HSL) as assessed by the modified biceps angle.

MATERIALS AND METHODS

Sixty-two patients with a history of anterior shoulder dislocation, who underwent preoperative MRI and arthroscopy at our institution and were tested for engagement on PE, were collected. Two musculoskeletal radiologists reviewed the MR studies, noting the presence of an HSL and documenting the location of the HSL with the modified biceps angle. Statistical analysis included the Mann-Whitney (MW) test and ROC (receiver-operating characteristic) curve.

RESULTS

Of 62 patients, there were 58 males and 4 females with a mean age of 30 (range 18-59 years). Twenty patients demonstrated engagement on PE, while 42 did not. All patients had evidence of an HSL on MRI and arthroscopy. The mean biceps angle for the engaging group was 151.5 ± 13.9°, and 142.4 ± 17.3° for the non-engaging group. The biceps angle was statistically significantly higher among patients who had engagement compared to those who did not (p = 0.027). Overall, diagnostic accuracy was highest for a biceps angle >149°, which resulted in a sensitivity of 70% and specificity of 67%.

CONCLUSION

The modified biceps angle, as measured on MRI, was significantly higher in patients who demonstrated engagement on physical examination than in those who did not. This supports the theory that the location of the Hill-Sachs lesion may play a role in engagement and may be its most important characteristic when determining its significance.

Shoulder instability with concomitant bone loss in the athlete

Thorough evaluation of the athlete with persistent shoulder instability and appropriate use of imaging modalities, such as 3-dimensional computed tomography, can help quantify the severity of bony deficiency. Based on obtained imaging and examination, surgical and nonsurgical methods can be considered. In many situations both the humeral- and glenoid-sided bone loss must be addressed. Depending on the extent of bone loss, athletic demands, and surgeon experience, arthroscopic or open surgical options can provide shoulder stability and return athletes to their prior level of activity.

Biomechanics of complex shoulder instability

Identification and treatment of the osseous lesions associated with complex shoulder instability remains challenging. Further biomechanical testing is required to delineate critical defect values and determine which treatments provide improved glenohumeral joint stability for the various defect sizes, while minimizing the associated complications.

Bilateral anterior dislocation of the shoulder: review of seventy cases and proposal of a new etiological-mechanical classification

BACKGROUND

Although anterior shoulder dislocation is common in everyday practice in Emergency Departments, bilateral presentation is a rare entity.

OBJECTIVES

The aim of this article is to report two additional cases of this rare injury and to introduce a new mechanism that can produce it. We made an exhaustive review of the literature and found 68 cases in printed publications. Also, we analyzed the mechanism of injury and the presence of predisposing factors, and propose a new etiological-mechanical classification.

CASE REPORT

One case occurred after a trivial fall, and the other was produced by a mechanism not previously reported: the patient pushed strongly forward, expecting a resistance and finding none, his arms kept the forward movement and the shoulders dislocated.

DISCUSSION

This lesion has a bimodal distribution, affecting mainly men (70%) with a mean age of 33.5 years, whereas in women, the average age is 57 years. The most common cause is trauma (50%), followed by muscle contractions (37%) due to seizures of different causes (epileptic, hypoglycemia, toxic, or hypoxic) or electrocution. In 15.7% of the cases, the diagnosis of bilateral anterior dislocation was not acute (<3 weeks), and in virtually all of these cases it was not traumatic.

CONCLUSION

The bilateral anterior shoulder dislocation may not be as rare as previously thought and must be taken into account in emergency services. The authors propose a new etiological-mechanical classification. Also, the importance of radiologic diagnosis must be highlighted.

[Correlation analysis between recurrent anterior shoulder dislocation and secondary intra-articular injuries]

OBJECTIVE

To explore the effect of recurrent anterior shoulder dislocation on the secondary intra-articular injuries through analyzing the correlation between the number of dislocation, disease duration, and the secondary intraarticular injuries.

METHODS

The clinical data were analyzed retrospectively from 59 patients with recurrent anterior shoulder dislocation who underwent arthroscopic Bankart reconstruction using suture anchor between January 2005 and June 2009. There were 48 males and 11 females, and the average age was 27.6 years (range, 15-42 years). The causes of first dislocation included contact sports (21 cases), non-contact sports (13 cases), daily activities (11 cases), and trauma (14 cases). The average number of preoperative dislocations was 10.6 times (range, 3-32 times). The time between first dislocation and surgery was 11 months to 12 years (median, 5.9 years). The results of apprehension test and relocation test were positive in all patients. The University of California Los Angeles (UCLA) score was 22.3 +/- 2.4, and Constant-Murley score was 73.1 +/- 5.8 preoperatively. According to the arthroscopic findings, the effect of recurrent anterior shoulder dislocation on the secondary intra-articular injuries was analyzed.

RESULTS

All incisions healed by first intention, and no early complication occurred. All 59 patients were followed up 37.3 months on average (range, 16-58 months). At last follow-up, UCLA score was 34.6 +/- 1.7 and Constant-Murley score was 86.7 +/- 6.1, showing significant differences when compared with preoperative scores (P < 0.05). The number of preoperative dislocations was positively correlated with the severity of secondary articular cartilage injury (r(s) = 0.345, P = 0.007) and the severity of Hill-Sachs injury (r(s) = 0.708, P = 0.000). The time between first dislocation and surgery had a positive correlation with the severity of secondary articular cartilage injury (r(s) = 0.498, P = 0.000), but it had no correlation with the severity of Hill-Sachs injury (r(s) = 0.021, P = 0.874).

CONCLUSION

For patients with recurrent anterior shoulder dislocation, early Bankart reconstruction is benefit to functional recovery of shoulder and can avoid or delay the occurrence or development of secondary intra-articular injuries.

[Triple endobutton technique for repair of chronic complete acromioclavicular joint dislocations]

OBJECTIVE

To evaluate the early result of triple Endobutton technique for reconstructing coracoclavicular ligament of chronic complete acromioclavicular joint dislocations.

METHODS

Between January 2009 and June 2010, 14 patients with chronic complete acromioclavicular joint dislocations were treated with triple Endobutton technique for reconstructing coracoclavicular ligament. There were 10 males and 4 females with a mean age of 38.5 years (range, 26-52 years). Injury was caused by traffic accident in 7 cases, by falling in 5 cases, and by bruise in 2 cases. The average time was 47 days from injury to the operation (range, 29-75 days). All patients had pain and activity restriction. The X-ray films showed complete dislocation of acromioclavicular joint. According to Allman's type, all cases were classified as III degree complete dislocations.

RESULTS

At postoperation, wound healed by first intention with no early complication of infection or neurovascular injury. All patients were followed up 18.3 months on average (range, 13-30 months). Acromioclavicular joint subluxation occurred in 1 patient at 1 week after operation, and no redislocation or other complication occurred in the other patients. American Shoulder and Elbow Surgeons (ASES) score was 90.8 +/- 4.1 at last follow-up, showing significant difference when compared with the preoperative score (65.3 +/- 4.4) (t = -17.57, P = 0.00); Constant-Murley score was 91.7 +/- 3.9, showing significant difference when compared with preoperative one (71.5 +/- 4.6) (t = -75.02, P = 0.00). The definite answer in Simple Shoulder Test (SST) averaged 9.7 (range, 7-12).

CONCLUSION

The triple Endobutton technique for reconstructing coracoclavicular ligament is an effective method in treatment of chronic complete acromioclavicular joint dislocations. The short-term results are satisfactory.

MRI and arthroscopy correlations of the shoulder: a case-based approach

Over the past three decades, shoulder arthroscopy and MRI have seen significant advancements. Initially, distinguishing between normal and pathologic anatomy was one of the greatest challenges. Radiologists and arthroscopic shoulder surgeons have provided feedback to each other based on their experiences with selected shared patients, thereby accelerating the understanding of the arthroscopic and MRI appearance of both normal and pathologic anatomy. This process has led to the current refined understanding of both the basics and subtleties of MRI and arthroscopy correlations in the shoulder. Using a case-based approach provides examples of the correlation between MRI and arthroscopic findings in selected shoulder conditions.

Changes of histology and capsular collagen in a rat shoulder immobilization model

BACKGROUND

Shoulder immobilization can induce adhesion of the joint, capsular contracture or lead to the condition of frozen shoulder. However, little is known about the histological effects of immobilization on the shoulder joint. This study aimed to explore the effect of immobility on the subscapular bursa (SSB) and the joint capsular content, including the distribution of types I and III collagen, within an immobilized rat shoulder.

METHODS

Forty-six Sprague-Dawley rats were randomly divided into one control group (n = 6) and four immobilization groups (n = 10 in each group), in which the left shoulders were immobilized with plaster for 1, 2, 3 and 4 weeks. At the end of each time point, 2 rats from each group were euthanized and shoulders prepared for serial histological observations of the glenohumeral joints, as well as picrosirius red and immunohistochemical observation of type III collagen. Histological sections of the remaining rat shoulders were used for the immunohistochemical detection of the capsular content of types I and III collagen.

RESULTS

The hyperplastic synovium of the anterior capsule obstructed the communication between the SSB and the glenohumeral joint cavity at 2 and 3 weeks. The adhesion of the SSB appeared at 3 and 4 weeks. The quantitative and qualitative results showed that the capsular contents of types I and III collagen progressively increased at 2, 3 and 4 weeks, and that type III collagen was distributed extensively within the joint capsule at 2 and 3 weeks.

CONCLUSION

Immobilization of the rat shoulder induced synovial hyperplasia of the joint capsule, adhesion of the SSB and an increase of the capsular content of types I and III collagen.

Double Hill-Sachs lesion: a report of two cases

Hill-Sachs lesions are common after anterior dislocation of the shoulder. We present two cases of uncommon double Hill-Sachs lesions composed of a typical Hill-Sachs lesion and an atypical extra compression fracture with a rim of normal cartilage in between. Both patients had two anterior shoulder dislocations before surgery. These case reports show that recurrent posttraumatic anterior glenohumeral dislocations can result in increased damage to the humeral cartilage.

[Primary anterior shoulder dislocation]

Anterior dislocations of the shoulder are common among young males following trauma. Dislocations may be associated with fractures, rotator cuff tears as well as nerve and vascular injuries. However, recurrent instability is the major complication following primary dislocation of the shoulder. After physical examination and radiologic evaluation the humeral head may be reduced using a variety of methods. The methods differ in sedation, analgesia, body and arm position, type of manipulation, number of staff required for manipulation and finally, rates of success and complications. Following successful reduction, the arm should be fixed in an arm sling for at least three weeks. Young and active patients may be advised to undergo primary arthroscopic repair due to high risk of recurrent dislocation and cumulative damage to the shoulder.

Arthroscopic management of a chronic primary anterior shoulder dislocation

Chronic anterior dislocation of the glenohumeral joint often leads to functional impairment and pain. Duration of dislocation is correlated with complications, and this injury is traditionally treated with an open procedure. A right-hand - dominant woman in her late 70s presented with traumatic chronic anterior dislocation of the glenohumeral joint. Her physical exam and imaging studies were consistent with anterior shoulder dislocation, a large Hill-Sachs deformity, and rotator cuff and anterior labral tears. A shoulder reduction under anesthesia was performed followed by an arthroscopic double-row rotator cuff repair. In addition, a labral repair was performed via percutaneously inserted suture anchors. Following this treatment, stability was restored to the glenohumeral joint. The patient progressed well with physical therapy and, at 1-year follow-up, the patient had returned to all routine activities pain-free. Arthroscopic repair of chronic primary traumatic anterior shoulder dislocations requiring surgical treatment is a valuable alternative to open procedures and should be considered in higher-functioning elderly patients. Percutaneous suture anchor placement minimizes trauma to an already pathologic rotator cuff and joint capsule.

Surgical management of traumatic anterior glenohumeral instability: an international perspective

The treatment of traumatic anterior glenohumeral instability has evolved considerably in recent years. The results of arthroscopic repair have considerably improved, and, for many surgeons, arthroscopic techniques have supplanted traditional open techniques. Although a scoring system and other assessment tools can be useful, the choice of a surgical treatment for glenohumeral stabilization requires a careful assimilation of the patient's expectations and the surgeon's experience as well as an understanding of the relevant individual pathoanatomy. Pathoanatomy, nonsurgical and surgical treatment of shoulder instability, bone loss, unsuccessful stabilization treatment, and review of recent literature are important factors.

Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: a diagnostic sign for an osseous defect of the anterior glenoid rim

BACKGROUND

The integrity of the glenoid defines the surgical treatment in anterior shoulder instabilities. The reliability of plain radiographs to detect anterior glenoid rim deficiencies was determined.

MATERIALS AND METHODS

The anterior sclerotic glenoid line (SGL) was assessed on anteroposterior radiographs of 86 shoulders (34 anterior instabilities, 15 posterior instabilities, 37 stable) and compared with computed tomography (CT) scans (gold standard). A loss of the SGL (LSGL) was defined as a positive LSGL sign.

RESULTS

On CT scans, 25 of 34 shoulders (74%) with anterior instabilities showed a defect of the anterior glenoid rim. No defects were found in shoulders without anterior instabilities. LSGL correctly predicted an anterior glenoid rim lesion in 16 (examiner A) or 14 (examiner B) of the 25 anterior instabilities (sensitivity, 64% and 56%), without a false-positive diagnosis (specificity, 100%).

CONCLUSION

The LSGL on anteroposterior radiographs is a moderately sensitive but highly specific finding for anterior glenoid rim defects.

LEVEL OF EVIDENCE

Level 4; Diagnostic study, case control study.

[Pathomorphology of shoulder instability]

In cases of a traumatic anterior first-time dislocation of the shoulder, pathomorphological changes may initially occur at three different sites: at the capsule itself, at its origin or at its insertion. The typical injury is an avulsion of the labrum and the capsule from the glenoid and is called a Bankart lesion. There is a tendency to underestimate the amount of plastic deformation of the capsule and alternative injuries, such as avulsion of the capsule from the humeral head (HAGL lesion). Bony deformities at the humeral head or at the glenoid are of utmost importance for the prognosis of shoulder instability. In the dislocated position the anterior glenoid rim may notch the posterior surface of the humeral head (Hill-Sachs lesion). Bony defects of the glenoid may be caused by a fracture or due to chronic wear (fracture or erosion type). If bony defects exceed a certain size, isolated reconstruction of soft tissues does not guarantee stability of the shoulder.

Anterosuperior dislocation of the shoulder joint in an older patient with Parkinson's disease

An 83-year-old woman, subsequently diagnosed with Parkinson's disease, fell on her right shoulder. Radiographs showed the humeral head dislocated anterosuperiorly. The supraspinatus tendon was massively disrupted and judged irreparable. The subscapularis tendon was repaired, however re-dislocation of the humeral head was confirmed after the surgery but further treatment was rejected as she was almost pain free and had a low activity level. The patient was followed up for one year after surgery and her shoulder became almost pain-free, but range of motion with active elevation was limited. In such cases a goal of absence or reduction of pain rather than real repair might be considered appropriate.

Glenohumeral bone defects in the treatment of anterior shoulder instability

There is a well-recognized association between osseous defects of the glenoid or humerus and shoulder dislocation, which often leads to recurrent instability. A variety of strategies have been used to treat bone loss, and procedures have become more refined as the goals of surgery have evolved. Achieving optimal motion and function and minimizing the risk of osteoarthritis have become almost as important as stabilizing the joint.

Bilateral luxatio erecta humeri and bilateral knee dislocations in the same patient

Bilateral knee dislocations seldom occur, and fewer than a dozen cases of bilateral luxatio erecta humeri (erect dislocation of the shoulder) have been reported. Here we present the case of a patient who sustained bilateral knee dislocations and bilateral luxatio erecta humeri in a motorcycle accident. Transient neurologic compromise resolved with closed reduction of the bilateral shoulder and left knee dislocations. To our knowledge, this is the first case report of a patient with this combination of injuries.

Ultrasonographic findings in shoulders of able-bodied, paraplegic and tetraplegic subjects

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To evaluate the association between spinal cord injury (SCI) and ultrasonographic findings in shoulders.

SETTING

Randomly selected patients of Käpylä Rehabilitation Centre and able-bodied citizens of Helsinki, Finland.

METHODS

Ultrasonography of the shoulder was performed on able-bodied, tetraplegic and paraplegic subjects. Subjects with SCI were selected from patients of Käpylä Rehabilitation Centre, who were injured more than 3 months before the examination.

RESULTS

Findings of the glenohumeral joint differed most clearly between the groups. Significant association between SCI level and oedema of the glenohumeral joint was noted in multiple regression analysis, where other background factors were also considered.

CONCLUSION

Paraplegic and tetraplegic subjects are prone to glenohumeral changes that can be verified with ultrasonography.

Anterior dislocation of shoulder with brachial plexus injury

Brachial plexus injury secondary to anterior dislocation of the shoulder is unusual injury. This is a case report of brachial plexus palsy following traumatic anterior dislocation of shoulder. Recovery took 6 months and patient was left with residual shoulder stiffness. A brief review of presentation and management of this condition is also presented.

First-time shoulder dislocation: High prevalence of labral injury and age-related differences revealed by MR arthrography

PURPOSE

To evaluate abnormalities and age-related differences after first-time shoulder dislocation.

MATERIALS AND METHODS

MRA images of first-time dislocators were assessed for labral-ligamentous-capsular / rotator cuff abnormalities and analyzed the age-related differences (< and >/=30 years old).

RESULTS

Sixty-six patients (34 <30 years old vs. 32 >/=30 years; 51 males; all anterior dislocations) were imaged. Forty-eight patients (73%) showed anteroinferior labral avulsion, consisting of: 6% (4/34 vs. 0/32) Perthes; 23% (8/34 vs. 7/32) free ALPSA (anterior labrum periosteal sleeve avulsion) lesion); 6% (1/34 vs. 3/32) adherent ALPSA; 23% (9/34 vs. 6/32) Bankart; 14% (5/34 vs. 4/32) inferiorly displaced avulsed labrum; 2% (1/34 vs. 0/32) GLAD. Extensive labral detachment (extended above 3 o'clock position) was present in 31% (11/28 vs. 4/20). There were 14% (6/34 vs. 3/32) superior labrum anterior-posterior (SLAP) lesion; 27% (1/34 vs. 17/34) rotator cuff tendon tear; 71% (25/34 vs. 22/32) Hill-Sachs defect. Young patients were more likely to have extensive labral avulsions (P = 0.054), but less likely to have rotator cuff tears (P < 0.001).

CONCLUSION

A high prevalence and wide variety of labral avulsions after first-time shoulder dislocation, especially adherent ALPSA, inferiorly displaced avulsed labrum, or GLAD lesion, may influence treatment choice and outcome, suggesting a role for early MRA to assist in treatment triage.

[Undiagnosed posterior dislocations of the shoulder joint. A preliminary report]

Posterior dislocations are infrequent injuries of the proximal humerus, counting for 1-4% of all shoulder dislocations. Frequently, they are related to epileptic seisures or electric current injuries or accompany complete anatomical neck fractures of the proximal humerus. Very frequently, they remain undiagnosed and their late diagnosis results in poor functional outcomes. The authors assess the surgical procedure and its results in five cases of primarily undiagnosed posterior dislocations. In two cases, transposition of the m. subscapularis was performed, in one case hemiarthroplasty, and in two cases derotation osteotomy of the proximal humerus was used. Although the study group was small, the preliminary results of the procedures for chronic posterior dislocation of the shoulder joint favours preservative procedures compared to hemiarthroplasty of the shoulder joint.

[Arthroscopic treatment of anterior-inferior shoulder instability]

OBJECTIVES

We evaluated patients who underwent arthroscopic repair for posttraumatic, recurrent anterior-inferior glenohumeral instability with capsular laxity.

METHODS

Seventeen patients (4 females, 13 males; mean age 27 years; range 18 to 40 years) were treated with arthroscopic Bankart repair and posterior capsular plication for posttraumatic, recurrent anterior-inferior glenohumeral instability with capsular laxity. Involvement was on the right side in 11 patients, and on the left in six patients. The mean duration from the first dislocation to surgery was 5.2 years (range 1 to 11 years). All the patients received conservative treatment before surgery. Range of motion was measured with a goniometer and muscle strength was measured manually. Apprehension test, Jobe apprehension-relocation test, and posterior apprehension test were used to assess instability. Preoperatively, all the patients were examined by anteroposterior and axillary radiographs and magnetic resonance imaging. Shoulder functions were assessed with the Rowe rating scale for Bankart repairs. The mean follow-up was 35.6 months (range 24 to 50 months).

RESULTS

Instability recurred in three patients (17.7%). The Rowe score increased from a mean of 41 (range 15-45) to 78 (range 43-100) postoperatively. Functional results were excellent-good in 13 patients (76.5%), fair in one patient (5.9%), and poor in three patients (17.7%). One patient underwent arthroscopic revision following redislocation. Pre- and postoperative values for active forward flexion, external rotation, and internal rotation did not differ significantly (p>0.05).

CONCLUSION

The results of arthroscopic Bankart repair and posterior capsular plication are satisfactory in the treatment of anterior glenohumeral instability with capsular laxity. However, the use of capsular plication with arthroscopic Bankart repair should be considered in selected cases.

Correlation between Bankart and Hill-Sachs lesions in anterior shoulder dislocation

BACKGROUND

Bankart lesions and Hill-Sachs lesions are commonly associated with anterior shoulder dislocations. The presence of Bankart lesion indicates the need for surgical repair. Magnetic resonance imaging (MRI) has been shown to be sensitive in detecting these two lesions. The aim of this study is to investigate the correlation between Bankart lesions and Hill-Sachs lesions on MRI for patients with traumatic anterior shoulder dislocations.

METHODS

Between 2003 and 2005, 61 patients from Alfred and Sandringham Hospitals had an MRI as part of the investigation for traumatic anterior shoulder dislocations. The MRI scans were reviewed and subsequently confirmed by a radiologist to show the presence or absence of Bankart and Hill-Sachs lesions. The data were then analysed by a statistician.

RESULTS

Although patients with one of these lesions were more than two-and-a-half times as likely to have the other, small study numbers precluded this result from achieving statistical significance. (odds ratio, 2.67 (0.83-8.61), P = 0.10). Younger age was a strong predictor of a recurrence of shoulder dislocation (odds ratio, 0.93 (0.89-0.98), P = 0.005). The presence of Bankart or Hill-Sachs lesions on MRI for the primary shoulder dislocation group was similar to the recurrent group (73% vs. 72% for Bankart lesion and 67% vs. 70% for Hill-Sachs lesion).

CONCLUSION

There is a strong correlation between both lesions. This apparent trend can be useful in predicting the presence of a Bankart lesion when a Hill-Sachs lesion is identified on a plain radiograph. This study suggests the consideration of surgical repair after identification of a Hill-Sachs lesion on plain radiographs, especially for younger patients where the rate of re-dislocation is high.

MR imaging of the sternoclavicular joint following trauma

The purpose of this study is to describe the magnetic resonance imaging (MRI) findings of the sternoclavicular (SC) joint seen in patients who presented to our department with joint pain related to trauma. Clinical history and MRI findings on 41 patients were reviewed retrospectively to establish types and frequencies of soft tissue injuries and subluxations. Because both SC joints were imaged, the asymptomatic joints were used as a control group. Articular disk injuries were seen in 80% of patients. Injuries of the anterior, posterior, interclavicular and costoclavicular ligaments were seen in 73%, 39%, 29% and 14% of patients, respectively. Most clavicular subluxations were in the superior and posterior directions. Posterior impingement of mediastinal structures was seen in cases of posterior clavicular subluxation as well as in cases of retrosternal inflammatory or fibrotic tissue without clavicular subluxation. Biomechanical models of the SC joint are discussed to explain how different ligamentous injuries typically result in different types of subluxations.

Posterior subluxation and dislocation of the shoulder in obstetric brachial plexus palsy

We describe the results of surgical treatment in a prospective study of 183 consecutive cases of subluxation (101) and dislocation (82) of the shoulder secondary to obstetric brachial plexus palsy between 1995 and 2000. Neurological recovery was rated 'good' or 'useful' in all children, whose lesions fell into groups 1, 2 or 3 of the Narakas classification. The mean age at operation was 47 months (3 to 204). The mean follow-up was 40 months (24 to 124). The mean gain in function was 3.6 levels (9.4 to 13) using the Mallet score and 2 (2.1 to 4.1) on the Gilbert score. The mean active global range of shoulder movement was increased by 73 degrees ; the mean range of active lateral rotation by 58 degrees and that of supination of the forearm by 51 degrees . Active medial rotation was decreased by a mean of 10 degrees . There were 20 failures. The functional outcome is related to the severity of the neurological lesion, the duration of the dislocation and onset of deformity.

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.

Histologic analysis of bony Bankart lesions in recurrent anterior instability of the shoulder

The histologic examination of bony Bankart lesions was performed with hematoxylin-eosin staining of specimens obtained intraoperatively from 27 patients. We assessed the incidence and extent of degeneration in the bony fragment and the surrounding ligament and the relationship of such pathologic changes to several clinical and radiologic factors. Loss of osteocytes in the bony fragment was defined as osteonecrosis, and loss of fibroblasts in the surrounding ligament was defined as ligament degeneration. Although extensive ligament degeneration was noted in 8 patients (29.6%) (degeneration group), no bony fragment with extensive osteonecrosis was found. The degeneration group showed a statistically higher frequency of dislocation than the other group (P = .045). All bony fragments in the bony Bankart lesion seemed to be viable and could be used to treat the fractured glenoid defect. The surrounding ligaments in cases with a higher frequency of dislocation were often degenerative and might not be good for repair.

Intra-articular volume assessment in glenohumeral instability

It is commonly claimed that instability of the shoulder is associated with an enlarged joint volume. The purpose of our study was to assess the intra-articular volume in acute and chronic glenohumeral dislocation. Sixty-seven patients were examined by intra-articular infusion of saline solution. Three groups could be formed. Group 1 (n = 51) consisted of patients with first time traumatic dislocation, group 2 (n = 8) of cases with recurrent post-traumatic dislocation. The patients of group 3 (n = 8) suffered from impingement syndrome and served as the control group. The joint volume was correlated to the body surface area (BSA). We found a strong correlation between height, sex and intra-articular joint volume. There was no statistically significant difference in joint volume correlated to BSA between the three groups. There is no statistically significant difference in joint volume correlated to BSA in patients with traumatic anterior instability, chronic instability and individuals without glenohumeral instability.

[A case of acromioclavicular dislocation without coracoclavicular ligament rupture accompanied by coracoid process fracture]

Acromioclavicular joint dislocation with intact coracoclavicular ligaments accompanied by fracture of the coracoid process is a rare injury. The patients are treated with conservative and/or surgical methods. A 30-year-old male patient developed type 3 acromioclavicular dislocation and coracoid process fracture due to a fall in the right shoulder. Both injuries were treated surgically. Following open reduction, the acromioclavicular joint was fixed with a Knowles pin, and the coracoid process was fixed with a 4.0-mm malleolar screw. Active-assisted rehabilitation of the shoulder was initiated a week after surgery. The patient returned to office work with a long arm splint at three weeks. Pain-free, active, and complete shoulder movements were seen in the fifth week. The Knowles pin in the acromioclavicular joint was removed under local anesthesia seven months postoperatively. A year after surgery, he resumed full shoulder functions without pain and there were no signs of complications such as heterotopic ossification.

[Arthroscopic treatment of type 2 superior labrum anterior posterior lesions]

OBJECTIVES

We retrospectively evaluated patients who underwent arthroscopic repair for isolated type 2 superior labrum anterior posterior (SLAP) lesions.

METHODS

Isolated type 2 SLAP lesions were treated with arthroscopic repair with suture anchors in eight patients (5 males, 3 females; mean age 48.5 years; range 27 to 60 years) with shoulder pain unresponsive to conservative treatment. The mean duration of symptoms was 18.6 months (range 2 to 48 months). Initial diagnoses were based on patients' complaints and findings of physical examination and radiologic imaging, and were confirmed at diagnostic arthroscopy. Two suture anchors were used in six patients. Patients were evaluated with physical examination, radiographs, and the UCLA (University of California at Los Angeles) score. The mean follow-up was 30.8 months (range 14 to 48 months).

RESULTS

The mean preoperative and postoperative UCLA scores were 13.3 (range 10 to 18) and 30.8 (range 24 to 33), respectively (p<0.05). The results were good in seven patients (87.5%), and fair in one patient (12.5%). The mean preoperative active forward elevation was 136.3 degrees (range 90 degrees to 170 degrees), adduction-external rotation was 42.5 degrees (range 40 degrees to 60 degrees), and adduction-internal rotation was at T7 in three patients, and at L1 in five patients. At final follow-ups, the mean active forward flexion increased to 164.3 degrees (range 150 degrees to 170 degrees), adduction-external rotation was 40 degrees (range 30 degrees to 60 degrees), and adduction-internal rotation was at T7 in four patients, and at T12 in four patients.

CONCLUSION

The results of arthroscopic fixation of type 2 SLAP lesions with suture anchors are successful in the majority of patients, provided that an appropriate arthroscopic technique is performed to re-establish the stability of the biceps anchor.

Open Bankart repair with suture anchors for traumatic recurrent anterior shoulder instability: comparison of results between small and large Bankart lesions

This retrospective study was to demonstrate the clinical outcome of open Bankart repair with suture anchors for recurrent anterior shoulder instability, and to compare surgical results of small (<3 clock units) and large (>3 clock units) Bankart lesions. With an average follow-up of 55.6 months (2-8 years), there were 82 patients (60 right, 22 left shoulders) with the mean age of 27 years accepting open Bankart repair with suture anchors and capsular shift procedure by the same team. According to surgical findings, these patients were grouped into small (<3 clock units) and large (>3 clock units) Bankart lesions. Subjective outcomes were recorded according to the Bankart scoring system of Rowe. Rowe scores averaged 85.9+/-12.9 (range 25-100). The patients, 92-7 %, had objectively excellent or good results. Twenty nine patients (35.4%) had small Bankart lesions and 53 patients had large Bankart lesions. The Rowe scores in small Bankart lesions were better than that in large Bankart lesions (93.5+/-6.8 vs. 81.8+/-13.6, Wilcoxon rank sum test, P<0.001). Mean scores of stability (Wilcoxon rank sum test, P=0.043), motion (Wilcoxon rank sum test, P=0.037), and function (Wilcoxon rank sum test, P<0.001) in small lesions also had superior outcomes than in large lesions. Four patients (4.9%) got fair results and two (2.4%) patients got poor results at the end of follow-up. The average loss of external rotation is 10 degrees . Open Bankart repair with the aid of suture anchors still got satisfactory results in the treatment of traumatic recurrent anterior instability of the shoulder. The size of the Bankart lesion was a factor affecting surgical outcome. Small Bankart lesions usually got better results than large Bankart lesions.