Anterior and anterior-inferior shoulder instability: Treatment by glenoid labrum reconstruction and a modified capsular shift procedure

An anterior glenoid labrum reconstruction in conjunction with a modified anterior-inferior capsular shift is described and was performed in 64 patients (69 shoulders) with traumatic anterior or anterior-inferior glenohumeral instability. Sixty-three operations were performed for recurrent dislocation and six for recurrent subluxation. The patients in this study were extremely active in sports, with the majority of Tegner ratings exceeding 7.0. Fifty-six patients with 61 operated shoulders were available for clinical follow-up at an average of 36 months (range 28 to 78 months). With rating scales from the American Shoulder and Elbow Surgeons, pain improved from an average of 3.1 to an average of 4.4, stability improved from 1.1 to 4.5, and function improved from 2.5 to 3.8. Postoperative average ranges of motion were 180° of forward elevation, 72° of external rotation with the arm at the side, 92° of external rotation with the arm at 90° of abduction, and 90° of internal rotation with the arm at 90° of abduction. Ninety-five percent of the patients were satisfied with the procedure. Five patients suffered a recurrent dislocation, four from significant trauma. One additional patient experienced an episode of subluxation early in the recovery period. According to the criteria of Rowe, 90% had excellent or good results.     

Open capsular shift for multi directional shoulder instability

We evaluated the outcome of open antero-inferior capsular shift in 17 patients with multidirectional instability of the shoulder who failed to respond to conservative treatment. Six shoulders presented with secondary impingement syndrome and 11 with involuntary instability. The mean duration of follow-up was 39 months (range 7-89 months). Based on the Rowe and Constant scores and the 12-item questionnaire of Dawson, the results were rated excellent in 14 patients, fair in 2 and poor in 1. All but 2 patients were satisfied with the results, although 6 patients experienced some residual pain, and 4 suffered minor instability. There were no neurovascular complications, infections or symptomatic posterior instability. Open antero-inferior capsular shift yields promising short-term to medium-term results in multidirectional, involuntary instability of the shoulder.     

A new technique of arthroscopic capsular shift in anterior shoulder instability

We describe a new arthroscopic technique to reinforce the torn inferior glenohumeral ligament (IGHL) and the elongated capsule to the glenoid rim. The arthroscope is inserted over the superior portal and, after the insertion of a suture anchor, both limbs are pulled out over the posterior portal. The IGHL is grasped and pulled upward onto the glenoid rim using a suture retriever clamp inserted over the posterior portal. A 45° curved blunt clamp (Sidewinder; Arthrex, Naples, FL) coming from the anterior penetrates the IGHL, and 1 end of the suture limb is given into the branches of the clamp and pulled out anteriorly. After a second perforation of the capsule, a horizontal suture creating a neolabrum can be placed. This technique allows a suitable reinforcement of the capsule without intraoperative complications. In cases of capsular elongation, especially a torn IGHL, the capsular instability can be addressed by the described Sidewinder technique. More sophisticated arthroscopic techniques such as this will increase the indication for arthroscopic shoulder stabilization.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 4 (April), 2001: pp 426–429     

Oblique capsular shift in anterior and anteroinferior shoulder instability

Patients submitted to oblique capsular shift were followed-up; this is a personal method used to treat recurrent anterior and anteroinferior dislocation of the shoulder. A total of 186 patients were followed-up. The results were good as there were no recurrences, recovery of shoulder movement was early and ample, and the Constant score was about 81.2.     

Surgical anatomy of the posterior shoulder: effects of arm position and anterior-inferior capsular shift.

The purposes of this study were to evaluate anatomically various surgical intervals to the posterior shoulder and to determine the effects of varying arm positions and anterior-inferior capsular shift (AICS) on the relation of the posterior neurovascular structures to fixed bony landmarks. Fourteen cadaveric shoulders were dissected. The posterior surgical anatomy was defined, and the distances from fixed bony landmarks to neurovascular and musculotendinous structures were determined with digital calipers. Measurements were made with the arm in various positions and repeated after AICS. The most direct anatomic approach to the posterior shoulder was through a deltoid split in the raphe from the posterolateral corner of the acromion (PLCA), followed by an infraspinatus (IS) splitting incision. The IS/teres minor interval was at the inferior aspect of the glenoid rim and was difficult to locate in all specimens. The distance to the axillary nerve from the PLCA averaged 65 mm and decreased by an average of 14 mm (22%) with abduction and by 19 mm (29%) with extension. The posterior humeral circumflex artery was located along the humeral neck and was vulnerable to injury during lateral capsular dissection. The suprascapular nerve had multiple branches to the IS with most penetrating the muscle at its inferior portion. The closest branch to the glenoid rim was an average of 20 mm medial from it. No branch entered at the level of the IS raphe. The anatomic relations of the suprascapular nerve were unchanged after AICS. On the basis of this study, surgical exposure of the posterior shoulder with a deltoid split from the PLCA, followed by an IS split, appears to be anatomically safe. The arm position should be in neutral rotation, especially if previous anterior capsular procedures have been performed, which can alter the posterior neurovascular anatomic relations.     

Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder

BACKGROUND: Neer and Foster previously described the inferior capsular shift procedure for treating multidirectional instability of the shoulder and reported preliminary results that were quite satisfactory. The purpose of our study was to perform a longer-term follow-up evaluation of the efficacy of the inferior capsular shift procedure for treating multidirectional instability of the shoulder. METHODS: An inferior capsular shift procedure was used to treat multidirectional instability of the shoulder in forty-nine patients (fifty-two shoulders). All patients had failed to respond to an exercise program. In this series, the operative approach (anterior or posterior) was based on the major direction of the instability, as determined by the preoperative history and physical examination and as verified by examination with the patient under anesthesia. In all of the patients, the inferior capsular shift was the primary attempt at operative stabilization. The repair consisted of a lateral-side (or humeral-side) shift of the capsule to reduce capsular redundancy and, when necessary, a reattachment of the avulsed labrum to the anteroinferior aspect of the glenoid. RESULTS: A redundant capsular pouch was seen in all of the shoulders in this series. In addition, detachment of the anteroinferior aspect of the labrum was found in ten shoulders and an anterior fracture of the glenoid rim was seen in two shoulders. At an average of sixty-one months (range, twenty-four to 132 months), results were available for forty-nine shoulders (forty-six patients). Thirty shoulders (61 percent) had an excellent overall result, sixteen (33 percent) had a good result, one (2 percent) had a fair result, and two (4 percent) had a poor result. Forty-seven (96 percent) of the forty-nine shoulders remained stable at the time of follow-up. Two of the thirty-four shoulders that had been repaired through an anterior approach began to subluxate anteroinferiorly again. None of the fifteen shoulders that had been repaired through a posterior approach had recurrent instability. Full function, including the ability to perform strenuous manual tasks, was restored to forty-five shoulders (92 percent). A return to sports was possible after thirty-one (86 percent) of the thirty-six procedures done in athletes; however, a return to the premorbid level of participation was possible after only twenty-five (69 percent) of the thirty-six procedures. CONCLUSIONS: The results in this series demonstrate the efficacy and the durability of the results of the inferior capsular shift procedure for the treatment of shoulders with multidirectional instability. The procedure directly addresses the major pathological feature - a redundant joint capsule. Similar results were seen with either an anterior or a posterior approach, and we continue to approach shoulders with multidirectional instability on the side of greatest instability. A postoperative brace was reserved for patients in whom a posterior approach had been used or in whom an anterior approach had involved extensive posterior capsular dissection (ten of the thirty-four shoulders treated with the anterior approach).     

Hip instability in myelomeningocele: 158 patients followed for 15 years

In 158 patients with myelomeningocele, the prevalence of hip dislocation at birth and subluxation or dislocation of unoperated on hips at 2 and 15 years of age were assessed. In neonates examined during the first 10 weeks of life, 10 percent of the hips were dislocated. In children with a thoracic or L1-2 neurologic level, the cumulative incidence of dislocated hips increased from 8 to 26 percent and subluxations from 33 to 45 percent. In children with L3 and L4 levels, one fourth of the hips had dislocations and nearly half subluxations. At L5 and the sacral motor level, dislocations did not occur, but one fifth of the hips had subluxations. Children with L3 or L4 neurologic levels had bilateral hip dislocation at an earlier age than those with higher levels of paralysis. There appears to be no risk of developing hip dislocation at neurologic levels below L4, and spasticity promotes hip dislocation above L3.     

The inferior capsular shift operation for instability of the shoulder. Long-term results in 34 shoulders

We reviewed 26 patients with 34 shoulders treated by the inferior capsular shift operation for inferior and multidirectional instability. The mean follow-up was 8.3 years. In total, 12 shoulders showed voluntary subluxation. Eight operations used an anterior and posterior approach, 11 were by the posterior route, and 15 shoulders had an anterior approach. In 30 shoulders (85%) the outcome was satisfactory and 20 (59%) scored good or excellent results on the Rowe system. Instability had recurred in nine shoulders (26%) from three months to three years after the operation. Six of the 12 shoulders with voluntary subluxation (50%) had recurrence, as against three of the other 22 (14%), a statistically significant difference. The operation is therefore not indicated for voluntary subluxation. The 19 shoulders which had been assessed in 1987 at a mean of 3.5 years after surgery, were also reviewed in 1995 and found to have no significant changes in instability or Rowe score. This shows that the capsular shift appeared to have maintained its tension over an eight-year period. After the use of a posterior approach, 64% of the shoulders showed a posterolateral defect on radiographs of the humerus.     

Good clinical outcome of combined Bankart-Bristow procedure for recurrent shoulder instability: 126 patients followed for 2-6 years

126 patients (100 men) with recurrent anterior shoulder dislocation or subluxation with severe Bankart lesion were treated with a combined Bankart and modified Bristow procedure and reviewed for this study. The mean age at operation was 25 (14-69) years, and mean follow-up period 41 (24-75) months. Averages of the Rowe score, the Constant score and the ASES score at final follow-up were 90, 95 and 91 points, respectively. The clinical outcome was excellent in 97 patients (77%), good in 16 (13%) and fair in 13 (10%). 2 patients had resubluxation, while no patient had a complete redislocation. The average loss of range of motion of external rotation, as compared to the contralateral shoulder side was 13 degrees. 67 of 72 patients returned to sports. No major postoperative complications occurred. This procedure had an excellent clinical outcome in cases of recurrent anterior shoulder dislocation or subluxation.     

Inferior capsular shift for inferior and multidirectional instability of the shoulder in young children: Report of two cases

The literature contains few reports of shoulder multidirectional instability in young children and no reports of surgical treatment of this condition in young children. This article presents the case reports of a 4-year-old girl and an 8-year-old girl who were treated with Neer's inferior capsular shift procedure. The surgical results of these patients remained good 4 and 5 years after the procedure, respectively. Surgical correction of multidirectional instability of the shoulder in a child should be performed only if the following indications are present: (1) the patients must have severe multidirectional instability, (2) the instability must have a significant negative impact on their daily activities, (3) the children must be able to understand the significance of the instability, and (4) school attendance and school participation must be compromised by the instability.     

Good clinical outcome of combined Bankart-Bristow procedure for recurrent shoulder instability: 126 patients followed for 2-6 years

126 patients (100 men) with recurrent anterior shoulder dislocation or subluxation with severe Bankart lesion were treated with a combined Bankart and modified Bristow procedure and reviewed for this study. The mean age at operation was 25 (14-69) years, and mean follow-up period 41 (24-75) months. Averages of the Rowe score, the Constant score and the ASES score at final follow-up were 90, 95 and 91 points, respectively. The clinical outcome was excellent in 97 patients (77%), good in 16 (13%) and fair in 13 (10%). 2 patients had resubluxation, while no patient had a complete redislocation. The average loss of range of motion of external rotation, as compared to the contralateral shoulder side was 13 degrees. 67 of 72 patients returned to sports. No major postoperative complications occurred. This procedure had an excellent clinical outcome in cases of recurrent anterior shoulder dislocation or subluxation.     

Long-term results of the Weber operation for chronic ankle instability: 37 patients followed for 20-30 years

BACKGROUND: The Weber operation is an anatomical reconstruction of the anterior talofibular ligament with the plantaris tendon. Few long-term studies have been published. METHODS: We evaluated 40 ankles in 37 patients (19 women) at an average of 24 years after the procedure. RESULTS: At follow-up, symptoms were present to vary-ing degrees in half of the ankles, but 32 patients were satisfied with the result and approximately two-thirds of the patients had a good or excellent result with the Karlsson and Good scores. Only 3 ankles had secondary arthrotic changes with narrowing (2 patients) or disappearance (1 patient) of the joint space. INTERPRETATION: We conclude that the Weber procedure is a good alternative for treatment of chronic anterolateral ankle instability when a direct anatomical reconstruction is not feasible, or has failed.