Posterior capsulorrhaphy for treatment of recurrent posterior glenohumeral instability

The surgical treatment of recurrent posterior shoulder instability via a posterior approach has had a variable degree of success reported in the literature with recurrence rates ranging between 8% and 45%. The purpose of this study was to review the results of posterior capsulorrhaphy in a consecutive series of patients with recurrent posterior instability. Seventeen consecutive patients underwent operative management for posterior glenohumeral instability. The dominant shoulder was involved in ten patients. All patients were male with an average age of 28.1 years (range: 16 to 54 years). Ten patients had sustained a specific injury which precipitated the instability. Six patients reported dislocations requiring formal closed reduction maneuvers; the remainder described episodes of recurrent subluxation with spontaneous reduction. All patients underwent a posterior capsulorrhaphy using an infraspinatus splitting approach. Eight shoulders required repair of a posterior capsulolabral detachment. In addition, one patient required augmentation with a posterior bone block for significant glenoid rim deficiency. Outcome was assessed by personal interview, clinical assessment, and standardized radiographs. At an average follow-up of 3.9 years (range: 1.8 to 10.8 years) patients estimated their overall shoulder function to be 81% of the contralateral unaffected shoulder. The subjective result was excellent for eight patients, good for five patients, fair in two patients, and poor in two patients. One of the poor outcomes was in a patient with glenohumeral degenerative changes at the index procedure which progressed and eventually required a total shoulder arthroplasty. The other poor result was in a patient found to have a full-thickness rotator cuff tear 10.6 years after the index procedure. Two patients (12%) had recurrence of their instability. Both of these patients sustained a significant re-injury which precipitated their symptoms. Five patients complained of occasional night pain at the time of their last follow-up examination. Only one patient (who was re-injured) had to change professions as a result of shoulder symptoms. Posterior capsulorrhaphy for treatment of isolated posterior glenohumeral instability yields satisfactory clinical results. Recurrent instability in this series was associated with a specific re-injury and did not appear to increase with longer follow-up.     

Revision anterior shoulder repair for recurrent anterior glenohumeral instability

Although the operative management of recurrent anterior glenohumeral instability has received significant attention in literature, the outcome of revision anterior shoulder repair is much less frequently reported. We report the results of our experience with this challenging problem. Retrospective chart review identified 29 patients who underwent revision anterior shoulder repair. Prior procedures included eight Bankart repairs, seven capsular shifts, 10 combined Bankart and capsular shift procedures, three Putti-Platt procedures, two staple capsulorrhaphies, two Bristow procedures, seven arthroscopie procedures, and one Magnuson-Stack. The average age of the patients was 31.6 years (range: 18 to 52 years) and the dominant extremity was involved in 69%. Findings at the time of revision anterior shoulder repair included 22 patients with capsulolabral detachment, 24 with capsular redundancy, and 14 with rotator interval defects. Twenty-three of the 29 patients were available for at least a two-year follow-up. Twenty-one (91%) remain stable. One patient was non-compliant with the postoperative immobilization and re-dislocated within the first month. The second patient, who had a prior Bankart procedure followed by a capsular shift two years later, underwent a capsular shift for significant capsular laxity. He re-dislocated approximately 15 months postoperatively. Our success rate of 91% in this small series approaches the results of primary open repair for recurrent glenohumeral instability. To achieve a successful outcome, it is essential to address all pathology at the time of revision repair.     

Glenoid rim morphology in recurrent anterior glenohumeral instability

BACKGROUND: Knowledge regarding the morphology of the glenoid rim is important when patients with recurrent anterior glenohumeral instability are assessed. Ordinary imaging techniques are not always sensitive enough to demonstrate the morphology of the glenoid rim accurately. We developed a method of three-dimensionally reconstructed computed tomography with elimination of the humeral head to evaluate glenoid morphology. The purpose of the present study was to quantify glenoid osseous defects and to define their characteristics in patients with recurrent anterior instability. METHODS: The morphology of the glenoid rim in 100 consecutive shoulders with recurrent unilateral anterior glenohumeral instability was evaluated on three-dimensionally reconstructed computed tomography images with the humeral head eliminated. The configuration of the glenoid rim was evaluated on both en face and oblique views. Concurrently, we also investigated seventy-five normal glenoids, including both glenoids in ten normal volunteers. Shoulders without an osseous fragment at the anteroinferior portion of the glenoid were compared with the contralateral shoulder in the same patient to determine if the glenoid morphology was normal. In shoulders with an osseous fragment, the fragment was evaluated quantitatively and its size was classified as large (>20% of the glenoid fossa), medium (5% to 20%), or small (<5%). Finally, all 100 shoulders were evaluated arthroscopically to confirm the presence of the lesion at the glenoid rim that had been identified with three-dimensionally reconstructed computed tomography. RESULTS: Investigation of the normal glenoids revealed no side-to-side differences. Investigation of the affected glenoids revealed an abnormal configuration in ninety shoulders. Fifty glenoids had an osseous fragment. One fragment was large (26.9% of the glenoid fossa), twenty-seven fragments were medium (10.6% of the glenoid fossa, on the average), and twenty-two were small (2.9% of the glenoid fossa, on the average). In the forty shoulders without an osseous fragment, the anteroinferior portion of the glenoid appeared straight on the en face view and it appeared obtuse or slightly rounded, compared with the normally sharp contour of the normal glenoid rim, on the oblique view, suggesting erosion or a mild compression fracture at this site. Arthroscopic investigation revealed a Bankart lesion in ninety-seven of the 100 shoulders and an osseous fragment in forty-five of the fifty shoulders in which an osseous Bankart lesion had been identified with the three-dimensionally reconstructed computed tomography. In the shoulders with distinctly abnormal morphology on three-dimensionally reconstructed computed tomography, the arthroscopic appearance of the anteroinferior portion of the glenoid rim was compatible with the appearance demonstrated by the three-dimensionally reconstructed computed tomography. CONCLUSIONS: We introduced a method to evaluate the morphology of the glenoid rim and to quantify the osseous defect in a simple and practical manner with three-dimensionally reconstructed computed tomography with elimination of the humeral head. Fifty percent of the shoulders with recurrent anterior glenohumeral instability had an osseous Bankart lesion; 40% did not have an osseous fragment but demonstrated loss of the normal circular configuration on the en face view and an obtuse contour on the oblique view, suggesting erosion or compression of the glenoid rim.     

Arthroscopic osseous Bankart repair for chronic recurrent traumatic anterior glenohumeral instability

BACKGROUND: A chronic osseous Bankart lesion has traditionally been treated with soft-tissue repair and/or open bone-grafting for a large glenoid defect. We developed an arthroscopic method of osseous reconstruction of the glenoid without bone-grafting. The purpose of this study was to evaluate the postoperative outcomes of our technique for chronic recurrent traumatic anterior glenohumeral instability. METHODS: A consecutive series of forty-two shoulders in forty-one patients with chronic recurrent traumatic glenohumeral instability underwent an arthroscopic osseous Bankart repair. All shoulders were evaluated preoperatively with three-dimensionally reconstructed computed tomography, which confirmed an osseous fragment at the anteroinferior portion of the glenoid. The average bone loss in the glenoid was 24.8% (range, 11.4% to 38.6%), and the average fragment size was 9.2% (range, 2.1% to 20.9%) of the glenoid fossa. In all shoulders, a displaced osseous fragment, firmly attached to the labroligamentous complex, was separated from the glenoid neck before reduction and fixation in the optimal position with use of suture anchors. All patients were assessed with use of the scoring systems of Rowe et al. and the University of California at Los Angeles preoperatively and at the final evaluation. RESULTS: The mean duration of follow-up was thirty-four months. At that time, thirty-nine of the forty-two shoulders were rated as having a good or excellent result. The mean Rowe score improved from 33.6 points preoperatively to 94.3 points postoperatively (p < 0.01). The mean score on the University of California at Los Angeles system improved from 20.5 points preoperatively to 33.6 points at the final evaluation (p < 0.01). The average passive external rotation was 75 degrees with the arm at the side and 93 degrees with the arm at 90 degrees of abduction. Two patients had a reinjury. Eventually, thirty-five of thirty-seven patients who were active participants in sports returned to the sport they had played before the injury. CONCLUSIONS: Arthroscopic osseous Bankart repair with use of suture anchors yields a successful outcome even in shoulders with a chronic large glenoid defect.     

A complication of posterior glenoid osteotomy for recurrent posterior shoulder instability

Posterior glenoid osteotomy (posterior glenoplasty) is a standard surgical reconstructive operation for recurrent posterior instability of the shoulder. A 34-year-old man was treated by glenoid osteotomy and subsequently developed significant glenohumeral arthritis. Following several surgical procedures, only total shoulder arthroplasty gave substantial pain relief and restored stability. Inadvertent penetration of the glenohumeral joint at the time of osteotomy may have predisposed the patient to glenohumeral arthritis. Extreme care should be exercised not to damage the shoulder joint during this procedure.     

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

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

Anterior glenohumeral instability

The understanding of and approach to anterior shoulder instability has changed and improved dramatically in recent years. It is now accepted that a shoulder can subluxate as well as dislocate and that chronic instability may or may not be caused by an initial traumatic event. An anteriorly unstable shoulder also can be unstable inferiorly and/or posteriorly (multi-directional instability). The author's diagnostic acumen has increased with the addition of glenohumeral axillary arthrotomography, glenohumeral CT arthrography, glenohumeral arthroscopy, and other studies. Surgical treatment has moved away from "repair of choice" to an "anatomic reconstruction." The current preferred treatment is to identify and repair only the pathology while preserving normal anatomy, hoping to restore shoulder stability, while preserving normal mobility and strength. Areas of controversy exist. 1) How long should acute dislocations be immobilized, if at all, and is physiotherapy helpful in preventing chronic instability? 2) How long should the surgically repaired shoulder be immobilized, if at all? 3) Is there a place for therapeutic arthroscopy in this area? Also controversial is the concept of "functional instability" or shoulder internal derangement. These patients are felt to have shoulder slipping and catching due to the intermittent interposition of a fragment of tissue (a torn labrum, a loose body, etc) between the articulating surfaces. Arthroscopic debridement of the pathology would be ideally suited for such a clinical entity. Undoubtedly, improvements and controversy will continue until orthopedists are able to accurately diagnose and correct shoulder instability, while preserving range of motion and strength at minimal inconvenience to the patient.     

Dynamic posterior stabilization of shoulder hemiarthroplasty in long-standing neglected posterior dislocation of the glenohumeral joint

Posterior dislocations of the shoulder are rare. They account for less than 3% of all shoulder dislocations. The treatment of neglected bilateral posterior dislocation of the shoulder is controversial. We present a novel operative technique to stabilize a shoulder hemiarthroplasty that we used in the treatment of a chronic posterior dislocation of a shoulder with an acute four-part fracture of the proximal humerus.     

Glenoplasty for recurrent posterior shoulder instability. An anatomic reappraisal

Posterior glenoplasty, as performed for the treatment of recurrent posterior shoulder instability, was shown to thrust the humeral head forward and was able to cause symptomatic impingement of the anterior cuff between the coracoid process and the humeral head. Such subcoracoid impingement is relieved by resection of the inferolateral part of the coracoid tip and of the coracoacromial ligament.     

Arthroscopic repair of posterior instability and reverse humeral glenohumeral ligament avulsion lesions

Posterior glenohumeral subluxation is not as uncommon as once believed. Unidirectional instability as a result of a traumatic event or the primary direction of multidirectional instability as a result of overuse can lead to recurrent involuntary subluxations. Failure of the posterior restraints can occur at the glenoid labral attachment, mid-capsule, and laterally, as in a RHAGL avulsion. Soft tissue reattachment to bone is by way of suture anchors. This may occur at the glenoid medially or laterally along the humeral head insertion (RHAGL lesion). Capsular plication and superior shift can obliterate the capsular pouch. Additional labral lesions superiorly and anteriorly are repaired to centralize the humeral head and reduce the possibility of subcoracoid and subacromial impingement. Recurrence rates are reduced with symmetric repairs that address multiple lesions that are not always seen with a unidirectional open approach. Capsular tears, detachments, and the rotator capsular interval are reduced with minimal alterations in range of motion. Immobilization is combined with intermittent range of motion exercises. Protective scapular and rotator strengthening is a prerequisite before return to strenuous activities. Surgical repair followed by a well monitored rehabilitation protocol can return most individuals back to sport and vocation.     

A 4-portal arthroscopic stabilization in posterior shoulder instability

The purpose of this study was to present an arthroscopic stabilization technique with 4 portals for posterior instability used in 11 patients (13 shoulders). There were 7 male and 4 female patients. All patients had an arthroscopic labral suture with anchors and capsular plication with 4 portals. The follow-up period averaged 34 months. No complication or recurrence of instability was noted. A moderate loss of range of motion was noted in 4 shoulders and moderate pain in 2 shoulders. All patients were satisfied. According to the literature, the rate of recurrence of instability is currently lower than 12% when a labral suture and capsular plication are performed. Our results for pain and range of motion are similar to those described in recent publications. However, we think that the 4-portal technique allows a facilitated access to the posteroinferior part of the glenoid and reduces the rate of postoperative instability.     

Bone-mediated anteroinferior glenohumeral instability

Recurrent anterior shoulder instability is commonly associated with defects of the anterior glenoid rim. Substantial osseous defects significantly diminish the glenohumeral stability and require a bony augmentation, either by a coracoid transfer or free bone grafting procedure. Both reconstructive techniques have been applied for a long time and evaluated biomechanically and clinically. Although neither treatment option has been recognized as clearly superior, both comprise certain advantages and disadvantages. The Latarjet technique enables a biomechanically superior stabilization through the additional sling effect at time zero, but constitutes an extra-anatomical procedure with a broad spectrum and relatively high incidence of complications. Free bone grafting techniques enable an anatomical reconstruction of the glenoid concavity, offer the advantage of an unlimited graft size and show generally less severe and more easily manageable complications. The indications need to be carefully considered depending on the specific defect type, the glenoid track concept in cases of bipolar lesions as well as the individual patient characteristics. For both reconstructive procedures, open and arthroscopic approaches have been described with very good results, allowing a selection based on individual surgical skills and experience levels.     

Thoracolumbopelvic stabilization for the treatment of instability caused by recurrent myxopapillary ependymoma

The authors report a patient with recurrent lumbosacral myxopapillary ependymoma, followed for more than 20 years, who presented with severe axial pain resulting from osteolytic destruction at the lumbosacral junction. Because the patient had a long history of paraplegia despite three previous incomplete tumor resections, we chose not to attempt a fourth resection. Moreover, because viable fixation points were not present within the sacrum and most of the lumbar spine, instrumented fusion was extended from T7 to the ilia using a modified Galveston L-rod technique, which we believe to be unique in its application to this problem. This case demonstrates the long-term potential for instability from locally destructive myxopapillary ependymoma that is incompletely excised. We are not aware of any previous reports of lumbopelvic instability in association with myxopapillary ependymomas.     

CT关节造影、常规磁共振成像及磁共振关节造影在诊断复发性肩关节脱位中的作用

目的　比较CTA、MRI和MRA在诊断复发性肩关节脱位中关节唇损伤的准确性。方法复习 57例复发性肩关节脱位或亚脱位患者的CTA、MRI和MRA片。其中 ,男 42例 ,女 15例 ;年龄 13～ 63岁 ,平均 2 6岁 ;左 34例 ,右 2 3例 ;前脱位 52例 ,后脱位 5例。经关节镜和开放修补手术证实 ,其中52例发生关节囊 -唇复合体损伤。结果　CTA、MRI、MRA的阳性诊断率分别为 89% (47/ 52 )、82 %(14/ 17)和 90 % (31/ 35)。经t检验 ,CTA与MRI、MRA与MRI之间P <0 .0 5 ,CTA与MRA之间P >0 .0 5。结论　CTA仍是目前诊断复发性肩关节脱位中盂唇损伤的最好方法之一。CTA和MRA结合能提高诊断准确率。