Iliac crest allograft glenoid reconstruction for recurrent anterior shoulder instability in athletes: Surgical technique and results

Performing a labral repair alone in patients with recurrent anterior instability and a large glenoid defect has led to poor outcomes. We present a technique involving the use of the iliac crest allograft inserted into the glenoid defect in athletes with recurrent anterior shoulder instability and large bony defects of the glenoid (>25% of glenoid diameter). All athletes with recurrent anterior shoulder instability and a large glenoid defect that underwent open anterior shoulder stabilization and glenoid reconstruction with the iliac crest allograft were followed over a 4-year period. Preoperatively, a detailed history and physical exam were obtained along with standard radiographs and magnetic resonance imaging of the affected shoulder. All patients also completed the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) evaluation forms preoperatively. A computed tomography scan was obtained postoperatively to assess osseous union of the graft and the patient again went through a physical exam in addition to completing the SST, ASES, and Western Ontario Shoulder Instability Index (WOSI) forms. 10 patients (9 males, 1 female) were followed for an average of 16 months (4–36 months) and had a mean age of 24.4 years. All patients exhibited a negative apprehension/relocation test and full shoulder strength at final follow-up. Eight of 10 patients had achieved osseous union at 6 months (80.0%). ASES scores improved from 64.3 to 97.8, and SST scores improved from 66.7 to 100. Average postoperative WOSI scores were 93.8%. The use of the iliac crest allograft provides a safe and clinically useful alternative compared to previously described procedures for recurrent shoulder instability in the face of glenoid deficiency.     

关节镜下Pushlock免结锚钉软式固定自体髂骨移植治疗复发性肩关节前向不稳伴严重骨缺损北大核心CSCD

目的探讨关节镜下Pushlock免结锚钉软式固定自体髂骨移植治疗复发性肩关节前向不稳伴严重骨缺损的临床疗效。方法回顾分析2016年1月—2019年1月采用关节镜下Pushlock免结锚钉软式固定自体髂骨移植治疗的80例复发性肩关节前向不稳伴严重骨缺损患者临床资料。患者均为男性;手术时年龄18~45岁,平均25岁。病程3个月~5年,平均2年。肩关节脱位3~50次,平均8次。术前行肩关节X线片、MRI、CT扫描及三维重建,前方关节盂骨性缺损面积为25%~45%,平均27.3%。采用术前及末次随访时肩关节活动度(前屈上举和外展90°外旋)、肩关节Constant-Murley评分和肩关节Rowe评分进行肩关节功能评估。结果术后患者均获随访,随访时间1~3年,平均2年。随访期间均未发生肩关节再次脱位。术后移植物均发生部分吸收,1周及3个月CT示移植物吸收比例<30%。术后1年CT三维重建示所有移植物已愈合至关节盂,前方关节盂骨性缺损面积均≤5%(0~5%,平均3.2%)。末次随访时,患者肩关节前屈上举活动度、外展90°外旋活动度、ConstantMurley评分及Rowe评分均较术前显著改善,差异有统计学意义(P<0.05);患侧外展90°外旋活动度较健侧受限(6.7±5.1)°。结论关节镜下Pushlock免结锚钉软式固定自体髂骨移植治疗复发性肩关节前向不稳伴严重骨缺损效果良好,该方法相对简单,学习曲线短。     

Surgical treatment of posterior instability of the shoulder with the posterior-inferior capsular shift

Surgical Principles The posterior-inferior capsular shift is performed to treat recurrent glenohumeral instability that has failed to respond to conservative therapy. Through a posterior approach, the excessively redundant posterior and inferior joint capsule is shifted superiorly to reduce excessive capsular volume. The extent of the lateral capsular dissection inferiorly, as well as the amount of tissue shifted, can be tailored to fit the degree and location of the laxity. When the posterior labrum is found to be detached, it is reattached to the glenoid rim before proceeding with the posterior capsulorrhahy. Bony augmentation of the repair is needed in only rare cases, i.e. in glenoid hypoplasia or in revision capsulorrhaphy procedures.     

Muscle activation patterns in patients with recurrent shoulder instability

Purpose:

The aim of this study is to present muscle patterns observed with the direction of instability in a series of patients presenting with recurrent shoulder instability.

Materials and Methods:

A retrospective review was carried out on shoulder instability cases referred for fine wire dynamic electromyography (DEMG) studies at a specialist upper limb centre between 1981 and 2003. An experienced consultant clinical neurophysiologist performed dual needle insertion into four muscles (pectoralis major (PM), latissimus dorsi (LD), anterior deltoid (AD) and infraspinatus (IS)) in shoulders that were suspected to have increased or suppressed activation of muscles that could be contributing to the instability. Raw EMG signals were obtained while subjects performed simple uniplanar movements of the shoulder. The presence or absence of muscle activation was noted and compared to clinical diagnosis and direction of instability.

Results:

A total of 140 (26.6%) shoulders were referred for fine wire EMG, and 131 studies were completed. Of the shoulders tested, 122 shoulders (93%) were identified as having abnormal patterns and nine had normal patterns. PM was found to be more active in 60% of shoulders presenting with anterior instability. LD was found to be more active in 81% of shoulders with anterior instability and 80% with posterior instability. AD was found to be more active in 22% of shoulders with anterior instability and 18% with posterior instability. IS was found to be inappropriately inactive in only 3% of shoulders with anterior instability but in 25% with posterior instability. Clinical assessment identified 93% of cases suspected to have muscle patterning, but the specificity of the clinical assessment was only correct in 11% of cases.

Conclusion:

The DEMG results suggest that increased activation of LD may play a role in both anterior and posterior shoulder instability; increased activation of PM may play a role in anterior instability.     

肩关节前向不稳定外科治疗3.0时代

肩关节稳定结构损伤或发育不良,失去维持正常关节稳定能力,肱骨头相对肩胛盂出现有症状的异常活动称为肩关节不稳定,以复发性和有症状(疼痛、恐惧、错动感等)为特征,包括复发性脱位和半脱位.创伤性肩关节脱位是肩关节不稳定最常见原因,一次脱位不等于不稳定,有13％～53％的初次脱位会出现肩关节不稳定[1].肩关节是人体脱位最多的...     

Posterior shoulder instability following anatomic total shoulder arthroplasty: A case report and review of management

We report a case of posterior shoulder instability following anatomic total shoulder arthroplasty (TSA). In addition, we present guidelines to aid in the management of posterior instability after TSA. A 50-year-old male underwent anatomic TSA for glenohumeral osteoarthritis. Postoperatively, the patient developed posterior instability secondary to glenoid retroversion. He did not improve despite conservative treatment. He underwent an arthroscopic posterior bone block procedure, 4-month after his index arthroplasty. At 14-month follow-up, the patient had regained near full motion and strength, and radiographs demonstrated osseous integration with no evidence of component loosening. Posterior instability following TSA is a relatively rare complication and challenging to manage. The posterior, arthroscopic iliac crest bone block grafting procedure represents a treatment option for posterior instability in the setting of a stable glenoid prosthesis following TSA.     

Reverse arthroplasty for osteoarthritis and rotator cuff deficiency after previous surgery for recurrent anterior shoulder instability

Purpose

Osteoarthritis in combination with rotator cuff deficiency following previous shoulder stabilisation surgery and after failed surgical treatment for chronic anterior shoulder dislocation is a challenging condition. The aim of this study was to analyse the results of reverse shoulder arthroplasty in such patients.

Methods

Thirteen patients with a median follow-up of 3.5 (range two to eight) years and a median age of 70 (range 48–82) years were included. In all shoulders a tear of at least one rotator cuff tendon in combination with osteoarthritis was present at the time of arthroplasty. The Constant score, shoulder flexion and external and internal rotation with the elbow at the side were documented pre-operatively and at the final follow-up. Pre-operative, immediate post-operative and final follow-up radiographs were analysed. All complications and revisions were documented.

Results

Twelve patients were either satisfied or very satisfied with the procedure. The median Constant score increased from 26 points pre-operatively to 67 points at the final follow-up (p = 0.001). The median shoulder flexion increased significantly from 70° to 130° and internal rotation from two to four points (p = 0.002). External rotation did not change significantly (p = 0.55). Glenoid notching was present in five cases and was graded as mild in three cases and moderate in two. One complication occurred leading to revision surgery.

Conclusions

Reverse arthroplasty leads to high satisfaction rates for patients with osteoarthritis and rotator cuff deficiency who had undergone previous shoulder stabilisation procedures. The improvements in clinical outcome as well as the radiographic results seem to be comparable with those of other studies reporting on the outcome of reverse shoulder arthroplasty for other conditions.     

Pathophysiology and treatment of atraumatic instability of the shoulder

The shoulder is stabilized mainly by negative intraarticular pressure when the arm is at the side of the body with all the muscles relaxed. During arm motion in the midrange of motion, the contraction force of the muscles provides dynamic stability. In shoulders with atraumatic instability, the joint capsule is thin and enlarged, making it more difficult to maintain the negative pressure. Decreased joint volume by capsular imbrication results in creating the negative intraarticular pressure. Imbalance of muscle forces may cause decreased abduction of the scapula during arm elevation or decreased concavity compression (or both), either of which may result in instability. Muscle exercises are effective in most cases of atraumatic instability. Congenital hypoplasia of the glenoid also contributes to decreased concavity compression. Glenoid osteotomy is the treatment of choice in such cases. One of these factors may play a role in the occurrence of atraumatic instability by itself or in combination. Better understanding of the pathophysiology of atraumatic shoulder instability is useful when selecting the best treatment option in each case.Presented at the 76th Annual Meeting of the Japanese Orthopaedic Association, Kanazawa, Japan, May 23, 2003