Instability failure in total shoulder arthroplasty

Glenohumeral instability is the second most common complication of shoulder arthroplasty, occurring in 4.9% of cases. Instability following arthroplasty is best classified based on its direction. The unconstrained shoulder arthroplasty can be unstable superiorly, anteriorly, inferiorly, and posteriorly. The causes and incidences of each direction are unique and individualized. The goal of this paper is to identify the cause of different types of total shoulder arthroplasty instability and discuss techniques to avoid such complications.     

Arthroscopic Capsular Plication in the Treatment of Shoulder Pain in Competitive Swimmers

Shoulder pain is a common and difficult problem in competitive swimmers due to cumulative loads from repetitive overhead motion. Capsular laxity has been implicated as a potential etiology for shoulder pain in competitive swimmers. No study has examined the role of capsular plication in addressing recurrent shoulder pain in competitive swimmers. The purpose of this study is to retrospectively describe our series of competitive swimmers treated with arthroscopic capsular plication with a primary outcome of return to competitive swimming. Eighteen shoulders in 15 patients underwent arthroscopic capsular plication from 2003 to 2007. Patients were contacted at an average follow-up of 29 months (range, 8–42) and a swimming history, American Shoulder and Elbow (ASES) scores, and L''Insalata scores were obtained. At time of surgery, all patients demonstrated laxity under examination under anesthesia. All patients had a positive drive-through sign. Eighty percent (12/15) of patients returned to competitive swimming although only 20% (3/15) were able to return to their pre-injury training regimen volume. All patients subjectively reported improved pain after surgery. The average ASES score was 78 ± 16 (average, standard deviation). The average L''Insalata score was 82 ± 11. Although our results demonstrate that arthroscopic capsular plication has utility in the treatment of shoulder pain in swimmers who have failed non-operative treatment, the inability of some athletes to return to pre-injury training volume illustrates the difficult nature of shoulder pain in swimmers.Level of Evidence: Retrospective case series, Level IV     

Thermal Shrinkage for Shoulder Instability

Thermal capsular shrinkage was popular for the treatment of shoulder instability, despite a paucity of outcomes data in the literature defining the indications for this procedure or supporting its long-term efficacy. The purpose of this study was to perform a clinical evaluation of radiofrequency thermal capsular shrinkage for the treatment of shoulder instability, with a minimum 2-year follow-up. From 1999 to 2001, 101 consecutive patients with mild to moderate shoulder instability underwent shoulder stabilization surgery with thermal capsular shrinkage using a monopolar radiofrequency device. Follow-up included a subjective outcome questionnaire, discussion of pain, instability, and activity level. Mean follow-up was 3.3 years (range 2.0–4.7 years). The thermal capsular shrinkage procedure failed due to instability and/or pain in 31% of shoulders at a mean time of 39 months. In patients with unidirectional anterior instability and those with concomitant labral repair, the procedure proved effective. Patients with multidirectional instability had moderate success. In contrast, four of five patients with isolated posterior instability failed. Thermal capsular shrinkage has been advocated for the treatment of shoulder instability, particularly mild to moderate capsular laxity. The ease of the procedure makes it attractive. However, our retrospective review revealed an overall failure rate of 31% in 80 patients with 2-year minimum follow-up. This mid- to long-term cohort study adds to the literature lacking support for thermal capsulorrhaphy in general, particularly posterior instability.     

SURGICAL REPAIR FOR RECURRENT ANTERIOR INSTABILITY OF THE SHOULDER

Background : The outcome of surgical repair for recurrent anterior instability of the shoulder at the Wellington Hospital was reviewed. Methods : A retrospective review was undertaken of patients undergoing surgical repair for recurrent anterior instability of the shoulder at Wellington Hospital between October 1989 and November 1996. Patients were asked to complete two shoulder-specific questionnaires, and the range of motion, stability, and strength was evaluated clinically. Results : A total of 37 patients (38 shoulders) who had recurrent anterior dislocation of the shoulder that was unresponsive to a physician-directed rehabilitation programme were managed with open surgical repair. Procedures included the Putti–Platt, Bristow, Magnuson–Stack, Botychev, and Bankart repairs. The mean age at the time of surgery was 24 years and the male-to-female ratio was 11.3:1. Surgery was performed on the dominant side in 63.2% of shoulders. The postoperative redislocation rate was 39.4% at an average of 4.6 years follow-up. Three patients have since required revision of their surgical repair and one patient is awaiting revision. A total of 63.2% of patients were unable to return to their previous level of sports. Differences existed between the motion in the surgically treated shoulder when compared with the contralateral side. Patients reported the most functional difficulty in throwing, working overhead, pulling, and working at shoulder level. Conclusions : The results of the present study indicate a high redislocation rate, and highlight the challenges in restoring a stable, mobile, functional shoulder.     

Posterior Chondrolabral Cleft: Clinical Significance and Associations with Shoulder Instability

Background

A high signal intensity cleft between the labrum and articular cartilage of the posterior glenoid is commonly visible on MRI and has been suggested to be anatomic variation [3, 10, 23]. The association of a posterior cleft with variations in glenoid morphology or with shoulder instability is unknown.

Questions/Purposes

The purposes of this study were to determine if posterior chondrolabral clefts are associated with variations in glenoid morphology, and to determine if they are associated with shoulder instability.

Patients and Methods

Shoulder MRI was performed in 1,264 shoulders, 1,135 male (89.8%), and 129 female (10.2%). A musculoskeletal radiologist blinded to history and outcomes evaluated the MR images for linear high signal intensity at the posterior chondrolabral junction and a rounded or truncated contour of the posterior glenoid. Glenoid version and depth were measured. Patients were followed prospectively for shoulder instability for 4 years. Univariate and multivariate statistical analysis were performed.

Results

Posterior chondrolabral cleft was present in 114/1,264. Posterior chondrolabral cleft was associated with a rounded or truncated posterior glenoid. There were 9.5° retroversion in shoulders with a posterior cleft, and 7.7° retroversion in shoulders without a cleft. Shoulders with a posterior chondrolabral cleft were more likely to develop shoulder instability.

Conclusions

Posterior chondrolabral clefts are not uncommon on MRI. They are associated with a rounded or truncated posterior glenoid and a small but significant increase in glenoid retroversion. They are associated with shoulder instability.     

关节镜和开放治疗复发性肩关节前方不稳的Meta分析

目的系统评价关节镜下和开放手术治疗青壮年复发性肩关节前方不稳定的疗效。方法计算机检索Cochrane图书馆(2011年第6期)、MEDLINE(1966年至2011年6月)、EMBase(1966年至2011年6月)、中国生物医学文献数据库(1979年1月至2011年6月)、PubMed(1966年6月至2011年6月)、万方数据库和维普数据库,手工检索中文骨科期刊的相关文献。收集所有关节镜与开放手术比较治疗青壮年患者(18～55岁)复发性肩关节前方不稳的随机对照试验,筛选出符合纳入标准的文献,对其进行严格的质量评价后应用RevMan5.0软件进行Meta分析。结果共纳入5个随机对照试验,包含278例患者。Meta分析结果显示,术后肩关节Rowe评分(WMD=4.43,95%CI2.27～6.59),关节镜手术治疗组优于开放手术治疗组。但二者在术后肩关节不稳复发(RR=1.31,95%CI0.51～3.34)、术后神经损伤(RR=0.51,95%CI0.11～2.32)、术后再手术(RR=0.49,95%CI0.11～2.27)、术后恢复伤前功能(RR=0.96,95%CI0.80～1.15)等方面比较均无统计学意义。结论与传统开放手术相比,关节镜手术治疗青壮年复发性肩关节前向不稳,术后肩关节Rowe评分具有优势,但术后并发症等方面二者间无明显差异。     

关节镜下单排带线锚钉固定治疗Ⅰ、Ⅱ型骨性Bankart损伤

目的 探讨关节镜下单排带线锚钉固定治疗Ⅰ、Ⅱ型肩关节骨性Bankart损伤的临床效果.方法 在关节镜下采用单排带线锚钉对11例肩关节前向不稳伴Ⅰ、Ⅱ型骨性Bankart损伤患者进行复位固定.术后行渐进性康复训练.手术前后采用Rowes评分和UCLA评分系统进行评估,并了解术后肩关节稳定性和活动度.结果 患者均获24个月随访.Rowes评分：术前和术后24个月分别为20分±7.07分和90分±2.74分（P〈0.05）;UCLA评分：术前和术后24个月分别为6.20分±1.30分和29.20分±1.10分（P〈0.05）;患者肩关节运动能力均较术前改善.结论 关节镜下单排带线锚钉固定治疗Ⅰ、Ⅱ型骨性Bankart损伤具有创伤小、固定可靠的优点,能够很好地恢复肩关节稳定性和运动功能.     

Beyond the peak of the anterior glenoid rim: A cadaveric study

Purpose:

The purpose of this study was to quantify the width of bone beyond the peak of the anterior glenoid rim and to determine if this anatomic region of the glenoid significantly affects measurement of the anteroposterior glenoid diameter.

Materials and Methods:

19 cadaveric scapulae were examined and the width of bone beyond the peak of the anterior glenoid rim was measured. The percent width of this region relative to the anteroposterior diameter of the glenoid was evaluated. Male and female specimens were compared. Measurements of the anteroposterior diameter of the glenoid, both including and excluding this region, were compared.

Results:

The mean width of bone beyond the peak of the anterior glenoid rim was 3.2 ± 0.7 mm, corresponding to 10.5% of the anteroposterior glenoid diameter. This anatomic region is of similar relative size in males and females (11% vs 10% of the glenoid diameter). Measurement of the anteroposterior diameter of the glenoid is significantly different depending on whether this region is included or not (P = 0.0064).

Conclusions:

There exists a portion of the anterior glenoid that is beyond the peak of the anterior rim, and is not part of the concave articular surface. The width of this anatomic area comprises a significant percent of the anteroposterior glenoid diameter, and should be understood when quantifying and describing anterior glenoid bone loss in cases of glenohumeral instability.

Clinical Relevance:

Understanding of anterior glenoid anatomy is important in the evaluation of glenohumeral instability. The portion of glenoid bone beyond the anterior rim peak is likely important for its soft tissue attachments, but its contribution to bony stability may be misunderstood.     

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.