Management of Glenoid Bone Loss with Anterior Shoulder Instability: Indications and Outcomes

Purpose of Review

Glenoid Bone Loss is a commonly encountered problem in anterior shoulder instability. In this article, we review current techniques for diagnosis, indications and management of glenoid bone loss.

Recent Findings

Multiple bone grafting techniques are available depending on the glenoid defect size including the coracoid, distal clavicle, iliac crest, and allograft distal tibia. Advancement in imaging methods allows for more accurate quantification of bone loss. Indications and techniques are continuing to evolve, and emerging evidence suggests that smaller degrees of bone loss “subcritical” may be best treated with bone grafting.

Summary

Future directions for innovation and investigation include improved arthroscopic techniques and a refinement of indications for the type of bone grafts and when to indicate a patient of arthroscopic repair versus glenoid bone grafting for smaller degrees of bone loss to ensure successful outcome.

     

Radiographic Evaluation of Patients with Anterior Shoulder Instability

Purpose of Review

Injuries to the labrum, joint capsule (in particular the inferior glenohumeral ligament), cartilage, and glenoid periosteum are associated with anterior shoulder instability. The goal of this review is to provide common radiographic images and findings in patients with anterior shoulder instability. Furthermore, we will demonstrate the best methods for measuring anterior glenoid bone loss.

Recent Findings

Magnetic resonance (MR) imaging is highly relied upon for evaluating anterior shoulder instability and can diagnose soft tissue injuries with high sensitivity. While 3D computed tomography (CT) scan has been considered the optimal tool for evaluating osseous defects, certain MR imaging sequences have been shown to have similar diagnostic accuracy. Repair of Bankart lesions is critical to stabilizing the shoulder, and in the recent years, there has been an increasing focus on imaging to accurately characterize and measure glenoid bone loss to properly indicate patients for either arthroscopic repair or anterior bony reconstruction. Furthermore, Hill-Sachs lesions are commonly seen with shoulder instability, and importance must be placed on measuring the size and depth of these lesions along with possible engagement, as these factors will dictate management.

Summary

The labral-ligamentous complex and rotator cuff are primary stabilizers of the shoulder. With anterior shoulder instability, the labrum is frequently injured. MRI with an arthrogram or provocative maneuvers is the gold standard for diagnosis. Various imaging modalities and methods can be performed to identify and measure Bankart and Hill-Sachs lesions, which can then be used for surgical planning and treating shoulder instability.

     

Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability

Purpose of review

The goal of this paper is to provide an overview in evaluating the patient with suspected or known anteroinferior glenohumeral instability.

Recent findings

There is a high rate of recurrent subluxations or dislocations in young patients with history of anterior shoulder dislocation, and recurrent instability will increase likelihood of further damage to the glenohumeral joint. Proper identification and treatment of anterior shoulder instability can dramatically reduce the rate of recurrent dislocation and prevent subsequent complications. Overall, the anterior release or surprise test demonstrates the best sensitivity and specificity for clinically diagnosing anterior shoulder instability, although other tests also have favorable sensitivities, specificities, positive likelihood ratios, negative likelihood ratios, and inter-rater reliabilities.

Summary

Anterior shoulder instability is a relatively common injury in the young and athletic population. The combination of history and performing apprehension, relocation, release or surprise, anterior load, and anterior drawer exam maneuvers will optimize sensitivity and specificity for accurately diagnosing anterior shoulder instability in clinical practice.

     

Understanding the Hill-Sachs Lesion in Its Role in Patients with Recurrent Anterior Shoulder Instability

Purpose of Review

The purpose of this study is to provide an update to the orthopedic field in regard to treatment of the Hill-Sachs lesion and anterior shoulder instability. The review highlights the most current knowledge of epidemiology, clinical evaluation, and surgical methods used to treat Hill-Sachs lesions. It also details the relevant clinical and surgical findings that have been made throughout the literature in the past couple of years.

Recent Findings

The most recent literature covering the Hill-Sachs lesion has focused on the relatively new and unexplored topic of the importance of concomitant injuries while treating a humeral head defect. The glenoid track concept has been clinically validated as a method to predict engagement. 3D-CT has become the “gold standard” for Hill-Sachs imaging; however, it has been noted that 3D-MRI produces results that are not significantly different from CT. Also, it has been found that when the arm is in a position of abduction during the primary injury, there is a higher risk of engagement and subsequent dislocation. Recent studies have demonstrated successful results stemming from purely arthroscopic procedures in treating Hill-Sachs lesions.

Summary

Anterior shoulder instability, specifically the Hill-Sachs lesion, is an area of orthopedic study that is highly active and constantly producing new studies in an attempt of gaining the best outcomes for patients. The past few years have yielded many excellent discoveries, but there is still much more work to be done in order to fully understand the role of the Hill-Sachs lesion in anterior shoulder instability.

     

Management of Complex Anterior Shoulder Instability: a Case-Based Approach

Purpose of the Review

The goal of this review is to provide a guide on surgical decision-making options for complex anterior shoulder instability using a case-based approach.

Recent Findings

Arthroscopic Bankart repair is well documented for having successful outcomes in patients with isolated labral tear involvement with minimal bone loss. Latarjet is a generally accepted procedure in patients with 20–30% glenoid bone loss. When bone loss exceeds that which cannot be managed through Latarjet, a range of options exist and are highly dependent upon the extent of osseous deficiency on both the glenoid and humeral sides, surgeon experience, and patient-specific factors. The use of reverse total shoulder arthroplasty for the management of chronic locked shoulder dislocations has been described as a successful management option.

Summary

Treatment options for complex anterior shoulder instability range widely based on patients’ presenting exam, surgical history, amount of glenoid bone loss, size of Hill-Sachs lesion, and surgeon preference. When selecting the appropriate surgical intervention, the treating surgeon must consider the patient history, physical exam, and preoperative imaging along with patient expectations.

     

Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability: Indications and Outcomes

Purpose of Review

Arthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability.

Recent Findings

Improvements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome.

Summary

When indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.

     

Return to Sports After Shoulder Stabilization Surgery for Anterior Shoulder Instability

Purpose of Review

Young athletes continue to experience traumatic shoulder instability and are often plagued by recurrent instability, limiting their return to sport. The purpose of this paper was to review return to sport in athletes after shoulder stabilization surgery for anterior shoulder instability.

Recent Findings

Athletes managed nonoperatively demonstrate unacceptably high rates of recurrent instability and are less likely to successfully return to sport. Operative management includes capsuloligamentous repair (arthroscopic versus open) and bone augmentation techniques. While modern arthroscopic techniques have provided favorable outcomes, open techniques have demonstrated lower recurrence rates among young collision athletes. A subset of athletes continue to experience recurrent instability, leading to further investigation of concomitant pathologies, which may put patients at risk of failure following Bankart repair. Bony augmentation procedures remain favorable for patients with glenoid bone loss; however, what constitutes critical bone loss in the decision between anterior labral repair versus bone augmentation has recently been questioned.

Summary

Operative management of anterior shoulder instability provides superior results, including lower recurrent instability and return to sport. Future research on patient-specific risk factors may aid surgical decision-making and optimization of outcomes.

     

Current Concepts in Rehabilitation for Traumatic Anterior Shoulder Instability

Purpose of review

The objectives of this review are to evaluate the current evidence-based literature and concepts surrounding rehabilitation in patients with anterior shoulder instability injuries and surgical repair.

Recent findings

The current literature evidence for shoulder rehabilitation for anterior shoulder instability and labral repair is limited. As a result, there are variations among surgeons and physical therapists in rehabilitation protocols after anterior shoulder instability injuries and repair. While general consensus on certain rehabilitation parameters exists, the evidence for the importance of rehabilitation and functional performance test for return to sport in future injury prevention is still lacking in literature.

Summary

Rehabilitation after anterior shoulder instability injury and anterior labral repair is paramount in the injured or post-operative shoulder. Restoration of soft tissue mobility, dynamic glenohumeral joint stability, and balance and strength around the shoulder not only protect healing of injured or repaired soft tissues but also potentially minimizes future re-injury or recurrence risk.

     

The Epidemiology and Natural History of Anterior Shoulder Instability

Purpose of Review

The purpose of this review is to outline the natural history and best clinical practices for nonoperative management of anterior shoulder instability.

Recent Findings

Recent studies continue to demonstrate a role for nonoperative treatment in the successful long-term management of anterior glenohumeral instability. The success of different positions of shoulder immobilization is reviewed as well.

Summary

There are specific patients who may be best treated with nonoperative means after anterior glenohumeral instability. There are also patients who are not good nonoperative candidates based on a number of factors that are outlined in this review. There continues to be no definitive literature regarding the return to play of in-season athletes. Successful management requires a thorough understanding of the epidemiology, pathoanatomy, history, physical examination, diagnostic imaging modalities, and natural history of operative and nonoperative treatment.

     

快速康复外科理念在胃癌围手术期治疗中的应用及护理体会

摘要 目的：采用快速康复外科(FTS)治疗理念,提高患者胃癌术后的营养状况,加快康复速度,减少并发症发生率。方法：通过术前营养风险筛查结合肠内营养支持、术后早期肠内营养支持、早期下床活动、围手术期护理等一系列措施,观察患者术后营养状况、肠蠕动恢复时间、并发症发生率。结果：治疗组术后血清白蛋白水平明显高于对照组;术后肠鸣音恢复及肛门排气更早;并发症发生率低。结论：合理的营养状况评估和肠内营养支持,辅以快速康复外科的护理措施,可以提高患者营养状况,加快胃癌术后的康复速度。     

Managing Shoulder Instability in the Overhead Athlete

Purpose of ReviewShoulder instability in the overhead athlete is a difficult problem because of the balance between necessary laxity for athletic movements and stability of the joint. The purpose of this review is to provide an overview of the clinical evaluation of shoulder instability in the overhead athlete and present evidence-based management strategies for each subtype of shoulder instability, including novel techniques and outcomes.Recent FindingsRecent investigation has shown that throwers and other overhead athletes are more likely to present with subtle subluxation events rather than discrete dislocations as their primary symptom. While overhead athletes with discrete anterior dislocation events are likely to begin with non-operative management, many progress on to surgical intervention. Surgical management of glenohumeral joint instability continues to pose challenges due to the potential for over-tensioning for the sake of stability at the expense of the adaptive laxity that often confers performance benefits in the overhead athlete. Novel, individualized, and sport/position specific approaches are needed to address this complex issue.SummaryThe optimal management of shoulder instability in the overhead athlete continues to be a controversial topic due to the complex work-up, an increasing number of surgical options with varying indications, and low volume of high-quality studies comparing any of the treatment options. The Anterior Shoulder Instability International Consensus Group guidelines from February 2022 offer the most updated guidelines on work-up and management. Overall, high-quality randomized controlled trials are required to determine the optimal treatment for specific pathologies and aid in creating patient-centered management plans.     

脑卒中肩关节半脱位患者使用肩吊带的护理观察

目的探讨肩吊带在脑卒中并发肩关节半脱位患者康复中的作用。方法 对脑卒中偏瘫并发肩关节半脱位患者佩带肩带和不佩带肩带各30例进行回顾性分析。结果 经过3个月的康复训练和康复护理,两组患者Fugl-Meyer上肢功能评分和Bar-thel指数均有改善(P<0.05),但两组间无显著性差异(P>0.05)。结论 脑卒中并发肩关节半脱位患者不使用肩吊带对上肢功能和ADL能力无明显影响。     

规范化疼痛管理在肩关节镜手术患者应用中效果观察

目的探讨规范化疼痛管理在肩关节镜手术患者围手术期应用的效果。方法将2011年10月～2013年12月行肩关节镜手术的60例患者,通过计算机随机法分为对照组和实验组,各30例。实验组采用围手术期规范化疼痛管理。对照组采取传统按需镇痛处理方法,即患者疼痛时给予镇痛处理。观察两组术后3天内疼痛评分、患者对疼痛控制的满意度。结果实验组疼痛评分在手术后6h、术后第1、2、3天低于对照组(P0.05);术后3天镇痛满意度评分高于对照组,有显著性差异(P0.05)。结论肩关节镜手术患者实施规范化疼痛管理,可以使患者以无痛或最低的疼痛状态度过围手术期,提高患者的舒适度,使其能尽早进行康复功能锻炼,促进疾病早日康复,提高了护理质量。     

快速康复外科理念在老年全髋关节置换术患者围术期中的应用

目的探讨快速康复外科(fast track surgery,FTS)理念在老年全髋关节置换术(total hip arthroplasty,THA)患者围术期护理中的应用效果。方法按随机数字表法将2009年10月至2011年12月浙江省杭州市第一人民医院骨科收治的拟行THA的69例患者分为对照组36例和观察组33例,对照组采取常规围术期护理,观察组在对照组基础上将FST理念融入围术期护理,采用汉密尔顿焦虑量表(hamilton anxiety scale,HAMA)及疼痛视觉模拟评分法(visual analog scale,VAS)于术前1d及术后7d分别对患者进行测评,同时记录相关的生理指标。结果两组患者术前的HAMA评分、VAS评分、收缩压、舒张压和心率的差异均无统计学意义(均P>0.05);术后的HAMA评分、VAS评分、收缩压、舒张压和心率等均较术前有所下降(P<0.05或P<0.01);术后观察组的HAMA评分、VAS评分及心率较对照组下降更明显(P<0.05或P<0.01),但两组患者收缩压和舒张压的差异无统计学意义(P>0.05)。结论将FST理念应用于老年髋关节置换患者的围术期护理,有助于减轻患者围术期的焦虑程度,缓解其术后疼痛,同时能改善患者的血压和心率等生理指标,值得在临床推广应用。     

Clinical Factors Predicting Fractures Associated with an Anterior Shoulder Dislocation

OBJECTIVES: To identify risk factors for fractures associated with an anterior shoulder dislocation treated in an emergency department (ED). METHODS: A retrospective case-control study over five years of patients with an anterior shoulder dislocation was accomplished in a university-affiliated ED. Chart review identified possible predictors of fractures. Comparing the profile of patients having a clinically important fracture associated with their shoulder dislocation (cases) with those sustaining a noncomplicated dislocation (controls) provided the outcome measure. RESULTS: A total of 334 patients were included in the study. Eighty-five (25.5%) had a clinically important fracture-dislocation, and the remaining 249 (74.5%) sustained a noncomplicated shoulder dislocation. Chi-square, logistic regression, and recursive partitioning analysis showed three significant factors for the presence of fracture-dislocation: 1) age 40 years or older, 2) a first episode of dislocation, and 3) mechanism of injury (i.e., a fall greater than one flight of stairs, a fight/assault episode, or a motor vehicle crash). A multiple logistic regression model estimated the significant adjusted odds ratios (and their 95% confidence intervals [95% CIs]) for each of the three factors: 5.18 (95% CI = 2.74 to 9.78), 4.23 (95% CI = 1.82 to 9.87), and 4.06 (95% CI = 1.95 to 8.48), respectively. A predictive model using any one of the three factors reached a sensitivity of 97.7% (95% CI = 91.8% to 99.4%), a specificity of 22.9% (95% CI = 18.1% to 28.5%), and a negative predictive value of 96.6% (95% CI = 88.3% to 99.6%). CONCLUSIONS: Three risk factors predict clinically important fractures that are associated with shoulder dislocation: age, first episode, and mechanism of dislocation. A prospective validation may lead to standardized use of prereduction radiographs of the shoulder in the ED.