Relationship between strength and functional indexes (Rowe and Walch-Duplay scores) after shoulder surgical stabilization by the Latarjet technique

IntroductionThe rotator cuff muscles help stabilize the glenohumeral joint. Postoperative recovery of rotator cuff muscle strength appears to be an important factor for optimal joint stabilization and the resumption of professional and/or sports activities.ObjectiveTo study the relationship between internal rotator (IR) and external rotator (ER) muscle strength, shoulder function and the resumption of sports activities (as typically evaluated with functional scores) following surgical stabilization with the Bristow-Latarjet procedure in cases of chronic shoulder instability.Patients and methodsTwenty patients with anterior, post-traumatic, chronic shoulder instability were included prospectively in a cohort study. The Rowe and Walch-Duplay functional scores were rated for the operated shoulder and the isokinetic IR and ER peak torque values were evaluated with a Con-Trex^® dynamometer before surgery and then 3, 6 and 21 months afterwards. The isokinetic evaluation was performed (at 180°/s, 120°/s and 60°/s) in the seated position, with the arms in 45° of abduction and 30° of antepulsion in the plane of the scapula.ResultsThere were no significant postoperative correlations between shoulder function (as judged by the Rowe and Walch-Duplay scores) and IR or ER muscle strength.ConclusionThis study did not provide evidence for a correlation between IR and ER muscle strength and functional scores after surgical stabilization of the shoulder. However, it is necessary to objectively measure the rotator cuff strength recovery to adequate the strengthening of rotator muscle prior to the resumption of sports activities. Isokinetic strength assessment may thus be a valuable decision support tool for the resumption of sports activities and would complement the functional scores studied here.     

Instabilité d’épaule et isocinétisme : apport de l’isocinétisme dans une situation clinique complexe

Introduction

The treatment of shoulder instability is codified. In case of a resistant instability to a well-conducted rehabilitation, the surgery can be proposed with good results. Sometimes, the situation can be more complex, and the case report presents the interest of isokinetics as an alternative therapeutic.

Case report

A man of 36 years, operated of Latarjet for recurrent anterior dislocation of the shoulder, presented in postoperation an infectious osteoarthritis. After recovery of the infectious episode, in a painful and stiffness shoulder, shoulder instability repeated with a clinical examination agreeing and an evocative context: failure of the surgical treatment, osseous postinfectious rehandlings. The surgery having been excluded and traditional rehabilitation having shown its limits. A rehabilitation oriented by the research of a muscular imbalance in isokinetic evaluation permitted a functional improvement with disappearance of the instability feeling.

Discussion

In complex clinical situations, isokinetic evaluation showed an interest to adapt and to optimize rehabilitation. A practical application of isokinetics is in the pathologies of articular instability and in particular the shoulder instability. The positions of evaluation will be adapted to the patients. That opens new prospects in rehabilitation.

Conclusion

This case report illustrates isokinetic interest for an objective and rigorous assessment of muscular strength and so an adaptation and optimization of the rehabilitation.     

Intérêts d’une évaluation musculaire isocinétique des rotateurs de l’épaule dans le parcours de soins de l’épaule instable

Given the role and the benefit of muscles as means of dynamic stability in an unstable shoulder, with a failure of passive stabilisation conditions, a better understanding of changes to the muscular strength of the medial (MR) and lateral rotators (LR), and the agonist/antagonist equilibrium of patients presenting with chronic instability appears relevant in order to best adapt treatment and rehabilitation strategies. As seen in the literature, in cases of no surgery on anterior post-traumatic scapulo-humeral instability, even if there does not appear to be a consensus on the MR and LR strength deficit, there is no disruption to the agonist/antagonist equilibrium (LR/MR ratio). After surgical stabilisation with anterior fixation using the Bristow-Latarjet technique, a temporary “over-deficit” of the MR and LR strength compared with pre-operative values occurs, lasting up to six months; however, the potential pre-operative deficit compared with a healthy contralateral shoulder remains despite the procedure and post-operative rehabilitation treatment. The isokinetic muscle assessment of strength and MR and LR equilibrium is relevant in the follow-up of patients presenting with chronic previous shoulder instability, whether they have had surgery or not, in order to determine the direction, the intensity and the methods of rehabilitation, its duration and to influence the decision of when to return to any previous sporting activities.     

Adaptation de la force isocinétique des muscles rotateurs de l’épaule à la pratique sportive

Physiological, anatomy and biomechanical adaptations of the shoulder joint to the stresses induced by the throwing gesture, which allow performance, could be the cause of “desadaptation” that can lead to injury by microtrauma. Thus, exploration of any adaptations or changes in internal (IR) and external (ER) muscle strength (and/or agonist/antagonist balance represented by the ratio ER/IR) to solicitations sports is relevant in order to better understand the pathophysiology of shoulder injury. Many studies have focused on identifying patterns of IR and ER muscle strength according to the practice of overhead sports. Despite the methodological limitations, although an increase in the IR strength of the dominant side was reported, it does not seem to exist an “imbalance” in muscle strength between the IR and ER, induced by overhead sports, which could be a “desadaptaion” in the origin of shoulder pathologies. There is no imbalance that could be implicated as a risk factor predisposing to shoulder pathologies.     

Les instabilités antérieures de l’épaule. Á propos de 50 cas

We performed 54 consecutive Latarjet procedures for the treatment of recurrent anterior instability of the shoulder between 1996 and 2005. We retrospectively reviewed the clinical and radiographic results of the procedure. The procedure was performed for the treatment of recurrent anterior dislocation in 51 shoulders, painful recurrent anterior subluxation in two cases and painful shoulder in one case. All patients had a radiographic evaluation before the operation and at the latest follow-up examination. At the time of the latest follow-up, none of the patients had recurrent dislocation. According to the system of Rowe, 51 (94 %) of the 54 shoulders had an excellent or good result. Fifty-one shoulders had no glenohumeral osteoarthrosis.     

Evolution of the isokinetic torque of shoulder rotators before and after 3 months of shoulder stabilization by the Latarjet technique]

OBJECTIVE: To compare prospectively isokinetic shoulder strength before and 3 months after shoulder stabilization by the Latarjet procedure indicated for the treatment of recurrent dislocation. METHOD: Twenty-five subjects, 23+/-6 years old, with anterior unidirectional recurrent shoulder dislocation, underwent isokinetic concentric (con) and eccentric (ecc) measurement of lateral rotators (LR) and medial rotators (MR) of both shoulders at the angular speed of 60 and 120 degrees par second. Evaluation was carried out in the scapular plane with the patient in a sitting position one month before and 3 months after shoulder stabilization by the Latarjet technique. We calculated the concentric ratio LR/MR and mixed ratios LR(ecc)/MR(con) and LR(con)/MR(ecc). RESULTS: Before surgery, the rotator peak torque for the operated shoulder side was similar to that of the healthy shoulder side. The concentric ratio for the healthy shoulder side was higher because the lateral rotators were slightly weaker on the recurrent-dislocated shoulder side. Three months after shoulder stabilization by the Latarjet technique, for the operated shoulder side, the isokinetic concentric torque of rotators was similar to that before surgery. For the operated shoulder side, only the eccentric torque of medial rotators was significantly lower after surgery than before surgery and lower than that for the healthy shoulder side (9 to 15%). Ratios did not differ before and after surgery. CONCLUSION: Three months after surgery with Latarjet technique for recurrent dislocated shoulder, operated shoulders showed a slight strength deficit as compared with healthy shoulders. The concentric deficit after surgery was not significantly different from that before surgery. This result could be explained by strengthening exercises performed during the shoulder rehabilitation program. However, the eccentric strength deficit of medial rotators of the operated shoulder is certainly associated with the opening and stitching of the sub-scapular muscle necessary for the shoulder stabilization.     

L’apport du muscle pectoralis minor dans le traitement de l’instabilité antérieure de l’épaule

The surgical stabilization of the shoulder knew many technical improvements energy. We propose a preliminary study about an engineering change by the addition of a fourth muscular bolt for the treatment of former instabilities of the shoulder. Our study is prospective gathering 16 patients having a stabilization of the shoulder by a quadruple locking using an osseous thrust by the coaracoid process, a tendineux bolt by a hammock applied thanks to the coaraco-biceps tendon to the lower bank of the sub-scapularis, a capsular bolt by joining the acromio-coracoid ligament to the glenohumeral capsule and a fourth bolt by the joining of the pectoral small tendon to the coraco-biceps. Our results evaluated by the score of Dupaly after 18 months show that the average retreat are satisfactory with an early resumption of the activity (2 months on average). The techniques of former stabilization of the shoulder are currently allowing that triple locking is indicated among all patients whose score ISIS exceeds five points. The addition of small pectoral as fourth bolt seems to us as well interesting because of the good preliminary results.     

Isokinetic strength measurement and training of the shoulder: methodology and results]

OBJECTIVE: To evaluate the contribution of isokinetic methods of shoulder strength measurement and training. METHOD: A Medline search of English and French publications, including referenced articles, allowed us to analyse non-indexed publications. Eighty-seven articles were retained for analysis. RESULTS: The isokinetic evaluation of the shoulder is valid. Although reproducibility of shoulder evaluation is inferior to that of the knee, it is nevertheless satisfactory when a rigorous test method is used. Normal values for the rotators, abductors-adductors, and extensors-flexors depend on diverse parameters such as age, gender, fat mass, and the type and intensity of physical activity. The agonist to antagonist ratio is particularly informative in pathological conditions. The ratio is modified in cases of impingement syndrome and shoulder instability, and this modification appears to be a cause rather than a consequence of pathologic features. The ratio generally remains modified post-surgery, and normalization must be a major focus of post-surgery rehabilitation. CONCLUSION: Isokinetic measurement, particularly disturbances in the agonist-antagonist balance, is a reference method for evaluating shoulder muscle strength and detecting deficits in specific muscle groups seen in certain shoulder abnormalities. Such measurement is a valuable tool for orienting rehabilitation towards the deficient muscle groups, complements classical techniques of muscle strengthening, and is an accurate means for following the rehabilitation progress.     

Luxation antérieure de l’épaule associée à une fracture de la diaphyse humérale homolatérale (à propos d’un cas)

The association of shoulder dislocation with ipsilateral humeral shaft fracture remains rare. Is presented along with a review of the literature regarding 18 reported cases. The prognosis depends on that of the shoulder. The authors report a case of shoulder dislocation with ipsilateral humeral shaft fracture at a patient of 34 years an accident of sport (cyclocross). After closed reduction of the anterior shoulder dislocation. The treatment was surgical, required open reduction of the humeral fracture with compression plating. At recession of one year, the clinical examination finds amplitudes comparable to the shoulder controlatéral without instability.     

Shoulder instability in the athlete

Shoulder instability is a common malady affecting the athlete's shoulder. A basic knowledge of shoulder anatomy and biomechanics is essential to understanding the pathophysiology and treatment options. The history and physical examination can lead the investigator to the correct diagnosis in most cases. Diagnostic imaging modalities can provide useful clues and help rule out concomitant pathology. Most patients are suitable candidates for a trial of shoulder rehabilitation. Those who fail nonoperative treatment may be candidates for surgical intervention. A variety of surgical techniques are available to reliably prevent recurrent instability. There has been a recent trend towards arthroscopic stabilization, including thermal capsulorrhaphy, which may prove as effective as open techniques.     

Sonography as a Tool for Identifying Engaging Hill‐Sachs Lesions

Engaging Hill‐Sachs lesions can be a factor predictive of recurrent anterior shoulder instability, yet no method has been recognized as an effective means to predict engagement. We evaluated the ability of sonography to identify engaging Hill‐Sachs lesions by using a transaxillary approach and dynamic scanning. In patients with engaging lesions, there was an abrupt change in the contour of the humeral head when the shoulder was in 90° of abduction and 90° of external rotation. Sonography therefore has the potential to be a useful preoperative tool in determining which patients may benefit from a surgical repair that also addresses Hill‐Sachs lesions.     

Traumatic shoulder instability. Nonsurgical management versus surgical intervention

Shoulder instability is classified as either traumatic or atraumatic based on the mechanism of injury. Traditional treatment for both forms of instability involves a nonsurgical approach, consisting of immobilization, rehabilitation, and a delay in the return to vigorous activities. This treatment is often quite successful in preventing recurrent dislocations in the patient with atraumatic instability. However, those patients with traumatic instability often experience further dislocations or subluxations, with recurrence rates as high as 94% in patients younger than 20 years. These recurrent episodes of instability can result in injuries to the capsulolabral structures (Bankart lesions), humeral head (Hill Sachs defect), and neurologic structures. Open surgical reconstructions for anterior instability have been reported to be 94-100% successful in preventing recurrence. Arthroscopic stabilization procedures are successful in preventing recurrence in 80-90% of patients and result in low morbidity. However, the most common form of initial treatment for traumatic anterior shoulder instability remains immobilization, supervised rehabilitation, and gradual return to full activity, despite significantly inferior results when compared to operative intervention. This article addresses the treatment options available to the nurse practitioner when managing the patient with traumatic anterior instability.     

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.

     

Kann eine Kette gleichzeitig an zwei Stellen rei?en?

It seems unlikely that a chain can break at two sites simultaneously and likewise it seems impossible that the inferior glenohumeral ligament (IGHL) can rupture at two sites simultaneously. Bankart lesions are the most common lesions associated with anterior shoulder instability. Humeral avulsion of glenohumeral ligament (HAGL) lesions are infrequent but are often responsible for recurrent instability if undetected. This case represents the third case reported in the literature of a combined Bankart-HAGL lesion and the exclusively arthroscopic stabilization makes it unique at this time.     

Recurrent anterior shoulder instability: Review of the literature and current concepts

The purpose of this review article is to discuss the clinical spectrum of recurrent traumatic anterior shoulder instability with the current concepts and controversies at the scientific level. Because of increasing participation of people from any age group of the population in sports activities, health care professionals dealing with the care of trauma patients must have a thorough understanding of the anatomy, patho-physiology, risk factors, and management of anterior shoulder instability. The risk factors for recurrent shoulder dislocation are young age, participation in high demand contact sports activities, presence of Hill-Sachs or osseous Bankart lesion, previous history of ipsilateral traumatic dislocation, ipsilateral rotator cuff or deltoid muscle insufficiency, and underlying ligamentous laxity. Achieving the best result for any particular patient depends on the procedure that allows observation of the joint surfaces, provides the anatomical repair, maintains range of motion, and also can be applied with low rates of complications and recurrence. Although various surgical techniques have been described, a consensus does not exist and thus, orthopedic surgeons should follow and try to improve the current evidence-based treatment modalities for the patients.     

Schulterinstabilität bei Epilepsie

Glenohumeral instability due to epilepsy is usually considered to be of the posterior type. In the literature, however, inconsistent data on the predominant direction of instability caused by epilepsy is provided. The largest reported series of 34 shoulders in 26 patients with primary dislocation caused by epileptic seizures showed a comparable incidence of anterior and posterior instability. We report the case of a 26-year-old woman with epilepsy and instability including hyperlaxity of both shoulders known since childhood who presented with a recurrent dislocation of the right shoulder after a fall downstairs. Clinical and radiological evaluation revealed unidirectional anteroinferior shoulder instability with hyperlaxity (type B3 according to Gerber). Thus, arthroscopic stabilization had to be considered. As pharmacological treatment of epilepsy was insufficient so far, conservative treatment was recommended including optimizing anticonvulsive medication and scapulothoracic dyskinesia. Four months later, symptoms of anterior instability had only slightly improved, and arthroscopic anteroinferior and posteroinferior stabilization was performed. Intraoperatively, a partial lesion of the anteroinferior labrum, a superficial Hill-Sachs lesion and extensive enlargement of the anterior and posterior capsular volume were found. In patients with shoulder instability due to epilepsy, recognition of unidirectional anterior instability with hyperlaxity is of importance regarding the high risk of recurrent instability.     

Chiropractic management of a professional hockey player with recurrent shoulder instability

OBJECTIVE: To describe the clinical management of recurrent shoulder instability in a professional hockey player by using chiropractic management and rehabilitation exercises. CLINICAL FEATURES: A 23-year-old professional hockey player with recurrent left shoulder pain and instability. He had two previous unsuccessful shoulder operations to correct the instability. He reported that the shoulder "slips out" in positions of abduction and external rotation or when the left arm is moved suddenly above shoulder height. The patient was still playing hockey professionally at the time of the initial visit and did not want to have to take time off for another surgery, so he chose to attempt a conservative approach. INTERVENTION AND OUTCOME: The patient had undergone strength training for rehabilitation after each of the previous two shoulder operations and had very strong rotator cuff and scapular musculature. Proprioceptive testing revealed a poor response in the left shoulder compared with the right shoulder. Two subjective outcome measures were used to determine the effectiveness of the treatment protocol in reducing the symptoms of recurrent shoulder instability. Much of the treatment focused on proprioceptive training, soft tissue mobilization, and improving joint function. CONCLUSION: This case demonstrates the potential benefit of chiropractic management and proprioceptive exercises to decrease the symptoms of recurrent shoulder instability.     

Instabilité antérieure récidivante de l'épaule chez le rugbyman. Résultats d'une série de 85 épaules opérées par la technique de Latarjet avec un recul moyen de sept ans

The stabilization of an unstable chronic shoulder is a difficult challenge in the contact sportsman especially the rugby player. We report our experience of the modified Latarjet procedure with a retrospective series of 85 shoulders (79 rugbymen at 75 months follow-up). It acted all young men with a prevalence of dominant shoulder, occupying all the stations (over-representation of the third lines). Eighty percent presented osseous lesions; the first luxation was traumatic during a tackle. We describe our technique and our postoperative protocol. Seven percent experienced recurrence of their instability after a new traumatism and 67% returned to rugby within 8 months by keeping for some of them a sport practice functional embarrassment (16 patients). Only two mechanical complications were observed, 93% of the patients were satisfied with their intervention.     

Rééducation accélérée après ligamentoplastie par la technique DIDT par un protocole simple et adapté à chacun

With most procedures of rehabilitation following reconstruction of the anterior cruciate ligament that was treated though the technique of ligamentoplasty using gracilis and semi-tendinous, the hamstring can’t resume activity until four to six weeks after the operation. Comparing the engraftment of post-traumatic muscle damage, the described rehabilitation procedure is an accelerated procedure that uses early eccentric strengthening of the hamstring starting on day 8. This is achieved first by manual resistance until day 21 then on a hamstring chair from day 21 to day 45. The aim of such a treatment is not to resume sporting activity more quickly, but to ensure that the conditions for recovery are optimized. The described treatment also presents some limitations and should therefore be applied with caution so as not to jeopardize the ultimate recovery of the ligament.