T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types

Forty patients who had a diagnosis of multidirectional instability of forty-two shoulders had a modified Bankart operation in which a T-shaped incision was made in the anterior portion of the capsule, with advancement of the inferior flap superiorly and of the superior flap medially. All of the patients had been injured during athletic activities. Some degree of anterior labral injury was present in thirty-eight of the forty-two shoulders. Half of the patients had generalized ligamentous laxity. The patients were followed for an average of three years (range, two to seven years). Four patients had episodes of instability after the operation. Three had a single episode of posterior subluxation during throwing, one had recurrent posterior subluxation that subsequently was treated by posterior stabilization, and one had anterior subluxation while he was diving from a high board. The average loss of external rotation after the operation was 5 degrees with the arm at the side and 4 degrees with the arm abducted 90 degrees. Satisfaction of the patient was rated excellent for forty (95 per cent) of the shoulders, good for one shoulder, and fair for one shoulder. However, throwing athletes found that they were unable to throw a ball with as much speed as before the operation.     

Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial

BACKGROUND: An initial anterior dislocation of the shoulder becomes recurrent in 66% to 94% of young patients after immobilization of the shoulder in internal rotation. Magnetic resonance imaging and studies of cadavera have shown that coaptation of the Bankart lesion is better with the arm in external rotation than it is with the arm in internal rotation. Our aim was to determine the benefit of immobilization in external rotation in a randomized controlled trial. METHODS: One hundred and ninety-eight patients with an initial anterior dislocation of the shoulder were randomly assigned to be treated with immobilization in either internal rotation (ninety-four shoulders) or external rotation (104 shoulders) for three weeks. The primary outcome measure was a recurrent dislocation or subluxation. The minimum follow-up period was two years. RESULTS: The follow-up rate was seventy-four (79%) of ninety-four in the internal rotation group and eighty-five (82%) of 104 in the external rotation group. The compliance rate was thirty-nine (53%) of seventy-four in the internal rotation group and sixty-one (72%) of eighty-five in the external rotation group (p = 0.013). The intention-to-treat analysis revealed that the recurrence rate in the external rotation group (twenty-two of eighty-five; 26%) was significantly lower than that in the internal rotation group (thirty-one of seventy-four; 42%) (p = 0.033) with a relative risk reduction of 38.2%. In the subgroup of patients who were thirty years of age or younger, the relative risk reduction was 46.1%. CONCLUSIONS: Immobilization in external rotation after an initial shoulder dislocation reduces the risk of recurrence compared with that associated with the conventional method of immobilization in internal rotation. This treatment method appears to be particularly beneficial for patients who are thirty years of age or younger.     

Results of the Latarjet procedure for recurrent anterior dislocation of the shoulder in patients with epilepsy

A total of 12 epileptic patients (14 shoulders) with recurrent seizures and anterior dislocations of the shoulder underwent a Latarjet procedure and were reviewed at a mean of 8.3 years (1 to 20) post-operatively. Mean forward flexion decreased from 165°?(100°?to?180°) to 160° (90° to 180°) (p = 0.5) and mean external rotation from 54°?(10°?to?90°) to 43° (5° to 75°) (p = 0.058). The mean Rowe score was 76 (35 to 100) at the final follow-up. Radiologically, all shoulders showed a glenoid-rim defect and Hill-Sachs lesions pre-operatively. Osteo-arthritic changes of the glenohumeral joint were observed in five shoulders (36%) pre-operatively and in eight shoulders (57%) post-operatively. Re-dislocation during a seizure occurred in six shoulders (43%). Five of these patients underwent revision surgery using a bone buttress from the iliac crest and two of these patients re-dislocated due to a new seizure. Due to the unacceptably high rate of re-dislocation after surgery in these patients, the most important means of reducing the incidence of further dislocation is the medical management of the seizures. The Latarjet procedure should be reserved for the well-controlled patient with epilepsy who has recurrent anterior dislocation of the shoulder during activities of daily living.     

Bristow surgical treatment of shoulder dislocation

14 shoulders with recurrent anterior dislocation were treated with a modified Bristow procedure and had a 38 to 66 months follow up after surgery. Postoperatively no patient had recurrent anterior dislocation. 4 patients had an average loss of external rotation of 10-15 degrees, one patient had a non-union of the transplanted coracoid. None of the patients was disappointed by the results.     

Good clinical outcome of combined Bankart-Bristow procedure for recurrent shoulder instability: 126 patients followed for 2-6 years

126 patients (100 men) with recurrent anterior shoulder dislocation or subluxation with severe Bankart lesion were treated with a combined Bankart and modified Bristow procedure and reviewed for this study. The mean age at operation was 25 (14-69) years, and mean follow-up period 41 (24-75) months. Averages of the Rowe score, the Constant score and the ASES score at final follow-up were 90, 95 and 91 points, respectively. The clinical outcome was excellent in 97 patients (77%), good in 16 (13%) and fair in 13 (10%). 2 patients had resubluxation, while no patient had a complete redislocation. The average loss of range of motion of external rotation, as compared to the contralateral shoulder side was 13 degrees. 67 of 72 patients returned to sports. No major postoperative complications occurred. This procedure had an excellent clinical outcome in cases of recurrent anterior shoulder dislocation or subluxation.     

Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging

BACKGROUND: Glenohumeral dislocations often recur, probably because a Bankart lesion does not heal sufficiently during the period of immobilization. Using magnetic resonance imaging, we assessed the position of the Bankart lesion, with the arm in internal and external rotation, in shoulders that had had a dislocation. METHODS: Coaptation of a Bankart lesion was examined with use of magnetic resonance imaging, with the arm held at the side of the trunk and positioned first in internal rotation (mean, 29 degrees) and then in external rotation (mean, 35 degrees), in nineteen shoulders. Six shoulders (six patients) had had an initial anterior dislocation, and thirteen shoulders (twelve patients) had had recurrent anterior dislocation. Fast-spin-echo T2-weighted axial images were made when the dislocation had occurred less than two weeks earlier, and spin-echo T1-weighted axial images after intra-articular injection of gadolinium-diethylenetriamine pentaacetic acid were made when the dislocation had occurred more than two weeks earlier. Separation and displacement of the anteroinferior portion of the labrum from the glenoid rim were measured on the axial images, and coaptation of the anterior part of the capsule to the glenoid neck was assessed by measurement of the detached area, opening angle, and detached length. RESULTS: Separation and displacement of the labrum were both significantly less (p = 0.0047 and p = 0.0017, respectively) when the arm was in external rotation than when it was in internal rotation. The detached area and the opening angle of the anteroinferior portion of the capsule were both significantly smaller (p = 0.0003 and p < 0.0001, respectively), and the detached length was significantly shorter (p < 0.0001) with the arm in external rotation. CONCLUSION: Immobilization of the arm in external rotation better approximates the Bankart lesion to the glenoid neck than does the conventional position of internal rotation.     

Radiographic evaluation of the Hill-Sachs lesion in patients with recurrent anterior shoulder instability

The Hill-Sachs lesion is an important bony sign of previous anterior shoulder dislocation and instability. Using orthographic projection, we evaluated the Hill-Sachs lesion in 30 shoulders in 27 patients with recurrent anterior shoulder instability. This produced a clear and undistorted view of the posterolateral notch. For orthographic imaging, the patient was placed supine with the arm in 135 degrees of flexion and 15 degrees of internal rotation. The x-ray beam was angled vertically through the humeral head. The width and depth of the posterolateral notches were measured on the orthographic radiographs. The average posterolateral notch depths were 3.9 +/- 0.9 mm in the dislocation group and 2.1 +/- 1.0 mm in the subluxation group. A shallow Hill-Sachs lesion was indicative of a greater degree of anterior instability of the shoulder.     

Hill-Sachs Remplissage手术治疗骨缺损性复发性肩关节前脱位

目的 探讨关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术治疗存在明显骨缺损的复发性肩关节前脱位的疗效.方法 回顾性分析随访2年以上的应用关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术治疗的复发性肩关节前脱位49例患者的病例资料,男42例,女7例;接受手术时年龄16.7～54.7岁,平均28.4岁.49例均为单向不稳定,合并明显的肩盂骨性损伤及巨大的Hill-Sachs损伤.术中采用金属缝合锚钉行Bankart修补,辅助后方冈下肌腱固定填充Hill-Sachs损伤.全部病例随访24～35个月,平均29.0个月,随访时采用ASES评分、Constant-Murley评分、Rowe评分进行功能评估,观察肩关节活动度变化.结果 术前及终末随访时肩关节平均前屈上举162.9°±17.1°和170.9°±7.4°(P=0.007),平均体侧外旋56.0°±17.6°和54.1°±17.1°(P=0.511);ASES评分为(84.7±11.3)分和(96.0±3.4)分(P=0.000),Constant-Murley评分为(93.3±8.7)分和(97.8±3.6)分(P=0.005),Rowe评分为(36.8±8.5)分和(89.8±12.5)分(P=0.000).终末随访时1例患者出现复发脱位,3例患者出现半脱位,失效率8.2%(4/49).此4例患者恐惧试验阳性.结论 肩关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术是治疗存在明显骨缺损的复发性肩关节前脱位的有效方法之一.手术适应证的正确选择、熟练的关节镜下操作技术以及术后长期、严格的功能康复锻炼是手术成功的关键.

Abstract：

Objective The purpose of our study was to report the results of using arthroscopic Remplissage and Bankart repair in patients who had an engaging Hill-Sachs lesion with significant glenoid bone loss. Methods We retrospectively reviewed 49 consecutive patients who underwent arthroscopic Remplissage and Bankart repair for anterior shoulder instability with a mean duration of follow-up of 29.0 months (24-35 months). At the time of surgery the mean age of 42 men and 7 women was 28.4 years. All patients were diagnosed as recurrent anterior shoulder dislocation with a bony lesion of glenoid and an engaging HillSachs lesion. An arthroscopic Remplissage and Bankart repair using metal anchor was performed in all cases.ASES score, Constant-Murley score and Rowe score were used to evaluate the stability and the function of the shoulder. Results Patients' active forward elevation significantly(P=0.007) improved from 162.9°±17.1°preoperatively to 170.9°±7.4° at final follow-up. The external rotation was 56.0°±17.6° before the surgery compared with the 54.1°±17.1° postoperatively(P=0.511 ). The ASES score, Constant-Murley score and Rowe score was 84.7±11.3, 93.3±8.7 and 36.8±8.5 preoperatively compared with 96.0±3.4, 97.8±3.6 and 89.8±12.5 postoperatively. Significant difference could be found with regard to ASES score (P=0.000), ConstantMurley score (P=0.005) and Rowe score (P=0.000). One redislocation happened and a subluxation was noticed in three patients (8.3%). Conclusion Arthroscopic Remplissage combined with Bankart repair can achieve satisfactory for recurrent anterior shoulder dislocation accompany with engaging Hill-Sachs lesion.     

Modification of Bankart reconstruction with lateral capsulotomy and selective anatomic repair using suture anchors

Twenty consecutive patients (17 male, 3 female) with a diagnosis of traumatic recurrent anterior instability of the shoulder were treated by a modified Bankart procedure using suture anchors. The technique consists of vertical incision of the capsule, just medial to the lateral insertion on the humerus and anatomic repair of the Bankart lesion. Humeral-based capsular shifting was performed in patients with anterior-inferior instability. The average age was 24 years (range: 14 to 39 years), and average follow-up period 68 months (range: 2 to 8 years). The average Bankart rating score was 92.5 (range: 70 to 100); with 16 (80%) excellent (score 90 to 100), 2 (10%) good (score 75 to 89), and 2 (10%) fair results. Failure in terms of recurrent dislocation was not reported. Eleven patients (55%) had a loss of 5 degrees to 10 degrees of external rotation either with the extremity at the side or at 90 degrees of abduction. Nine (45%) patients had external rotation equal to the contralateral side. We believe selective anatomic Bankart reconstruction by lateral capsulotomy and humeral-based capsular shifting in cases with marked inferior laxity is a more anatomic and physiologic technique.     

Good clinical outcome of combined Bankart-Bristow procedure for recurrent shoulder instability: 126 patients followed for 2-6 years

126 patients (100 men) with recurrent anterior shoulder dislocation or subluxation with severe Bankart lesion were treated with a combined Bankart and modified Bristow procedure and reviewed for this study. The mean age at operation was 25 (14-69) years, and mean follow-up period 41 (24-75) months. Averages of the Rowe score, the Constant score and the ASES score at final follow-up were 90, 95 and 91 points, respectively. The clinical outcome was excellent in 97 patients (77%), good in 16 (13%) and fair in 13 (10%). 2 patients had resubluxation, while no patient had a complete redislocation. The average loss of range of motion of external rotation, as compared to the contralateral shoulder side was 13 degrees. 67 of 72 patients returned to sports. No major postoperative complications occurred. This procedure had an excellent clinical outcome in cases of recurrent anterior shoulder dislocation or subluxation.     

A modified Bristow-Helfet-May procedure for recurrent dislocation and subluxation of the shoulder. Report of two hundred and twelve cases

A modified Bristow-Helfet-May procedure was performed for recurrent dislocation or subluxation of the glenohumeral joint in 207 patients (212 shoulders), whose average age at the time of surgery was 20.3 years (range, fourteen to forty-seven years). The procedure was modified by directing the coracoid segment and conjoined tendon over the superior border rather than through the substance of the subscapularis tendon and muscle. The indications were either documented recurrent anterior dislocation of the glenohumeral joint or subluxation with instability as demonstrated on examination with the patient under anesthesia. The procedure was evaluated on the basis of the rate of recurrence of dislocation and subluxation, postoperative complications, the patients' subjective evaluation, and the effect of the procedure on the motion of the glenohumeral joint and the strength of the muscles of the shoulder as related to overhead throwing. Eight (3.8 per cent) of the shoulders redislocated and ten (4.7 per cent) had one or more subjective episodes of subluxation after the procedure. Complications included postoperative infection in two patients and problems with the screw that required its removal in ten. One hundred and thirty-one (62 per cent) of the patients responded to a questionnaire regarding their subjective evaluation of the results of surgery. Eleven (8 per cent) were unable to perform daily activities that involved overhead work, and forty-five (34 per cent) stated that they still had some degree of discomfort or pain in the shoulder. One hundred and twenty-six patients (96.2 per cent) stated that they were happy with the results of the surgery and would have the procedure again. Thirty patients had Cybex testing of the muscles of the shoulder. Only three (16 per cent) of the nineteen athletes whose dominant arm had been operated on returned to their pre-injury level of throwing. Data obtained with regard to changes in the range of motion and strength of the glenohumeral joint indicate that this loss of throwing ability was not due solely to a loss of glenohumeral motion. It appeared to be also related to a concomitant loss of strength at the extreme of external rotation of the humerus and the initiation of internal rotation of the humerus.     

关节镜下非打结型缝合锚钉修补Bankart损伤治疗复发陛肩关节前脱位

目的 探讨关节镜下非打结型缝合锚钉修补Bankan损伤治疗复发性肩关节前脱位的疗效.方法 复发性肩关节前脱位患者14例,均为男性;年龄18～34岁,平均25.2岁;左侧4例,右侧10例,涉及主力侧12例;均为单向不稳.术前脱位次数为3～36次,平均13.5次.关节镜下采用可吸收非打结型缝合锚钉治疗Bankart损伤.术前及术后随访采用ASES评分及Constant-Murley功能评估.结果 所有患者均获得随访,随访时间11～22个月,平均17个月.术中发现9例合并Hill-Sachs损伤,3例合并骨性Bankart损伤,2例合并后下盂唇损伤,2例合并SLAPⅡ型损伤,1例合并关节内游离体.14例患者术前及末次随访时肩关节平均前屈上举为163.4°±8.6°和169.7°±4.2°;外展90°时,平均外旋角度分别为58.5°+13.6°和90.3 °±5.5.;术后外展90°时,患侧外旋角度较健侧受限8.4°±6.2°术前及末次随访时ASES评分为(77.4±3.7)分和(94.3±2.6)分,两者比较差异有统计学意义(P＜0.05);其中VAS不稳定评分平均为(7.2±1.4)分和(1.2 ±0.6)分(P＜0.01);Constant-Mudey评分平均为(78.1±4.6)分和(93.9±3.7)分.术后无一例患者发生再脱位,且均重返伤前工作岗位.结论 肩关节镜下Bankart 重建手术是治疗复发性肩关节脱位的有效方法 .非打结型缝合锚钉简化了手术操作步骤,减少手术时间和创伤.     

Ruhigstellung in Außenrotation bei primärer Schulterluxation

INTRODUCTION: The standard method of treating acute primary dislocation of the glenohumeral joint is immobilization of the arm in adduction and internal rotation with a sling. The recurrence rate for anterior instability after nonoperative treatment in young active patients is extremely high (up to 90%) and well reported. A new method of immobilization with the arm in external rotation improves the position of the displaced labrum on the glenoid rim. With the use of control MRI before and after immobilization in external rotation, a study on this new repositioning of the labrum is evaluated. METHODS: Ten patients (mean age 30.4 years) with primary anterior dislocation of the shoulder and Bankart lesion as shown on MRI but with no hyperlaxity of the contralateral side were immobilized in 10-20 degrees of external rotation for 3 weeks. Scans with MRI were taken in internal and external shoulder rotation post trauma and in internal rotation after 6 weeks. All patients were reevaluated after 6 and 12 months. RESULTS: Dislocation and separation of the labrum were both significantly less with the arm in external rotation due to the tension of the anterior capsule and the tendon of the subscapularis muscle. In the MRI taken in internal rotation 6 weeks post trauma, all Bankart lesions were fixed in reposition after three weeks of immobilization in external rotation. At 12-month follow-up, the average Constant Score was 96.1 points (range 63-100), and the Rowe Score was 91.5 points (range 25-100). One patient had traumatic redislocation after 8 months. CONCLUSION: After primary shoulder dislocation, immobilizing the arm in 10-20 degrees external rotation provided stable fixation of the Bankart lesion in an anatomic position. First long-term indications from an ongoing prospective study of recurrence rates after immobilization in external rotation are promising.     

Comparison of glenohumeral mechanics following a capsular shift and anterior tightening

BACKGROUND: Numerous surgical techniques have been developed to treat glenohumeral instability. Anterior tightening procedures have been associated with secondary glenohumeral osteoarthritis, unlike the anterior-inferior capsular shift procedure, which has been widely advocated as a more anatomical repair. The objective of the present study was to quantify glenohumeral joint translations, articular contact, and resultant forces in cadaveric specimens in order to compare the effects of unidirectional anterior tightening with those of the anterior-inferior capsular shift. METHODS: Six normal fresh-frozen cadaveric shoulders were tested on a custom rig with use of a coordinate-measuring machine to obtain kinematic measurements and a six-axis load transducer to measure resultant external joint forces. Shoulders were tested in the scapular plane in three configurations (normal anatomical, anterior tightening, and anterior-inferior capsular shift) and in three humeral rotations (neutral, internal, and external). Glenohumeral articular surface geometry was quantified with use of stereophotogrammetry for kinematic and contact analyses. Resultant joint forces were computed on the basis of digitized coordinates of tendon insertions and origins. RESULTS: Compared with the controls (maximum elevation, 167 degrees 8 degrees ), the anteriorly tightened specimens demonstrated loss of external rotation, significantly restricted maximum elevation (135 degrees 16 degrees , p = 0.002), posterior-inferior humeral head subluxation, and significantly greater posteriorly directed resultant forces at higher elevations (p < 0.05). In contrast, compared with the controls, the specimens that had been treated with the anterior-inferior capsular shift demonstrated a similar maximum elevation (159 degrees +/- 11 degrees , p = 0.8) without any apparent loss of external rotation and with reduced humeral translation. CONCLUSIONS: Anterior tightening adversely affects joint mechanics by decreasing joint stability, limiting both external rotation and arm elevation, and requiring greater posterior joint forces to attain maximum elevation. The anterior-inferior capsular shift improves joint stability while preserving external rotation with no significant loss of maximum elevation.     

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.     

Extra-glenohumeral joint shoulder surgery in rheumatoid arthritis: The role of bursectomy, acromioplasty, and distal clavicle excision

Twenty-four painful shoulders in patients with rheumatoid arthritis have been studied before and after extra-glenohumeral joint surgery. Preoperative local anesthetic injections were used to localize sites of pain and served as a basis for the surgical procedure performed. Radiographs were graded with the Larsen classification; 17 shoulders had radiographic evidence of advanced glenohumeral disease. Surgery included subacromial bursectomy, anterior acromioplasty, and excision of the outer end of the clavicle. At an average follow-up of 30 months (range 18 to 50 months) for 22 of the shoulders, 19 had minimal pain. Average motions improved in flexion from 68° to 121° and in external rotation from 23° to 52°. Two experienced infections, one superficial and one deep. One further operation has been necessary to treat the shoulder arthritis. Extra-glenohumeral joint surgery, planned according to the results of preoperative injection testing, has a useful role in management of the shoulder in rheumatoid arthritis, even when the glenohumeral joint is involved radiographically.     

Arthroscopic repair of Bankart lesion in traumatic anterior-inferior shoulder instability using the two-portal method: A preliminary report

BackgroundIn this report, we describe our preliminary clinical results of arthroscopic Bankart repair in traumatic anterior-inferior shoulder instability using the two-portal method.MethodFrom August 2009 to December 2011, arthroscopic repair of Bankart lesion using this method was performed in 16 consecutive patients who were prospectively enrolled. Fifteen shoulders were treated with two-anchor sutures and one was treated with three-anchor sutures. Twelve patients received metallic anchor screws and four patients received bioanchor screws. The assessments were performed using the Rowe score, the University of California at Los Angeles shoulder rating scale, the American Shoulder and Elbow Surgeons score, and the shoulder range of motion (ROM) deficit.ResultsWith an average follow-up period of 22.9 months, all shoulder scores improved after surgery (p < 0.001). The average ROM deficit of the operated shoulders was not significant as compared with the healthy side in forward elevation (p > 0.05), but was significant in external rotation (p < 0.05). All of the 16 shoulders remained stable (100%) after the arthroscopic repair surgery. All patients returned to their preinjury levels of daily activity without recurrent problems.ConclusionIn patients with traumatic anterior glenohumeral instability, arthroscopic Bankart repair with the two portal method can provide good results. It can be an alternative method of treating patients with Bankart lesion without associated major glenoid defect or rotator cuff lesion in traumatic anterior-inferior instability.     

Recurrent anterior shoulder instability. Results of the glenoid based inferior capsular shift

A total of forty consecutive patients suffering from recurrent traumatic anterior shoulder instability underwent stabilisation with a glenoid based inferior capsular shift. The patients were followed up prospectively by an independent observer (JM) using the Constant-Murley score and objective evaluation of shoulder movement and strength with an isometric dynamometer. The mean follow-up period was 50 months (range, 2 to 6.8 years). Three patients (7.5%) suffered a repeat, high energy, traumatic dislocation following an early return to sports activities. "Cybex" testing documented a minimal average loss of external rotation movement (4.4 degrees) and strength (4.3%) with the arm in neutral, which was higher with the arm at 90 degrees of abduction (i.e., 13.7 degrees and 15.6%, respectively). The deficit in internal rotation strength was similarly lower in neutral position (2%), when compared to the deficit with the arm at 90 degrees of abduction (13.5%). There was no measurable loss of internal rotation motion. Our study supports the use of a glenoid based inferior capsular shift, as there is a low recurrence rate and minimal deficit in shoulder movement and strength.     

Recurrent anterior shoulder dislocation caused by a midsubstance complete capsular tear

BACKGROUND: A midsubstance complete capsular tear is one of the well-known causes of anterior glenohumeral instability. However, its prevalence and clinical picture have not been well elucidated. The purpose of this study was to examine the prevalence of isolated complete capsular tears and to assess the clinical features as well as the results of surgical treatment of recurrent anterior glenohumeral instability caused by such tears. METHODS: Three hundred and three shoulders underwent surgery to treat recurrent anterior glenohumeral instability at our institution during a five-year period. Twelve (4.0%) of these shoulders had an isolated complete capsular tear as the main pathological condition. Those twelve patients (nine male and three female) were the subjects of the present study. The average age at the time of the operation was twenty-five years. Patient age; the cause of the initial dislocation; the position of the arm at the initial dislocation; and the findings of the preoperative physical examination, of computed tomographic arthrography, and at surgery were assessed. Eleven patients underwent arthroscopic capsular repair, and one was treated with an open capsular repair. RESULTS: The twelve patients either did not have a Hill-Sachs lesion or had a chondral indentation-type of Hill-Sachs lesion. When assessed with arthrography, the Hill-Sachs lesions were small compared with those in shoulders with an isolated Bankart lesion and, interestingly, they were quite similar in size to those seen with humeral avulsion of the inferior glenohumeral ligament. The average Rowe score for the twelve patients improved from 30.4 points preoperatively to 90.4 points at an average of thirty-one months postoperatively. CONCLUSIONS: The prevalence of isolated complete capsular tears causing recurrent glenohumeral instability was 4.0% (twelve of 303). These tears were associated with either a small or no Hill-Sachs lesion. We believe that a complete capsular tear should be recognized as one of the essential lesions causing recurrent anterior shoulder dislocation. Arthroscopic examination and repair can provide effective treatment.