Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Instability of the Shoulder

Abstract

Historically, much of the literature on glenohumeral instability has concerned recurrent locked anterior glenohumeral dislocation. As the standard objective of operative intervention was the elimination of such a dislocation, many operations yielded a high proportion of successful results. However, increased attention to the special needs of active, athletic individuals has led to a higher standard for the success of operative reconstruction: the maintenance of full motion and strength in addition to the restoration of stability. Modern repair procedures avoid overtightening and emphasize restoration of the integrity of the capsular-ligamentous-labral complex. Although there is controversy as to whether an operation for unidirectional anterior instability should include a capsulorrhaphy in addition to repair of a Bankart lesion, most investigators agree that no more than a minor capsular tightening, with no procedure on bone, is needed for this most common type of shoulder instability60,75,88,100. The situation is understandably more complex in the small number of patients in whom the instability of the shoulder is associated with more severe anatomical distortions. The recognition that symptomatic glenohumeral translations could occur in multiple directions in shoulders with global capsular laxity led to the development of more extensive capsular reconstructions. Furthermore, although capsular and ligamentous structures are usually the major sites of abnormality, in unusual instances severe loss of glenoid bone or a large humeral impression fracture may necessitate operative treatment. Little information is available to guide the clinician in the care of these difficult problems as reports in the literature and discussions at meetings have tended to focus on recurrent anterior glenohumeral instability, especially with regard to the choice between open and arthroscopic techniques. The purpose of the current paper was to review the evaluation and management of patients who have multidirectional instability, major loss of bone from …