SHORT-TERM MRI EVALUATION OF CAPSULOLABRAL REPAIR IN ATHLETES WITH ANTERIOR GLENOHUMERAL INSTABILITY: CORRELATION WITH CLINICAL OUTCOMES

Scapular muscles weakness in subjects with traumatic anterior glenohumeral instability

Objectives The objective of this systematic review is to compare the effect of arthroscopic stabilization with open surgical stabilization for the management of traumatic anterior glenohumeral instability. We aim to address the following questions that are of clinical interest: 1. Is arthroscopic stabilization equally effective as open surgical stabilization in the management of anterior glenohumeral instability for: a. The general population? b. Population sub-groups? 2. Are there any differences in the outcome of various arthroscopic techniques (suture anchors, bioabsorbable tacks, transglenoid sutures and metallic fixators) for shoulder stabilization, compared with open surgical stabilization? 3. What factors and prognostic indicators are considered when deciding between arthroscopic versus open surgical stabilization for the management of anterior glenohumeral instability? Criteria for considering studies for this review Types of participants Patients with traumatic anterior glenohumeral instability, confirmed by one or more of the following: a history of trauma precipitating anterior dislocation/subluxation, radiological evidence, clinical examination, examination under anaesthesia (EUA) and arthroscopy will be included. By definition, traumatic anterior glenohumeral instability may include first-time dislocators as well as patients with recurrent dislocations, subluxation or a positive apprehension test. Patient groups that are specifically 40 years and older will be excluded from the study because of a higher rate of associated rotator cuff pathology within this age-group. Patients with multidirectional instability and any other concomitant shoulder pathology will also be excluded to eliminate potential confounding factors that could affect the outcome of the stabilization procedures for the management of traumatic anterior glenohumeral instability. Types of interventions Interventions will include all types of arthroscopic shoulder stabilization techniques such as suture anchors, bioabsorbable tacks, transglenoid sutures and metallic fixators, with or without additional suture plication of the capsule, compared with open surgical shoulder stabilization techniques, for the management of traumatic anterior glenohumeral instability. Studies that applied non-anatomical surgical procedures i.e. Putti-Platt, Bristow will be excluded because, they do not correct the underlying pathological lesion; they alter normal shoulder kinematics; have high complication rates and are infrequently performed in clinical practice today. Types of outcome measures A minimum follow-up period of 2 years will be TRUNCATED AT 350 WORDS

Anterior instability is a frequent complication following a traumatic glenohumeral dislocation. Frequently the underlying pathology associated with recurrent instability is a Bankart lesion. Surgical correction of Bankart lesions and other associated pathology is the key to successful treatment. Open surgical glenohumeral stabilisation has been advocated as the gold standard because of consistently low postoperative recurrent instability rates. However, arthroscopic glenohumeral stabilisation could challenge open surgical repair as the gold standard treatment for traumatic anterior glenohumeral instability. Primary evidence that compared the effectiveness of arthroscopic versus open surgical glenohumeral stabilisation was systematically collated regarding best-practice management for adults with traumatic anterior glenohumeral instability. A systematic search was performed using 14 databases: MEDLINE, Cumulative Index of Nursing and Allied Health (CINAHL), Allied and Complementary Medicine Database (AMED), ISI Web of Science, Expanded Academic ASAP, Proquest Medical Library, Evidence Based Medicine Reviews, Physiotherapy Evidence Database, TRIP Database, PubMed, ISI Current Contents Connect, Proquest Digital Dissertations, Open Archives Initiative Search Engine, Australian Digital Thesis Program. Studies published between January 1984 and December 2004 were included in this review. No language restrictions were applied. Eligible studies were those that compared the effectiveness of arthroscopic versus open surgical stabilisation for the management of traumatic anterior glenohumeral instability, which had more than 2 years of follow up and used recurrent instability and a functional shoulder questionnaire as primary outcomes. Studies that used non-anatomical open repair techniques, patient groups that were specifically 40 years or older, or had multidirectional instability or other concomitant shoulder pathology were excluded. Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion with an independent researcher. Studies were assessed for homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format; otherwise a meta-analysis was conducted. Eleven studies were included in the review. Two were randomised controlled trials. Evidence comparing arthroscopic and open surgical glenohumeral stabilisation was of poor to fair methodological quality. Hence, the results of primary studies should be interpreted with caution. Observed clinical heterogeneity in populations and outcomes was highlighted and should be considered when interpreting the meta-analysis. Authors also used variable definitions of recurrent instability and a variety of outcome measures, which made it difficult to synthesise results. When comparable data were pooled, there were no significant differences (P > 0.05) between the arthroscopic and open groups with respect to recurrent instability rates, Rowe score, glenohumeral external rotation range and complication rates. Statistically, it appears that both surgical techniques are equally effective in managing traumatic anterior glenohumeral instability. In light of the methodological quality of the included studies, it is not possible to validate arthoscopic stabilisation to match open surgical stabilisation as the gold standard treatment. Further research using multicentred randomised controlled trials with sufficient power and instability-specific questionnaires with sound psychometric properties is recommended to build on current evidence. The choice of treatment should be based on multiple factors between the clinician and the patient.

Background Anterior instability is a frequent complication following a traumatic glenohumeral dislocation. Frequently the underlying pathology associated with recurrent instability is a Bankart lesion. Surgical correction of Bankart lesions and other associated pathology is the key to successful treatment. Open surgical glenohumeral stabilisation has been advocated as the gold standard because of consistently low postoperative recurrent instability rates. However, arthroscopic glenohumeral stabilisation could challenge open surgical repair as the gold standard treatment for traumatic anterior glenohumeral instability. Objectives Primary evidence that compared the effectiveness of arthroscopic versus open surgical glenohumeral stabilisation was systematically collated regarding best-practice management for adults with traumatic anterior glenohumeral instability. Search strategy A systematic search was performed using 14 databases: MEDLINE, Cumulative Index of Nursing and Allied Health (CINAHL), Allied and Complementary Medicine Database (AMED), ISI Web of Science, Expanded Academic ASAP, Proquest Medical Library, Evidence Based Medicine Reviews, Physiotherapy Evidence Database, TRIP Database, PubMed, ISI Current Contents Connect, Proquest Digital Dissertations, Open Archives Initiative Search Engine, Australian Digital Thesis Program. Studies published between January 1984 and December 2004 were included in this review. No language restrictions were applied. Selection criteria Eligible studies were those that compared the effectiveness of arthroscopic versus open surgical stabilisation for the management of traumatic anterior glenohumeral instability, which had more than 2 years of follow up and used recurrent instability and a functional shoulder questionnaire as primary outcomes. Studies that used non-anatomical open repair techniques, patient groups that were specifically 40 years or older, or had multidirectional instability or other concomitant shoulder pathology were excluded. Data collection and analysis Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion with an independent researcher. Studies were assessed for homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format; otherwise a meta-analysis was conducted. Results Eleven studies were included in the review. Two were randomised controlled trials. Evidence comparing arthroscopic and open surgical glenohumeral stabilisation was of poor to fair methodological quality. Hence, the results of primary studies should be interpreted with caution. Observed clinical heterogeneity in populations and outcomes was highlighted and should be considered when interpreting the meta-analysis. Authors also used variable definitions of recurrent instability and a variety of outcome measures, which made it difficult to synthesise results. When comparable data were pooled, there were no significant differences (P > 0.05) between the arthroscopic and open groups with respect to recurrent instability rates, Rowe score, glenohumeral external rotation range and complication rates. Conclusions Statistically, it appears that both surgical techniques are equally effective in managing traumatic anterior glenohumeral instability. In light of the methodological quality of the included studies, it is not possible to validate arthoscopic stabilisation to match open surgical stabilisation as the gold standard treatment. Further research using multicentred randomised controlled trials with sufficient power and instability-specific questionnaires with sound psychometric properties is recommended to build on current evidence. The choice of treatment should be based on multiple factors between the clinician and the patient.

Background Anterior instability is a frequent complication following a traumatic glenohumeral dislocation. Frequently the underlying pathology associated with recurrent instability is a Bankart lesion. Surgical correction of Bankart lesions and other associated pathology is the key to successful treatment. Open surgical glenohumeral stabilisation has been advocated as the gold standard because of consistently low postoperative recurrent instability rates. However, arthroscopic glenohumeral stabilisation could challenge open surgical repair as the gold standard treatment for traumatic anterior glenohumeral instability. Objectives Primary evidence that compared the effectiveness of arthroscopic versus open surgical glenohumeral stabilisation was systematically collated regarding best-practice management for adults with traumatic anterior glenohumeral instability. Search strategy A systematic search was performed using 14 databases: MEDLINE, Cumulative Index of Nursing and Allied Health (CINAHL), Allied and Complementary Medicine Database (AMED), ISI Web of Science, Expanded Academic ASAP, Proquest Medical Library, Evidence Based Medicine Reviews, Physiotherapy Evidence Database, TRIP Database, PubMed, ISI Current Contents Connect, Proquest Digital Dissertations, Open Archives Initiative Search Engine, Australian Digital Thesis Program. Studies published between January 1984 and December 2004 were included in this review. No language restrictions were applied. Selection criteria Eligible studies were those that compared the effectiveness of arthroscopic versus open surgical stabilisation for the management of traumatic anterior glenohumeral instability, which had more than 2 years of follow up and used recurrent instability and a functional shoulder questionnaire as primary outcomes. Studies that used non-anatomical open repair techniques, patient groups that were specifically 40 years or older, or had multidirectional instability or other concomitant shoulder pathology were excluded. Data collection and analysis Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion with an independent researcher. Studies were assessed for homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format; otherwise a meta-analysis was conducted. Results Eleven studies were included in the review. Two were randomised controlled trials. Evidence comparing arthroscopic and open surgical glenohumeral stabilisation was of poor to fair methodological quality. Hence, the results of primary studies should be interpreted with caution. Observed clinical heterogeneity in populations and outcomes was highlighted and should be considered when interpreting the meta-analysis. Authors also used variable definitions of recurrent instability and a variety of outcome measures, which made it difficult to synthesise results. When comparable data were pooled, there were no significant differences (P > 0.05) between the arthroscopic and open groups with respect to recurrent instability rates, Rowe score, glenohumeral external rotation range and complication rates. Conclusions Statistically, it appears that both surgical techniques are equally effective in managing traumatic anterior glenohumeral instability. In light of the methodological quality of the included studies, it is not possible to validate arthoscopic stabilisation to match open surgical stabilisation as the gold standard treatment. Further research using multicentred randomised controlled trials with sufficient power and instability-specific questionnaires with sound psychometric properties is recommended to build on current evidence. The choice of treatment should be based on multiple factors between the clinician and the patient.

Background:Descriptive parameters for the evaluation of the labrum’s appearance on magnetic resonance imaging (MRI) after capsulolabral repair are not well established.Purpose:To assess the morphology and structural appearance of the postoperative glenoid labrum on MRI in athletic patients with anterior glenohumeral instability.Study Design:Case series; Level of evidence, 4.Methods:This prospective study examined MRI scans of the involved shoulder in a population of 27 athletic patients with traumatic anterior instability before arthroscopic capsulolabral repair and at 3 and 6 months after surgery. The morphology, axial height, coronal height, axial angle, coronal angle, integrity, and homogeneity of repaired capsulolabral tissue were evaluated. The labrum was considered healed if it was integrated or intact (ie, if there was no discontinuity between the labrum and the glenoid). For each of these variables, a comparison was made between the MRI scans preoperatively and at 3 and 6 months after surgery to verify significant differences in these measures. Linear and logistic regression models were built to verify the associations between exposure variables and outcome variables. For all analyses, a significance level of .05 was used.Results:Each continuous outcome variable (ie, morphology, angle, and height) showed statistically significant differences across the 3 different MRI time points, indicating that we observed an increase in height and angle as well as an improvement in morphology throughout the follow-up period. Integrity was not significantly different on MRI between 3 and 6 months. Homogeneity was not significantly different between preoperative and 3-month MRI but significantly differed between preoperatively and 6 months postoperatively. The difference between postoperative and preoperative coronal height (increase in height) was associated with the occurrence of multiple dislocation episodes. Advanced age or multiple dislocations reduced the improvement in morphology. At 6 months, the integrity of the labrum on MRI was observed in all patients; however, 17 patients (63%) still had a heterogeneous labrum. Patients who underwent surgery within 90 days or those with a first dislocation episode had better integrity and homogeneity of labral tissue.Conclusion:There were statistically significant differences in the morphology, height, and angle of the labrum between the preoperative and postoperative periods in patients who underwent arthroscopic repair for glenohumeral instability. Although a 6-month MRI revealed labral integrity in all the athletes, 63% still had heterogeneous labral tissue.

Arthroscopic posteroinferior capsular plication and rotator interval closure after Bankart repair in patients with traumatic anterior glenohumeral instability—A minimum follow-up of 5 years

Magnetic resonance imaging evaluation of the inferior glenohumeral ligament: Non-arthrographic imaging in abduction and external rotation

The aim of this systematic review is to analyze outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with traumatic anterior glenohumeral instability. A secondary aim is to establish in clinical settings which percentage of glenoid or humeral bone loss needs to be treated with a bony procedure to avoid recurrence of dislocation. A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using various combinations of the keywords "shoulder", "instability", "dislocation", "bone loss", "bony bankart", "osseous glenoid defects", "glenoid bone grafting", "Latarjet", "glenoid", "humeral head", "surgery", "glenohumeral", "Hill Sachs", "Remplissage", over the years 1966-2012 was performed. Twenty-seven articles, describing patients with glenoid bony defect, humeral bony defect or both in the setting of traumatic anterior glenohumeral instability, were included. A total of 1,816 shoulders in 1,801 patients were included, with a median age at surgery of 27.1 years, ranging from 12 to 75 years. Patients were assessed at a median follow-up period of 2.8 years (ranging from 6 months to 28.2 years). The overall recurrence of redislocation occurred in 117 (6.5 %) shoulders. The redislocation event occurred in 40 of 553 (7.2 %) shoulders with glenoid bony defect, in 30 of 225 (13.3 %) shoulders with humeral bony defect and in 63 of 1,009 (6.3 %) shoulders with both glenoid and humeral involvement. Even though the general principle of recognizing and treating glenoid and humeral bone defects in patients with traumatic anterior glenohumeral instability is widely accepted, few studies are available to date to accurately establish which bone defects should be treated with bone procedures and the exact percentage of bone loss leading to higher risk of redislocation in clinical settings.

Background: In patients with traumatic anterior shoulder instability, a large Hill-Sachs lesion is a risk factor for postoperative recurrence. However, there is no consensus regarding the occurrence and enlargement of Hill-Sachs lesions. Purpose: To investigate the influence of the number of dislocations and subluxations on the prevalence and size of Hill-Sachs lesions evaluated by computed tomography (CT) with 3-dimensional reconstruction. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The prevalence and size of Hill-Sachs lesions were evaluated preoperatively by CT in 142 shoulders (30 with primary instability and 112 with recurrent instability) before arthroscopic Bankart repair. First, the prevalence of Hill-Sachs lesions was compared with the arthroscopic findings. Then, the size of Hill-Sachs lesions confirmed by arthroscopy was remeasured using the previous CT data. In addition, the relationship of Hill-Sachs lesions with the number of dislocations and subluxations was investigated. Results: Hill-Sachs lesions were detected in 90 shoulders by initial CT evaluation and were found in 118 shoulders at arthroscopy. The Hill-Sachs lesions missed by initial CT were 15 chondral lesions and 13 osseous lesions. However, all 103 osseous Hill-Sachs lesions were detected by reviewing the CT data. In patients with primary subluxation, the prevalence of Hill-Sachs lesions was 26.7%, and the mean length, width, and depth of the lesions (calculated as a percentage of the diameter of the humeral head) were 9.0%, 5.3%, and 2.1%, respectively, while the corresponding numbers for primary dislocation were 73.3%, 27.7%, 14.8%, and 7.0%, all showing statistically significant differences. Among all 142 shoulders, the corresponding numbers were, respectively, 56.3%, 20.7%, 11.2%, and 4.8% in patients who had subluxations but never a dislocation; 83.3%, 33.4%, 19.1%, and 7.6% in patients with 1 episode of dislocation; and 87.5%, 46.8%, 22.2%, and 10.2% in patients with ≥2 episodes, all showing statistically significant differences. There were no differences in lesion measurements in relation to the number of subluxations. Conclusion: Computed tomography is a useful imaging modality for evaluating Hill-Sachs lesions except for purely cartilaginous lesions. Hill-Sachs lesions were more frequent and larger when the primary episode was dislocation than when it was subluxation. Among patients with recurrent episodes of complete dislocation, the prevalence of Hill-Sachs lesions is increased, and the lesions are larger.

Open Operative Treatment for Anterior Shoulder Instability: When and Why?

Background:Bone defects of the glenoid are often found in patients with traumatic anterior glenohumeral instability. There is no consensus regarding which glenoid defects need to be treated surgically. The aim of this review is to describe the management of glenoid defects in anterior shoulder instability in patients with traumatic anterior glenohumeral instability.Methods:We conducted a review of the literature through a Pubmed search.Results:The management of glenoid defects in anterior shoulder instability consists of conservative or operative treatment. There is a wide variety in the treatment options. Also, the diagnostics of the presence and size of a glenoid bone defect is still debated on in literature.Conclusion:Based on the current available literature, we advise to begin management of traumatic anterior shoulder instability combined with glenoid defects with conservative treatment. Operative treatment can be used when the bone fragment consists of a large glenoid surface and the patient is active, or in the case of a chronic defect or recurrent instability.

Glenohumeral instability is a common problem in the athletic population. Instability can range from microinstability to dislocation and the mechanism of injury often varies between sports. Collision athletes are often subjected to isolated traumatic events resulting in the humeral head being displaced either anteriorly or posteriorly with resultant instability. In contrast, throwing athletes can develop instability resulting from repetitive ‘microtrauma’ to the labrum and capsule. Management decisions for the athlete with shoulder instability must take into consideration their age, hand dominance, sport, position, level of activity, timing of season, expectations, and recovery timetable [1]. The sizable loads transferred to shoulders in collision athletes result in an incidence of traumatic shoulder instability double that of the general population, and make this a significant problem in sports medicine [2]. Also, the risk of recurrence after anterior shoulder dislocation is higher in young, active patients, and approaches 90–95 % in patients younger than 20 years [3]. For these reasons, special consideration must be given to treating the collision athlete with shoulder instability. This chapter will discuss the management of shoulder instability in collision athletes with a focus on evaluation, indications, techniques, outcomes, and current evidence on this topic. Evaluation of all types of shoulder instability will be covered in this chapter, however management will focus on traumatic anterior glenohumeral instability as this is most common among collision athletes. Management of posterior instability will be covered in different chapter.

Bankart repair in traumatic anterior shoulder instability: Open versus arthroscopic technique

Between 1976 and 1985, we repaired avulsion of the glenohumeral ligaments in sixty-three shoulders (sixty-one patients) that had traumatic anterior glenohumeral instability. We describe the indications for operation, the operative technique, and the findings at the time of operation. We located thirty-seven patients (thirty-nine shoulders) for clinical follow-up (average, 5.49 years). One patient had recurrent anterior dislocation four years postoperatively, but no patient needed reoperation. The average range of motion was 171 degrees of forward elevation and 84 degrees of external rotation in abduction. According to the criteria of Rowe et al., 97 per cent of the results were good or excellent.