Capsulolabral Lesions Research Articles

Consequences of a Perthes-Bankart lesion in twenty cadaver shoulders

This study investigated whether an anteroinferior capsulolabral lesion is sufficient to allow the humeral head to dislocate and whether a limited inferior approach for creating the lesions influenced the results compared with an all-arthroscopic approach. Four ligamentous zones of the glenohumeral capsule were sequentially detached from the glenoid neck and labrum in 20 cadaver shoulders through an inferior approach. Before and after each resection step, inferior stability was tested using a sulcus test and anterior stability using a drawer test and an apprehension maneuver. Dislocation was only possible when at least 3 zones were cut. This study confirmed that superior and posterior extension of the classic anteroinferior Perthes-Bankart lesion is necessary before the capsular restraint in external rotation and abduction is overcome and dislocation occurs. Lesions other than the Perthes-Bankart need to be investigated when recurrent dislocation is treated, because this anteroinferior injury is most probably not the sole factor responsible for the instability.

전방 급성 견열손상 후 발생한 변형된 SLAP Ⅱ손상과 전방 관절순 파열 -증례 보고 1 례-

Superior labrum anterior to posterior (SLAP) lesions of the shoulder has recently been a popular issue to shoulder surgeons. Now we are correlating many shoulder symptoms to this SLAP lesion. A 45 year-old female patient injured her shoulder when her arm sleeve was entrapped in moving automobile door. A forceful pull of the arm in external and abduction position was suspected. She complained continuous shoulder pain with limited range of motion for 2 months. Magnetic resonance image showed possible SLAP lesion but no definite diagnosis were made prior to the operation. Arthroscopic evaluation revealed SLAP type Ⅱ lesion with concomitant avulsion of the superior glenoid cartilage. In addition anterior labrocapsular tear was seen from 7 to 9 o`clock of anterior glenoid. The SLAP lesion and the anterior capsulolabral lesion were repaired properly to the glenoid. We report a case of glenoid-cartilage avulsion type of SLAP Ⅱwith anterior labrocapsular lesion.

ARTHROSCOPIC ANTERIOR STABILIZATION OF THE SHOULDER

The purpose of this study was to evaluate prospectively the surgical outcomes of arthroscopic repair of anterior capsulolabral lesions with use of suture anchors in a large series of patients who were followed for two to six years. We evaluated the results of arthroscopic Bankart repair with use of suture anchors and nonabsorbable sutures in 167 patients with traumatic recurrent anterior instability of the shoulder. The mean age at the time of the operation was twenty-five years. Preoperatively and at the time of follow-up (at a mean of forty-four months), the patients were assessed with three objective outcome measurement tools (the Rowe score, the University of California at Los Angeles [UCLA] shoulder rating scale, and the American Shoulder and Elbow Surgeons [ASES] score) and two subjective measurement tools (pain and function visual analog scales). The recurrence rate, range of motion, and risk factors for postoperative recurrence were evaluated. All shoulder scores improved after surgery (p < 0.001). According to the Rowe scale, 130 patients (78%) had an excellent score; twenty-nine (17%), a good score; six (4%), a fair score; and two (1%), a poor score. Overall, the rate of postoperative recurrence of instability was 4% (one dislocation, two subluxations, and four positive results on the anterior apprehension test). Postoperative recurrence was related to an osseous defect of >30% of the entire glenoid circumference. In the patients with recurrent postoperative instability, the episodes were less frequent than they had been preoperatively and shoulder function was related to activity level. A revision arthroscopic Bankart repair stabilized three of the four shoulders in which it was performed. One hundred and fifty-two patients (91%) returned to >/=90% of their preinjury activity level. The mean loss of external rotation (and standard deviation) was 2.0 degrees +/- 4.0 degrees. We found that, in contrast to previous reports on the results of arthroscopic repair, arthroscopic capsulolabral repair with use of suture anchors can provide satisfactory outcomes in terms of recurrence rate, activity, and range of motion.

Intraarticular pathology of atraumatic shoulder dislocations. An arthroscopic study

According to the literature, atraumatic shoulder dislocations occur without or only minor trauma,self-reduction and no or little pain. Little is known about intraarticular pathology in this entity. It was the purpose of our study to evaluate such findings. During a 2-year period,226 patients had surgery for shoulder dislocation.28 patients met the criteria for atraumatic dislocation as above (group A). Patients with bony pathology or recurrent microtrauma were excluded. All had been treated with a rehabilitation program without success.28 consecutive patients with surgery after posttraumatic dislocation served as a control group (group B). At the beginning of the surgery,arthroscopy was performed in all patients and the intraarticular findings were recorded. For the capsulo-labral pathology,we determined 3 types: type I had capsular elongation or scarring and included so called "non-Bankart-lesions"; type II had classic "Bankart"-lesions and type III more complex capsulo-labral lesions like e.g. "ALSPA"-lesions. The mean age in group A was 27.6 y and 26.2 y in group B.12 patients in group A and 5 in group B were female. The average no.of dislocations was 10 (1-30) or 9 (1-28), respectively. In group A we saw type I lesions in 11 patients (39.3%), type II lesions in 9 (32.1%) and type III lesions in 8 (28.6%) patients. In group B we found type I lesions in 8 (28.6%), type II lesions in 4 (14.3%) and type III lesions in 16 (57.1%) patients.Hill-Sachs lesions were found in 22 (78.6%) and 23 (82.1%) of the patients, respectively.Also, we saw chondral glenoid damage, cuff lesions and SLAP-lesions in both groups. The above mentioned criteria for atraumatic shoulder dislocation do not exclude intraarticular pathology comparable to posttraumatic cases, at least for patients, who do not respond to a conservative treatment. Besides the etiology, the given pathology must be considered for therapy.

A novel cadaveric model for anterior-inferior shoulder dislocation using forcible apprehension positioning.

A novel cadaveric model for anterior-inferior shoulder dislocation using forcible apprehension positioning is presented. This model simulates an in vivo mechanism and yields capsulolabral lesions. The scapulae of 14 cadaveric entire upper limbs (82 +/- 9 years, mean +/- standard deviation) were each rigidly fixed to a custom shoulder-testing device. A pneumatic system was used with pulleys and cables to simulate the rotator cuff and the deltoid muscles (anterior and middle portions). The glenohumeral joint was then positioned in the apprehension position of abduction, external rotation, and horizontal abduction. A 6-degree-of-freedom load cell (Assurance Technologies, Garner, North Carolina) measured the joint reaction force that was then resolved into three orthogonal components of compression force, anteriorly directed force, and superiorly directed force. With the use of a thrust bearing, the humerus was moved along a rail with a servomotor-controlled system at 50 mm/s that resulted in horizontal abduction. Force that developed passively in the pectoralis major muscle was recorded with an independent uniaxial load cell. Each of the glenohumeral joints dislocated anterior-inferior, six with avulsion of the capsulolabrum from the anterior-inferior glenoid bone and eight with capsulolabral stretching. Pectoralis major muscle force as well as the joint reaction force increased with horizontal abduction until dislocation. At dislocation, the magnitude of the pectoralis major muscle force, 609.6 N +/- 65.2 N was similar to the compression force, 569.6 N +/- 37.8 N. A cadaveric model yielded an anterior dislocation with a mechanism of forcible apprehension positioning when the appropriate shoulder muscles were simulated and a passive pectoralis major muscle was included. Capsulolabral lesions resulted, similar to those observed in vivo.

Classification of glenohumeral joint instability.

Shoulder instabilities have been classified according to the etiology, the direction of instability, or on combinations thereof. The current authors describe a classification system, which distinguishes between static instabilities, dynamic instabilities, and voluntary dislocation. Static instabilities are defined by the absence of classic symptoms of instability and are associated with rotator cuff or degenerative joint disease. The diagnosis is radiologic, not clinical. Dynamic instabilities are initiated by a trauma and may be associated with capsulolabral lesions, defined glenoid rim lesions, or with hyperlaxity. They may be unidirectional or multidirectional. Voluntary dislocation is classified separately because dislocations do not occur inadvertently but under voluntary control of the patient.

A dynamic analysis of glenohumeral motion after simulated capsulolabral injury. A cadaver model.

We used a dynamic shoulder-testing apparatus and nine fresh-frozen, entire upper extremities from cadavera to evaluate the effects of varying degrees of capsulolabral injury on the kinematics of the glenohumeral joint during abduction in the scapular plane and external rotation. Joint kinematics were recorded with use of a six-degrees-of-freedom magnetic tracking device before and after the creation of each capsulolabral lesion in a progressive manner. Dislocation did not occur after simulation of a large Bankart lesion or even after sectioning of the anterior aspect of the joint capsule. However, division of the entire joint capsule (that is, both the anterior aspect and the posterior aspect) resulted in a significant increase (p < 0.05) in posterior translation during abduction in the scapular plane, and two of the nine shoulders dislocated posteriorly. External rotation of the abducted extremity produced no increase in anterior or posterior translation.

Assessment of failed arthroscopic anterior labral repairs. Findings at open surgery.

To assess capsulolabral lesions present in patients after unsuccessful arthroscopic procedures, we reviewed the records of 20 patients who had undergone open shoulder procedures after unsuccessful arthroscopic Bankart procedures for chronic shoulder instability. The Bankart lesion had initially been repaired arthroscopically by transglenoid sutures (N = 10), bioabsorbable tacks (N = 7), suture anchors (N = 2), or arthroscopic screws (N = 1). Five of the 20 patients (25%) had reinjuries to the shoulder after the arthroscopic procedure. The average time from the arthroscopic to the open procedure was 17.9 months. Overall, 12 of the 20 patients (60%) had healed Bankart lesions at the time of open surgery. Eight of the 20 patients (40%) were found to have persistent Bankart lesions, and 15 of the 20 patients (75%) were found to have redundant anterior capsules. The presence of a persistent Bankart lesion significantly correlated with postarthroscopic dislocation, and the presence of capsular laxity significantly correlated with postarthroscopic subluxation. We concluded that capsular laxity is difficult to quantify arthroscopically and is present in a significant percentage of patients with chronic traumatic shoulder instability. Failure to successfully treat either the Bankart lesion or capsular laxity at the time of an arthroscopic Bankart procedure may lead to postoperative instability.

Magnetic resonance imaging evaluation of capsulolabral tears after traumatic primary anterior shoulder dislocation: A prospective comparison with arthroscopy of 25 cases

The purpose of our study was to evaluate the use of static magnetic resonance imaging (MRI) as a preoperative diagnostic tool in young patients with a traumatic primary anterior shoulder dislocation. Twenty-five patients who had acute primary traumatic anterior shoulder dislocation were examined with MRI and arthroscopy. The patients (18 male and 7 female) were between 16 and 39 years old (mean age, 27 years). They had no previous shoulder dislocations. The dislocations were confirmed radiographically. Examination with MRI and arthroscopy was performed within 10 days after the trauma. The MRI evaluation was performed before the arthroscopic examination, and the images were interpreted by an experienced magnetic resonance radiologist. No information from the MRI examination was available to the orthopedic surgeons before arthroscopy. The standard of reference for comparison was arthroscopy. Subacute MRI evaluation identified 15 labral tears, 12 Hill-Sachs lesions, 1 total rotator cuff lesion, 1 partial joint side rotator cuff lesion, and 1 partial rupture of the biceps tendon. Arthroscopic examination revealed 22 labral tears, 15 Hill-Sachs lesions, 1 total rotator cuff lesion, 1 partial joint side rotator cuff tear, 1 partial rupture of the biceps tendon, and 1 osseous Bankart lesion. Anterior capsulolabral tears and Hill-Sachs lesions appeared with a high incidence after acute anterior primary shoulder dislocation. Conventional MRI was only moderately reliable in the preoperative evaluation of labral tears and Hill-Sachs lesions, and it failed to give an accurate, differentiated preoperative diagnosis of the capsulolabral lesions.

Möglichkeiten der CT-Arthrographie in der Diagnostik von Schulterinstabilitäten

In the course of a prospective study, CT arthrography was carried out on 40 patients with shoulder instability. In 35 of these patients a lesion of the capsule and labrum was demonstrated, indicating glenohumeral instability; in three patients this was shown primarily by CT arthrography. In three patients, multidirectional instability was demonstrated. In four patients there was an isolated lesion of the labrum, whereas in one patient all the findings were normal. Compared with the capsulo-labral lesions, bone changes involving the head of the humerus and the glenoid were of lesser importance, although their severity affected the choice of operative treatment in four patients. Fifteen of the 40 patients have undergone surgery so far and in all cases the findings on CT arthrography could be confirmed.