Glenoid Rim Fractures Research Articles

Arthroscopic reduction and cannulated screw fixation of a large anterior glenoid rim fracture

Repair of displaced anterior glenoid rim fractures has been advocated4,8,12,17 to restore articular congruity, glenoid concavity, and glenohumeral stability. Large displaced anterior glenoid rim fragments have typically required open reduction and internal fixation2,10,13,14 using a deltopectoral approach and a subscapularis tendon split or tenotomy. Fracture exposure and visualization can be challenging, and subscapularis dysfunction can occur postoperatively.13

Arthroscopic Treatment for Posterior Shoulder Instability with a Glenoid Rim Fracture:a case report

Arthroscopic Treatment for Posterior Shoulder Instability with a Glenoid Rim Fracture:a case report

Bony Bankart is a positive predictive factor after primary shoulder dislocation

It would be a great advantage if it were possible to categorise the patients with first time dislocations to an initial treatment with the most beneficial outcome. MRI could be a useful method for finding lesions after shoulder dislocation. Fifty-eight patients with traumatic anterior shoulder dislocation were treated by closed reduction and were examined by MRI after a maximum of 2weeks. The hemarthrosis or effusion present in the joint after the primary dislocation could be used as a contrast for arthrography to identify the lesions present on MRI. At follow-up more than 8years later, the MRI findings were compared to the shoulder function, shoulder stability, Rowe score and Western Ontario Shoulder Instability Index (WOSI). Besides the age of the patient being above 30, the MRI findings analysed showed that an isolated fracture of the major tubercle, as well as a bony Bankart lesion are prognostic factors for a good functional result and a stable shoulder after a primary dislocation. The glenoid rim fracture was only detected on plain radiographs in 6 out of 10 findings on MRI. MRI findings of a gleniod rim fracture, equal to a bony Bankart lesion, were found to be a prognostic factor for stability and a good functional outcome.

Iliac bone-block autograft for posterior shoulder instability

Posterior shoulder instability is a rare condition, representing only 4% of all shoulder-joint instabilities. Numerous surgical techniques are used to treat it when conservative functional treatment proves to be insufficient. This retrospective study relates to 8 patients, presenting recurrent posterior shoulder instability, all treated with a posterior iliac bone-block procedure. The results were assessed both clinically and with contemporary imaging techniques. A unique identical surgical technique was used in all these cases including a posterior deltoid head detachment, an infraspinatus muscle dissociation and a bone-block positioning intended to extend and enlarge the glenoid cavity rather than to act as an actual block. Seven of these 8 cases were posttraumatic (including 2 with a concomitant congenital hyperlaxity past history) and the non-traumatic 1 was secondary to an epileptic seizure episode. All the patients had a typical posterior shoulder instability clinical presentation in the form of recurrent true dislocation incidents. In 6 cases, imaging revealed lesions of the humeral head or the glenoid cavity. These lesions were displacement-related anterior impaction defects of the humeral head (McLaughlin lesion) and/or a fracture (or erosion) of the posterior glenoid rim. Mean postoperative follow-up was 34 months. No cases of postoperative suprascapular nerve deficit were observed. All patients recovered normal joint range of motion in abduction and anterior elevation; in 3 patients, however, external rotation ended up being limited by an average 20 compared to the opposite side. The mean Constant score was 96.25 points and the mean Duplay score 90. Only 4 patients were able to return to their preoperative sports activity level. Three required an additional procedure, 2 for hardware removal and 1 for posterior deltoid repair, which all lead to an uneventful evolution. Imaging at follow-up (X-ray or CT) did not show any instance of bone-block pseudoarthrosis or osteolysis nor did it exhibit glenohumeral early degenerative changes. In all, at a mean 3 years' follow-up, the present series showed satisfactory results in 80% of cases. A literature review found comparable results for bone-block stabilization procedures. No recurrences of instability are reported with this technique, the main difficulty of which residing in the correct positioning of the bone-block. The stabilizing efficacy and low subsequent arthritic changes of the iliac posterior bone-block graft procedure seem thus confirmed by these encouraging results. The iliac posterior shoulder bone-block is effective in managing instances of involuntary posterior shoulder instability. A review of the literature confirmed these satisfactory results in terms of non-recurrence, pain relief and function recovery with this technique; the main difficulties of this technique remains in the correct positioning of the bone-block and the proper orientation of the fixation screws.

Results of open reconstruction of anterior glenoid rim fractures following shoulder dislocation

The present study evaluates the clinical and radiological outcome following open reconstruction of avulsion fractures of the anterior glenoid rim in traumatic shoulder dislocation. A total of 20 patients (mean age 49.4 years) were treated with open reduction and cannulated screw fixation. Eighteen patients were available for clinical and radiological follow-up after 3.1 (2.0-6.5) years. The average Constant Score was 78 and the average Rowe Score was 90 points. Documented complications were implant failure in one and neurological dysfunction in one patient. Radiographs revealed the bony fragment located in an unimproved displaced position in one patient and a progress in osteoarthritic changes in three patients. No recurrent subluxation or dislocation was observed. Open reconstruction of glenoid rim fractures is a valuable procedure regarding medium-term subjective and objective outcome measures. Recurrent dislocation, glenoid defects and early onset of osteoarthritic degeneration can be avoided.

Glenoid Rim Fracture in Contact Athletes With Absorbable Suture Anchor Reconstruction

Absorbable suture anchors are widely used in arthroscopic shoulder reconstruction procedures and provide a good solution for stabilization in athletes. In our practice we identified a group of 3 patients who had participated in contact sports and in whom traumatic instability developed. Subluxation of the shoulder followed repair by use of absorbable suture anchors. Each patient had a new injury characterized by a glenoid rim fracture that was not amenable to further arthroscopic reconstruction and was revised by use of a modified Latarjet procedure. All patients successfully returned to contact sports. We conclude that resorption defects resulting from the use of absorbable anchors contribute to an increased risk of rim fracture.

Open screw fixation of large anterior glenoid rim fractures: mid- and long-term results in 29 patients

The aim of this retrospective study was to analyse the clinical, functional and radiographic outcomes of patients sustaining traumatic anterior dislocations of the shoulder in combination with large anterior glenoid rim fractures, treated by open reduction and internal screw fixation (ORIF). Twenty-nine patients with a mean follow-up of 6.5 years (2.5-12 years) were evaluated clinically using the Constant and DASH scores, radiographs in two planes and isokinetic muscle strength measurement (Biodex 3 PRO). Mean age was 41.6 years (17-68 years). There was no case of postoperative re-dislocation. Eight out of 29 patients (27.5%) underwent revision surgery to remove the screws. The mean age- and gender-adjusted Constant score was 93.3% (range 64-102%), and the mean DASH score was 10.1 points (range 0-71 points). On radiological examination, 6 patients had signs of osteoarthritis: Samilson type I (n = 3) and II (n = 3). Significant differences for maximal strength in external rotation and muscular endurance compared to the unaffected side were found (P < 0.035). Twenty-seven patients (93%) were satisfied or very satisfied with the result after surgery. ORIF seems to be a good treatment option in cases of large glenoid rim fractures to avoid re-dislocation in the mid-term. Prospective randomised studies are necessary to compare these findings with those after non-operative or arthroscopic treatment of these injuries.

Luxation récidivante antérieure de l’épaule et rupture de la coiffe des rotateurs : résultats du traitement chirurgical

Recurrent anterior dislocations associated with full thickness rotator cuff tear (RCT) carry a difficult therapeutic problem: should we treat instability and rotator cuff tear at the same time or only one of both pathologies? The goal of this study was to analyse a retrospective series of patients operated on to try to answer this question. Twenty-eight shoulders (27 patients) were operated on between 1988 and 2002. The mean age at first dislocation was 47 years (16-65), the average delay between first dislocation and operation was 6.1 years. Twenty-four shoulders presented with recurrent dislocations and four shoulders with recurrent subluxations; the average number of dislocations was 2.6 (1-20). Preoperatively, Hill-Sachs lesion was present in 96%, anterior glenoid rim fracture in 53.5% and glenohumeral osteoarthritis was observed in 37.5%. All the cases had full thickness rotator cuff tears: isolated supraspinatus in 43%,, Supra- plus infraspinatus in 35%, supraspinatus plus subscapularis in 4% and rupture of the three tendons in 18%. An isolated open stabilization with the technique of Trillat was performed in 19 cases when the cuff was not repairable or when the patient was not willing to accept rotator cuff (RC) repair (age and motivation); the mean age of the patients was 59.3 years in this group. Whereas an open anterior stabilization (Latarjet procedure) associated with RC repair was done in nine cases (average age at operation: 40 years). All the patients were followed up and had clinical-radiographic examinations more than two years after the operation. With a mean follow-up of 73.5 months (24-178), the average Constant score progressed from 63.1 to 78.1 points (p<0.05). Three patients who had isolated anterior stabilization had recurrence of instability (16%) whereas none of the patients with both anterior stabilization and RC repair had recurrence. Subjectively, 96% of the patients were satisfied with their operation. Postoperatively, the rate of osteoarthritis progressed to 64.3%. The decision not to repair the RCT in 19 cases was justified by the size of the tear, the muscular fatty infiltration of the RC muscles and the age-motivation of the patients. This decision lead to a greater rate of recurrence (16%) and less satisfactory functional results but the age at FU was 20 years higher in this group than in the group with cuff repair. No patient had an isolated RC repair because 92.5% of the patients in this series had either a bony Bankart (53.5%) or a Bankart type lesion (39%). The recurrent instability in this series was clearly under the dependence of the "anterior mechanism" and not under the dependence of the "posterior mechanism". Therefore, isolated repair of the cuff has never been performed because of the fear of higher rate of postoperative instability leading to RC re-tear. In case of recurrent dislocations associated with rotator cuff tear, treatment of instability should be proposed whereas the concomitant repair of the cuff depends upon the possibility to perform it: size of the rupture, fatty infiltration, age and motivation of the patients.

Prevalence, Pattern, and Spectrum of Glenoid Bone Loss in Anterior Shoulder Dislocation: CT Analysis of 218 Patients

The purpose of our study was to determine the prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation, to relate this to the frequency of dislocation, and to test the appropriateness of the measurement method. Two hundred eighteen patients with single or recurrent anterior shoulder dislocation underwent shoulder CT examination. Fifteen patients had bilateral dislocation. Prevalence and severity of glenoid bone loss and glenoid fracture were assessed. CT examinations of 56 control subjects without shoulder dislocation were evaluated for glenoid contour and side-to-side variation in glenoid width. Glenoid bone loss was present in 27 (41%) of 66 patients with first-time unilateral dislocation and 118 (86%) of 137 patients with recurrent unilateral dislocation. Glenoid bone loss ranged from -0.3% to -33% (mean, -10.8% +/- 7.9%). Seventy-four (51%) of 145 patients had < or = 10% glenoid bone loss, 54 (37%) had between 10% and 20%, eight (6%) had between 20% and 25% glenoid bone loss, and nine (6%) had > or = 25% glenoid bone loss. Glenoid rim fractures were present in 49 (21%) of 233 dislocated shoulders. The number of dislocations correlated moderately with the severity of glenoid bone loss (r = 0.56). The normal side-to-side glenoid width variation was small (0.46 +/- 0.81 mm). Glenoid bone loss is common in anterior shoulder dislocation. It is probably multifactorial in origin, is usually mild in degree, and has a maximum observed severity of -33%. Dislocation frequency cannot accurately predict the degree of bone loss.

The J-Bone Graft for Anatomical Glenoid Reconstruction in Recurrent Posttraumatic Anterior Shoulder Dislocation

Background Posttraumatic shoulder dislocations with glenoid rim fractures show high rates of dislocation recurrence. For glenoid rim defects exceeding a certain size, several investigators recommend bone grafting. Few reports on anatomical glenoid reconstruction addressing this problem are published. Hypothesis Anatomical glenoid reconstruction by the J-bone graft creates permanent joint stability without a clinically relevant loss of motion. Study Design Case series; Level of evidence, 4. Methods Forty-seven shoulders with glenoid rim fractures after recurrent anterior dislocation were stabilized by a J-bone graft. For clinical outcome, motion and strength compared with the uninjured shoulder, as well as sports activity, were recorded. The Rowe score and the Constant-Murley score were used for scoring. In cases of follow-up exceeding 6 years, computed tomography scans were obtained and compared to preoperative radiographs. Results The mean Rowe score was 94.3 for the affected shoulder and 96.8 for the uninjured side. The Constant score reached 93.5 and 95 points, respectively. Loss of external rotation was 4.36° in adduction and 3.19° at 90° of abduction. The computed tomography evaluation included 24 shoulders at a mean follow-up of 106.2 months. There were no recurrences of instability and 1 traumatic graft fracture. Of the 19 patients in whom arthropathy was present at follow-up, 11 had arthrosis before surgery. Conclusion The J-bone graft is capable of creating a stable shoulder joint without causing extensive loss of motion on the long term in patients with traumatic glenoid rim fractures after shoulder dislocation. In some patients, mild to moderate arthropathy develops despite anatomical glenoid reconstruction.

Non-operative treatment of large anterior glenoid rim fractures after traumatic anterior dislocation of the shoulder

The generally-accepted treatment for large, displaced fractures of the glenoid associated with traumatic anterior dislocation of the shoulder is operative repair. In this study, 14 consecutive patients with large (> 5 mm), displaced (> 2 mm) anteroinferior glenoid rim fractures were treated non-operatively if post-reduction radiographs showed a centred glenohumeral joint. After a mean follow-up of 5.6 years (2.8 to 8.4), the mean Constant score and subjective shoulder value were 98% (90% to 100%) and 97% (90% to 100%), respectively. There were no redislocations or subluxations, and the apprehension test was negative. All fragments healed with an average intra-articular step of 3.0 mm (0.5 to 11). No patient had symptoms of osteoarthritis, which was mild in two shoulders and moderate in one. Traumatic anterior dislocation of the shoulder, associated with a large displaced glenoid rim fracture can be successfully treated non-operatively, providing the glenohumeral joint is concentrically reduced on the anteroposterior radiograph.

Arthroscopic reconstruction of a complex glenoid rim fracture using suture anchors

The gold standard for the treatment of large displaced glenoid rim fractures has been open reduction and internal fixation using cannulated screws. With the advancement in arthroscopic techniques there has been a growing trend towards arthroscopic treatment of glenoid rim fractures. This report outlines the case of 39-year-old health men who sustained a complex multifragmented displaced glenoid rim fracture after a fall on the right shoulder. The injury was diagnosed by standard radiographs and 3D-CT. An arthroscopic reconstruction including closed reduction and internal fixation using suture anchors was performed. After a follow-up of 1 year the Constant Score was 94 points, the Rowe Score 100 points and the Western Ontario Shoulder Instability Index was 99.9 points. In the Simple Shoulder Test all questions were answered with “yes”. At the latest follow-up the patient was completely painfree and regained a full work activity level. On postoperative 3D-CT imaging the fracture was consolidated in an almost anatomic position with a nearly complete reconstruction of the inferior glenoid circle. In cases of displaced glenoid rim fractures closed reduction and arthroscopic reconstruction using suture anchors can lead to excellent clinical and radiological results.

Indirekte Reposition und Retention der Bankart-Fraktur in Außenrotation

The treatment of anterior glenoid rim fractures depends on the size of the fracture and the articular surface involved. The operative treatment is open or arthroscopic refixation. In cases with small fragments and a stable shoulder nonoperative treatment is recommended. In patients with a primary shoulder dislocation immobilization in external rotation has been showed to improve the position of the displaced labrum on the glenoid rim. However, whether external rotation can reduce displaced glenoid rim fractures is not known. With the use of CT the repositioning of a glenoid rim fracture in a single patient in external rotation is evaluated.A 26-year-old patient with an anterior glenoid rim fracture after a primary shoulder dislocation was referred to our shoulder service. After initial reduction a CT scan in internal and external rotation of the involved shoulder was performed. In the external rotation CT the glenoid rim fracture was reduced in anatomic position. The patient was immobilized in a 30 degrees external rotation brace for 4 weeks. Six weeks after trauma the internal rotation CT showed the fracture healed in the anatomic position. At the 1-year follow-up the Constant Score and the Rowe Score were 100 points each. In patients with anterior glenoid rim fractures immobilization of the shoulder in external rotation seems to allow a reduction of the fracture. A study with a large number of patients is under way to evaluate long-term results.

Arthroscopy-assisted percutaneous fixation of glenoid fossa fracture

We are reporting an interesting case of glenoid fracture in a 46-year-old male which was fixed with the help of arthroscopy. At present, anterior or posterior glenoid rim fractures and some greater tuberosity fractures are widely treated arthroscopically. We report the arthroscopically assisted fixation of a transverse articular glenoid fracture. Arthroscopic reduction and percutaneous fixation of glenoid fractures not only allows anatomic reduction with minimal surgical trauma but provides a valid diagnostic and treatment alternative for associated capsular, ligamentous, labral or tendon injuries as well as joint irrigation. The principle portals are discussed. We suggest fixation with cannulated screws for better stability of fracture fragments and advise K-wires for fractures that are comminuted and not amenable to cannulated screw fixation. However, arthroscopic fixation of shoulder fractures is associated with a learning curve depending on surgeon's experience in shoulder arthroscopy.

Schwerwiegende Komplikation nach perkutan-transaxillärer Verschraubung einer Glenoidfraktur

The common treatment for glenoid rim fractures has been open reduction and internal fixation by a deltopectoral approach. Minimally invasive procedures with percutaneous transaxillary manipulation have a high risk for neurovascular damage. In a single case we demonstrate the possible complications associated with percutaneous refixation of a glenoid rim fracture. A 34-year-old patient with an anterior glenoid rim fracture was referred to our shoulder service after percutaneous transaxillary fixation of the fracture of the glenoid. He presented a dislocated fracture with joint infection and damage of the axillary nerve and artery. During revision surgery, joint infection with Staphylococcus aureus, dislocation of the fracture, aneurysm of the axillary artery, and a lesion in continuity of the axillary nerve were diagnosed. The fragment was excised and the capsule reattached to the remaining glenoid rim. The aneurysm was resected with an end-to-end anastomosis. The outcome was a noninfected and stable shoulder with a limited range of motion. In patients with a glenoid rim fracture with more then 21% of the glenoid fossa involved, refixation of the fracture is recommended. Open reduction and internal fixation is the gold standard. In some cases arthroscopic repair is possible. Percutaneous transaxillary manipulation is not recommended.

Treatment of Glenoid Rim Fractures of the Scapula

Treatment of Glenoid Rim Fractures of the Scapula

Open reconstruction of anterior glenoid rim fractures.

The present study evaluates the clinical and radiological results of patients with anterior glenoid rim fractures treated with two different open surgical techniques depending on the size of the bony fragment. In patients with displaced glenoid rim fractures involving less than 25% of the glenoid surface (Type I, II and IIIA fractures) suture anchor repair was performed. Patients with a bony defect involving more than 25% of the glenoid surface (Type IIIB fractures) underwent open reduction and internal fixation using cannulated screws. After a mean follow-up of 22 months, 15 patients (mean age 42.2 years) treated with suture anchor repair achieved an average Constant Score of 85.5 points (range 67.1-100) and an average Rowe Score of 94 points (range 70-100). In six patients the bony fragment was located in an unimproved medial position compared to the preoperative X-ray. In another six patients the fragment was consolidated medially to the level of the glenoid rim, and in three cases an anatomic situation was found. Patients treated with cannulated screws (ten cases, mean age 46.6 years) had a mean follow-up of 30 months and achieved a mean Constant Score of 81.9 points (range 61.7-96.1) and a mean Rowe Score of 90 points (range 70-100). Radiologically, the bony fragment was consolidated in an anatomic position in nine out of ten cases. Three patients suffered from screw impingement and one patient had screw loosening. No recurrent subluxations or dislocations were observed in either group. Three patients in group one and one patient in group two had glenohumeral osteoarthritic changes. In cases of small glenoid-rim fractures (Type I, II and IIIA fractures), suture anchor repair resulted in an excellent clinical outcome; however, the radiological results of chronic Type I fractures revealed in many cases a non-anatomical glenoidal reconstruction. For Type IIIB fractures with significant loss of glenoid concavity, open reduction and internal fixation with cannulated screws gave good clinical and radiological results; however the early complication rate was higher.

Arthrosonography of the Shoulder Joint for Evaluation of the Glenoid Labrum, Glenoid Rim and Humeral Head: Comparison with Conventional Ultrasonography and MR Arthrography

Purpose: To compare the diagnostic role of arthrosonography, conventional ultrasonography and MR arthrography in the assessment of glenoid labral tear, glenoid rim fracture and humeral head fracture of the shoulder joint. Materials and Methods: The findings of arthrosonography, conventional ultrasonography and MR arthrography were prospectively evaluated in 62 consecutive patients with chronic pain or a history of recurrent dislocation of the shoulder joint. The glenoid labrum was arbitrarily divided into four quadrants: anterosuperior, anteroinferior, posterosuperior, and posteroinferior, and for each, visibility at arthrosonography and conventional ultrasonography was subjectively scored as one of four grades. By means of statistical analysis, the two techniques were then compared. Twenty-six patients subsequently underwent arthroscopy, and the presence or absence of labral tear, glenoid rim fracture and humeral head fracture was determined. The sensitivity and specificity of each modality were separately calculated for each of the three types of shoulder joint injury, and observed differences in these findings were statistically analysed. Results: For all individual quadrants of the labrum, visibility at arthrosonography was higher than at conventional ultrasonography (p.05), though its specificity was significantly higher (p=.003). In this respect, there was no significant difference in sensitivity or specificity between arthrosonography and MR arthrography (p>.05). For the detection of glenoid rim and humeral head fracture, there were no statistical differences in sensitivity and specificity between the three imaging modalities (p> .05). Conclusion: Compared with conventional ultrasonography, arthrosonography provides higher visibility of the labrum, thus improving the capacity of ultrasonography to detect labral tear. Arthrosonography could therefore be useful in the diagnosis of labral tear, glenoid rim fracture and humeral head fracture, and may thus partially replace MR arthrography.

Arthroscopic approach to acute bony Bankart lesion

Purpose: To report on an arthroscopic approach to a bony Bankart lesion that uses a modified Bankart technique to fix the avulsed bone fragment to the healthy glenoid. Type of Study: Case series study. Methods: Of 250 patients who received surgical treatment for shoulder dislocation at our unit, 25 sport-practicing patients with acute traumatic dislocation of the shoulder and anterior glenoid rim fracture were included in this study. Inclusion criteria were bony Bankart lesions less than 3 months old and involving less than 25% of the glenoid, absence of associated lesions, and follow-up longer than 2 years. Arthroscopic procedures were performed using a modified Bankart technique to fix the avulsed bone fragment to the healthy glenoid rim using suture anchors. A modified Rowe score was devised for evaluating range of motion outcomes. Results: Shoulder function and stability were restored in 23 patients (92%) by 2 years after surgery. There was no recurrence of instability. Range of motion was minimally reduced. All patients resumed sports activities: 23 (92%) at the same level of performance as before surgery and 2 (8%) at a lower level because of 20° loss of external rotation. Conclusions: This arthroscopic technique seems to offer an optimal method for evaluating and treating isolated acute bony Bankart lesions involving less than 25% of the glenoid.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 7 (September), 2002: pp 764–769

Shoulder instability related to epileptic seizures

Epileptic seizures can cause shoulder dislocation and instability, but a characteristic pattern of instability and structural lesions is not well known. We reviewed 34 shoulders in 26 patients in whom the initial dislocation had been caused by an epileptic seizure. All patients were followed up clinically and radiologically for a mean of 10 years (range, 2-21 years) after initiation of treatment. Thirteen patients (17 shoulders) were treated for anterior instability. A large Hill-Sachs lesion was found 12 times and a large glenoid rim fracture 5 times. There were 12 recurrent and 2 locked dislocations. The recurrence rate after the first repair was 47% (8/17 shoulders). The final overall results at a mean follow-up of 10 years (range, 2-12 years) were good in 12 cases, satisfactory in 2, and unsatisfactory in 2. The reoperation rate was 40%. With skeletal reconstruction, 12 of 13 shoulders were stable at final follow-up. Another 13 patients (17 shoulders) were treated for posterior dislocation. A large reverse Hill-Sachs lesion was observed 13 times and a posterior glenoid rim fracture twice. There were 15 locked but only 2 recurrent dislocations. The recurrence rate after repair was 12% (2/17 shoulders). The final outcome at a mean follow-up of 7 years (range, 2-12 years) was good in 11 shoulders and satisfactory in 6. The reoperation rate was 12%. Anterior and posterior dislocations occurred with equal frequency in this series. Large bony lesions were the hallmark finding in this group of patients. Skeletal reconstruction was necessary to obtain clinical stability, especially in the more difficult-to-treat anterior instability. (J Shoulder Elbow Surg 2002;11:339-344)