Positive Apprehension Sign Research Articles

Results of Modified Latarjet Reconstruction in Patients With Anteroinferior Instability and Significant Bone Loss

The purpose of this study was to analyze the results of the modified Latarjet procedure for shoulder instability associated with an inverted-pear glenoid (bone loss of at least 25% of the width of the inferior glenoid) or an engaging Hill-Sachs lesion. From March 1996 to December 2002, 102 patients underwent an open Latarjet procedure for shoulder instability with an inverted-pear glenoid, with or without an associated engaging Hill-Sachs lesion, by the 2 senior authors (S.S.B. and J.F.D.), and 47 of them were available for follow-up physical examination. The remaining 55 patients were contacted by telephone or letter to see if they had had recurrent dislocation or subluxation. The mean age of the patients was 26.5 +/- 6.6 years (range, 16 to 41 years). There were 46 male patients and 1 female patient. Preoperatively, mean forward elevation was 177.2 degrees +/- 13.6 degrees (range, 90 degrees to 180 degrees) and mean external rotation with the arm at the side was 55.3 degrees +/- 16.1 degrees (range, 0 degrees to 80 degrees). All patients had a positive apprehension sign preoperatively. The median number of dislocations before surgery was 6, with 20 patients having had more than 15 dislocations preoperatively. The mean follow-up time for the 47 patients who were personally examined was 59.0 +/- 18.5 months (range, 32 to 108 months). Postoperatively, mean forward elevation was 179.6 degrees +/- 2.0 degrees (range, 170 degrees to 180 degrees; gain of 2.4 degrees) and external rotation with the arm at the side was 50.2 degrees +/- 12.6 degrees (range, 22 degrees to 78 degrees; loss of 5.1 degrees). As for postoperative functional scores, the mean Constant score was 94.4 and the mean Walch-Duplay score was 91.7. None of these 47 patients showed any further dislocation, and 1 of them still had a positive apprehension sign (2.2%) indicating subluxation. However, 4 patients out of the total 102 who underwent the modified Latarjet procedure had a recurrence. With 4 recurrent dislocations and 1 recurrent subluxation, there was a 4.9% recurrence rate. The 4 patients with recurrent dislocations were not among the 47 who returned for personal follow-up evaluation. The 2 senior authors (S.S.B. and J.F.D.) have previously reported an unacceptably high recurrence rate (67%) for arthroscopic Bankart repair in the presence of an inverted-pear glenoid with or without an engaging Hill-Sachs lesion. They have recommended an open modified Latarjet procedure in such patients. The present study confirms the validity of that recommendation, because the same 2 surgeons have had only a 4.9% recurrence rate in that same category of patient at a mean follow-up of 59 months. Furthermore, the results of this study show the efficacy of the modified Latarjet procedure in the extremely challenging category of patients who present with such dramatic bone loss that soft-tissue reconstruction, either open or arthroscopic, is not a reasonable option. Level IV, therapeutic case series.

Hybrid Medial Patellofemoral Ligament Reconstruction Using the Semitendinous Tendon for Recurrent Patellar Dislocation: Minimum 3 Years’ Follow-up

The purpose of this study was to evaluate the results of a new hybrid medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar dislocation. Hybrid MPFL reconstruction by use of the semitendinous tendon was performed in 12 knees with recurrent patellar dislocation. The results were evaluated at a minimum follow-up of 3 years (mean, 4.2 years). According to the grading system of Insall et al., the results were classified as excellent in 8 knees (66%), good in 2 (17%), and fair in 2 (17%), with none being classified as poor. The mean Kujala score was 56.3 points (range, 29 to 82) preoperatively and 96.0 points (range, 84 to 100) at follow-up. There were no patients with recurrent dislocation and subluxation. No knees had a positive apprehension sign, and there were no postoperative complications. At a midterm follow-up, hybrid MPFL reconstruction by use of the semitendinous tendon for recurrent patellar dislocation should be considered as an effective operation for cases without severe predisposing factors. Level IV, therapeutic case series, no or historical control group.

A Modified Capsular Shift for Atraumatic Anterior-Inferior Shoulder Instability

Purpose To evaluate the long-term outcome of a modified inferior capsular shift procedure in patients with atraumatic anterior-inferior shoulder instability by analyzing a consecutive series of patients who had undergone a modified inferior capsular shift for this specific type of shoulder instability. Study Design Case series; Level of evidence, 4. Methods Between 1992 and 1997, 38 shoulders of 35 patients with atraumatic anterior-inferior shoulder instability that were unresponsive to nonoperative management were operated on using a modified capsular shift procedure with longitudinal incision of the capsule medially and a bony fixation of the inferior flap to the glenoid and labrum in the 1 o'clock to 3 o'clock position. The patient study group consisted of 9 men and 26 women with a mean age of 25.4 years (range, 15-55 years) at the time of surgery. The mean follow-up was 7.4 years (range, 4.0-11.4 years); 1 patient was lost to follow-up directly after surgery. The study group was evaluated according to the Rowe score. Results After 7.4 years, 2 patients experienced a single redislocation or resubluxation, 1 patient had recurrent dislocations, and 1 patient had a positive apprehension sign, which is an overall redislocation rate of 10.5%. The average Rowe score increased to 90.6 (SD = 19.7) points from 36.2 (SD = 13.5) points before surgery. Seventy-two percent of the patients participating in sports returned to their preoperative level of competition. Conclusions Results in this series demonstrate the efficacy and durability of a modified capsular shift procedure for the treatment of atraumatic anterior-inferior shoulder instability.

Arthroscopic revision Bankart repair: A prospective outcome study

Purpose: The clinical outcome of the revision surgery for the failed Bankart repair is not well known. The purpose of this study was to prospectively analyze a series of patients with recurrent instability after primary Bankart repair that were revised arthroscopically using a suture-anchor technique. Type of Study: Prospective, nonrandomized outcome study. Methods: Twenty-three patients with failed Bankart repair were treated with arthroscopic surgery and were followed up for a mean of 36 months (range, 24-52 months; SD, 9 months). There were 21 men and 2 women with the mean age of 24 years (range, 17-34 years; SD, 4.4 years). Eight patients had previously received an open Bankart repair (5 transosseous-suture technique, 3 suture-anchor technique), and 15 had received an arthroscopic repair (10 transglenoid multiple-suture technique, 5 suture-anchor technique). The revision surgery included repair of the anterior labrum using suture anchors and nonabsorbable sutures, capsular plication, and proximal shift of the inferior capsule with or without closure of the rotator interval. The characteristics of the patients, possible modes of failure, surgical findings, shoulder scores (University of California at Los Angeles [UCLA] scale, Simple Shoulder Test, and Rowe score), and clinical outcome were evaluated. Results: Recurrent instability developed at a mean of 21 months (range, 11-39 months; SD, 8 months) after the initial stabilization. A possible cause of failure in 5 patients was a nonanatomic repair, with the labral tissue fixed proximal or medial to the glenoid margin. At the follow-up, 15 patients had excellent results, 4 good, 3 fair, and 1 poor, according to the UCLA scale. The mean Rowe score improved from 87.3 (range, 30-100; SD, 12.6) to 91.2 (range, 40-100; SD, 14.2) (P =.023). The Simple Shoulder Test responses improved from 8 yes responses preoperatively to 11 postoperatively. Eighteen patients achieved an activity return of more than 90% of preinjury level. Five patients had recurrence after revision surgery (1 frank dislocation, 2 subluxation, 2 positive anterior apprehension sign). Engagement in contact sports was correlated with the recurrence (r =.683, P =.003). With the number available, no significant difference could be detected in the outcome between the types of the primary surgery. Arthroscopic revision Bankart repair did not result in any additional loss of external rotation compared with the contralateral side (P =.723). The most predictable factor for the functional return was preoperative range of external rotation (r =.793, P =.001). Conclusions: Arthroscopic revision Bankart surgery using suture anchors can provide a satisfactory outcome, including a low recurrence rate and reliable functional return, in carefully selected patients.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 5 (May-June), 2002: pp 469–482

Intra-articular ganglion cyst (paralabral cyst) of the shoulder associated with recurrent anterior dislocation: A case report

J Shoulder Elbow Surg 2002;11:95-7.

Immediate surgical repair of the medial patellar stabilizers for acute patellar dislocation. A review of eight cases.

An open surgical repair of the injured medial patellar stabilizers, including the vastus medialis obliquus muscle and the medial patellofemoral ligament, after acute patellar dislocation was studied in eight patients. At initial examination, all patients had tenderness over the adductor tubercle and a positive patellar apprehension sign. Four of eight patients had obvious ecchymosis over the adductor tubercle. Magnetic resonance imaging, diagnostic arthroscopy, and open surgical exploration documented injury to both the medial patellofemoral ligament and the origin of the vastus medialis obliquus muscle. In all patients, the torn muscle was retracted in an anterior and superior direction and an arthroscopic lateral release was performed followed by open primary repair of the medial patellofemoral ligament to the adductor tubercle and repair of the vastus medialis obliquus muscle to the adductor magnus tendon. Patients were evaluated postoperatively with the Kujala scoring questionnaire. The average follow-up was 3.0 years, with a minimum of 1.5 years. No patients experienced a recurrent dislocation. The average Kujala score was 91.9. Patients rated their return to athletic activity at an average 86% of their pre-injury level. The average subjective satisfaction was 96%. In appropriate cases of acute patellar dislocation, we recommend primary repair of the medial patellofemoral ligament and the vastus medialis obliquus muscle to avoid recurrent dislocation, chronic subluxation, pain, and disability.

SHOULDER TAPING IN THE MANAGEMENT OF IMPINGEMENT OF THE ATHLETE

961 Overhead athletes exhibit generalized laxity compared to non-athletic counterparts. This may predisopose some athletes to shoulder impingement because of a lack of humeral head stabilization. This, coupled with weakness of the posterior rotator cuff, promotes anterior migration of the humeral head. Shoulder taping may be effective in helping the athlete restore normal glenohumeral function. The purpose of this poster is to present the results of this treatment, including inclusion criteria and specific treatment guidelines. Seven recreational athletes (range 17-32 years) presented to physical therapy with a diagnosis of shoulder impingement. Their average length of symptoms was 7.5 months (range 1-24 weeks). Each had shoulder pain with forward flexion and a positive impingement sign, as well as a positive apprehension and relocation sign for pain in the involved shoulder. They also presented with capsular laxity in both shoulders and relative forward position of the humerus. Treatment included posture education and shoulder taping to reposition the humerus more posterior and superior. Subjective complaints of pain with forward elevation were decreased after application of the tape. Each patient was instructed on a home program and attended physical therapy for rotator cuff and scapular stabilizer exercises over an average of 11.4 visits (range 7-20 visits). No modalities were used in the treatments. Each athlete returned to full activity in a mean of 6 weeks (range 2-8 weeks) from the onset of therapy. This study provides (1) inclusion criteria for canditates which may benefit from shoulder taping: shoulder hypermobility, relative forward position of the humerus, positive apprehension and relocation for pain sign, and decreased pain with forward flexion after humeral reposition taping; and, (2) a description of management of impingement without the use of modalities.

Clinical findings in competitive swimmers with shoulder pain.

We clinically evaluated 36 competitive swimmers who had shoulder pain; the majority were women. Twenty-three swimmers had unilateral shoulder pain and 13 had bilateral pain, making a total of 49 painful shoulders. Shoulder pain had been present significantly longer in swimmers with bilateral shoulder pain (mean, 104 weeks) than in swimmers with unilateral pain (mean, 33 weeks). Twelve shoulders exhibited signs of impingement without excessive humeral head translation. In 25 shoulders, concomitant signs of impingement and increased glenohumeral translation, together with a positive apprehension sign, were found. Four swimmers, who were generally joint hypermobile, exhibited bilateral impingement signs and excessive humeral head translation, most commonly in the anteroinferior direction. Four shoulders had excessive humeral head translation and apprehension without impingement. Lack of coordination in the scapulohumeral joint was seen significantly more often in symptomatic than in asymptomatic shoulders. Hawkin's test for impingement was more sensitive than Neer's test. Swimmers with shoulder pain have variable clinical findings. The majority demonstrate signs of impingement and increased humeral head translation in the anteroinferior direction together with a positive apprehension sign. This nontraumatic instability might result from wearing of the anteroinferior capsuloligamentous complex. The different clinical findings might represent different stages of the same condition.

Posterior detachment of the glenoid labrum in athletes with posttraumatic chronic shoulder pain

We examined 20 consecutively admitted athletes suffering from chronic shoulder pain for more than 6 months following a single shoulder trauma without dislocation. Two of them suffered from a posterior detachment of the glenoid labrum. Both had pain during loading, especially during over‐the‐head activities, with a clicking sensation. No previous dislocation of the involved dominant arm was recorded. Both were resistant to conservative treatment. On examination both patients had slightly decreased range of motion, a positive posterior apprehension sign and a negative impingement sign/test. One shoulder was clinically unstable. Special X‐ray identified one minor avulsion of the posterior margin of the glenoid cavity. Magnetic resonance imaging revealed a total posterior glenolabral detachment in both patients and also a bony avulsion of the glenoid posterior margin in one. Arthroscopy identified the posterior labral lesions and reinsertion of the detached labrum using the Mitek‐anchor system was performed. After 1 year, both were able to participate in shoulder‐demanding sports. In conclusion, posterior labral detachment might cause chronic shoulder pain after a single nondislocating shoulder trauma in athletes.

Anterior Staple Capsulorrhaphy for Recurrent Dislocation of the Shoulder

Thirty-three anterior staple capsulorrhaphies of the shoulder were reviewed at an average 49.7 months postoperatively (range 12 to 127 months); one postoperative dislocation occurred. The patients' quality of athletic participation improved with surgical therapy in 50%, remained the same in 38%, and was lowered in 12%. Average loss of external rotation was 11.4 degrees with the arm adducted and 13.9 degrees with the arm abducted 90 degrees. A positive apprehension sign persisted in 50%. Shoulder function was good or excellent in 84%. Mild pain was admitted by 55%, moderate pain by 6%, and severe pain by 3%. Staple malpositioning or loosening was identified in 12 shoulders; six of these patients had attributable clinical problems. Biomechanical studies in porcine bone were used to demonstrate that predrilling facilitates proper staple positioning without compromising staple fixation strength and, in a synthetic trabecular model, that a 5 degrees variance in the alignment of the staple holder during staple insertion weakens the fixation strength by 51% (P less than .001). The operation usually prevents recurrent dislocation, permits recovery of normal (or near normal) shoulder motion, and allows satisfactory return to competitive athletics. If staple malpositioning and loosening occur, they may cause clinical problems, including degenerative arthritis. Though most patients (92%) stated they would again have the operation, when practical, we recommend other methods of repair of capsule and labral detachment.

Arthroscopic shoulder capsulorraphy: does it work?

The purpose of this project was to answer the question, "Can shoulder instability be dealt with safely and effectively arthroscopically?" This study, which began in December 1982 and concluded in February 1985, involved 12 patients, 3 females and 9 males whose ages ranged from 14 to 40 years. Followup ranged from 31 to 63 months, the average being 44.8 months. The arthroscopic procedure was based on the use of a tool designed to capture the capsule, thus allowing placement of either one or two low profile extraarticular staples in the capsule. Two cases were failures. The remaining 10 patients were pleased with their operation. Based on the classification of Rowe et al., functional results were six excellent, two good, two fair, and two poor. The six patients with excellent results had shoulders of normal appearance. They were fully active and had neither pain nor limitation of motion. All six patients had negative apprehension signs. The two patients with good results had similar outcomes, but they had occasional morning stiffness and intermittent mild pain, as well as a 10 degrees limitation of external rotation in both adduction and abduction. One patient who had a fair result had a positive apprehension sign and occasional pain with quick motion. The other patient with a fair result was hampered by more significant pain on an intermittent basis, yet the pain was not a constant issue. None of these patients had radiographic evidence of increased degenerative changes of the shoulder or staple migration. There were two complications and two failures.(ABSTRACT TRUNCATED AT 250 WORDS)

The Trillat procedure for recurrent anterior instability of the shoulder.

In the Trillat procedure for recurrent anterior instability of the shoulder the coracoid process is osteotomised and tilted downward to act as a bone block, and a screw is used to fix it and the Bankart lesion to the anterior scapular neck. We reviewed 52 cases after a mean follow-up of 69 months. Results in 73% of shoulders were excellent, 10% were good, 7% fair and 10% poor. Dislocation recurred in 4%, but a positive apprehension sign was present in 10 other shoulders. Some degenerative changes were seen in 62% of shoulders, a complication known to be associated with bone-block procedures. The most important reason for loss of lateral rotation was iatrogenic impingement of the coracoid. This frequent and potentially serious complication can also cause posterior subluxation of the humeral head and osteoarthritis.

Current concepts in the diagnosis and treatment of shoulder instability in athletes.

Glenohumeral joint instability is a fairly common clinical disorder in athletes, especially in sports that involve the throwing motion. The direction of shoulder instability can be anterior, inferior, posterior, or multidirectional. The cause can be trauma, congenital laxity, or voluntary muscle action. Normal shoulders that have been disrupted by injury respond well to surgical correction. Shoulders that have inherently lax supporting structures, as found in patients with atraumatic and voluntary dislocation, have less consistent success with surgical repair. A common condition encountered in the shoulder of a throwing arm is anterior subluxation, which can be diagnosed by the positive apprehension sign and confirmed by arthroscopy. A torn glenoid labrum is a common injury also. Improvement in the diagnosis and treatment of shoulder disorders has been made recently by arthroscopy which allows direct visualization of the joint; many conditions can now be corrected by means of arthroscopic surgery. Radiographic techniques have also been improved.