Recurrent Anterior Instability Research Articles

Isokinetic rotator muscles fatigue in glenohumeral joint instability before and after Latarjet surgery A pilot prospective study

We aimed to analyze the changes in isokinetic internal (IR) and external (ER) rotator muscles fatigue (a) in patients with non-operated recurrent anterior instability, and (b) before and after shoulder surgical stabilization with the Bristow-Latarjet procedure. Thirty-seven patients with non-operated unilateral recurrent anterior post-traumatic instability (NG) were compared with 12 healthy subjects [control group (CG)]. Twenty patients with operated recurrent anterior instability group (OG) underwent isokinetic evaluation before and 3, 6, and 21 months after Bristow-Latarjet surgery. IR and ER muscles strength was evaluated with Con-Trex® dynamometer, with subjects seated and at a 45° shoulder abduction angle in scapular plane. IR and ER muscle fatigue was determined after 10 concentric repetitions at 180° · s(-1) through the fatigue index, the percent decrease in performance (DP), and the slope of peak torque decrease. There were no differences in rotator muscles fatigue between NG and CG. In OG, 3 months post-surgery, IR DP of operated shoulder was significantly (P < 0.001) higher than presurgery and 6 and 21 months post-surgery. Rotator muscles fatigability was not associated with recurrent anterior instability. After surgical stabilization, there was a significantly higher IR fatigability in the operated shoulder 3 months post-surgery, followed by recovery evidenced 6 months post-surgery and long-term maintenance over 21 months.

Accurate coracoid graft placement through use of a drill guide for the Latarjet procedure

The Latarjet procedure has widely become the preferred treatment option for recurrent anterior glenohumeral instability in the presence of glenoid bone loss. The success of this procedure is largely dependent on accurate placement of the coracoid bone graft relative to the glenoid margin. With malpositioning of the coracoid graft, complications can arise, such as recurrent instability if placed too medially or impingement and subsequent early degenerative changes if positioned too laterally. To increase the accuracy and reproducibility of coracoid graft placement, we developed a simple and efficient drill guide that assists in accurate and safe positioning of the graft against the anterior glenoid to provide a congruent articular surface. A new drill guide was used in 12 consecutive open Latarjet procedures. Accuracy of placement of the graft with respect to the anterior glenoid rim was assessed using postoperative computed tomography imaging. Accurate graft placement with a distance between the glenoid and the graft surface of less than 1 mm was obtained in all 12 interventions. The mean angulation of the screws relative to the glenoid face was 4.3° (range, 1°-7°). All screw heads were positioned medial to the articular edge of the graft, and the distance was always greater than 3 mm. The use of a simple drill guide allows safe and accurate graft placement during an open Latarjet procedure.

Reconstruction for anterior sternoclavicular joint dislocation and instability

Sternoclavicular joint (SCJ) instability is relatively rare. Surgical treatment may be considered for severely displaced dislocations or symptomatic recurrent anterior instability. The purpose of this study was to describe an SCJ ligament reconstruction technique and retrospectively evaluate its safety and effectiveness for treating anterior SCJ dislocations and instability. A retrospective review of demographics, medical history, injury characteristics, and pretreatment pain and functional levels was performed. A soft-tissue graft woven in a Roman numeral X pattern through clavicular and sternum subcortical bone tunnels was used. Patients were evaluated with postoperative visual analog scale (VAS) and functional scores, and their ability to return to normal preoperative sports and activities was determined. Six patients were evaluated with a mean follow-up of 40 months (range, 24.5-58 months). Injury mechanisms included acute trauma (3 patients), minor trauma (1 patient), and chronic atraumatic instability (2 patients). The mean preoperative symptom duration was 11 months (range, 0.5-27.5 months). Autograft hamstring graft was used in all cases with no resulting surgical complications. All 6 patients had full range of motion with no instability after treatment. Five patients had no pain (0 of 10 on VAS), whereas one patient had mild pain (1 to 3 of 10 on VAS). All 6 patients had improved functional scores.All returned to preoperative activities and participation in sports. No recurrent instability occurred. In 1 case, failure occurred at 4 years with recurrent pain, and revision was performed. The results of our study indicate that reconstruction for anterior SCJ dislocation is safe with results comparable to previously described surgical stabilization techniques. This technique provides a surgical treatment option for symptomatic anterior SCJ dislocation and instability.

The Evaluation of Arthroscopic Remplissage by High-Resolution Magnetic Resonance Imaging

Background: Arthroscopic remplissage is a novel procedure recently advocated for the treatment of large Hill-Sachs lesions with recurrent anterior glenohumeral instability. We have shown previously that infraspinatus tenodesis and Bankart repair reduce the risk of recurrent instability in high-risk patients. The ability to perform this procedure arthroscopically and without the need for bone grafting or an open approach makes this an appealing alternative to more traditional techniques. Purpose: To evaluate and characterize the postoperative appearance of the remplissage procedure on high-resolution magnetic resonance imaging (MRI) and to correlate these findings to clinical outcome (Western Ontario Shoulder Instability [WOSI] score, range of motion). Study Design: Case series; Level of evidence, 4. Methods: In patients who had undergone arthroscopic remplissage for recurrent glenohumeral instability with large Hill-Sachs defects, images were acquired with a 3-T protocol (and reviewed by 2 musculoskeletal radiologists) with the shoulder in the abduction-external rotation (ABER) and neutral positions at the time of the latest clinical examination. Measured parameters included signal intensity of tissue within the prior defect, signal intensity of the residual infraspinatus, degree of fatty infiltrate and muscle atrophy as a percentage of fat signal versus muscle signal (Goutallier grade), presence of marrow edema, and number of anchors in the defect. Functional scores were obtained with the WOSI questionnaire, and comprehensive range of motion data were recorded with a goniometer. Results: In 11 patients with an average clinical follow-up of 18.0 months (range, 8.8-27.2 months), the average size of the Hill-Sachs deformity was 334.3 mm3 (range, 93.6-825.1 mm3). The percentage of the deformity filled in with tendon was 75% to 100%, and the degree of atrophy was 0% to 25% for all patients studied. No defects were left unfilled. Two patients had granulation tissue filling the lesion, and 3 patients had fibrous tissue, while the rest of the patients had the MRI appearance of both granulation and fibrous tissue. Four of 9 patients had tendinopathy or partial tears of the residual infraspinatus tendon insertion, and 1 patient demonstrated residual bone marrow edema. The average number of anchors used was 1.4 (range, 1-3). The average WOSI score was 74.3% (range, 41.6%-99.2%), with an average external rotation loss of 5.8° (range, 0°-22°). One patient had recurrence of instability. Conclusion: Our data suggest that there is evidence of tendon incorporation and fill into the Hill-Sachs defect following arthroscopic remplissage at 8 months and beyond. Although MRI findings did not correlate with the clinical findings, patients were satisfied with the procedure and demonstrated minimal loss of external rotation (average, 5.8°) at early follow-up.

Arthroscopic Bankart Repair and Capsular Shift for Recurrent Anterior Shoulder Instability

Arthroscopic Bankart repair and capsular shift is a well-established technique for the treatment of anterior shoulder instability. The purpose of this study was to evaluate the outcomes following arthroscopic Bankart repair and capsular shift and to identify risk factors that are predictive of recurrence of glenohumeral instability. We performed a retrospective review of a prospectively collected database consisting of 302 patients who had undergone arthroscopic Bankart repair and capsular shift for the treatment of recurrent anterior glenohumeral instability. The prevalence of patient and injury-related risk factors for recurrence was assessed. Cox proportional hazards models were used to estimate the predicted probability of recurrence within two years. The chief outcome measures were the risk of recurrence and the two-year functional outcomes assessed with the Western Ontario shoulder instability index (WOSI) and disabilities of the arm, shoulder and hand (DASH) scores. The rate of recurrent glenohumeral instability after arthroscopic Bankart repair and capsular shift was 13.2%. The median time to recurrence was twelve months, and this complication developed within one year in 55% of these patients. The risk of recurrence was independently predicted by the patient's age at surgery, the severity of glenoid bone loss, and the presence of an engaging Hill-Sachs lesion (all p < 0.001). These variables were incorporated into a model to provide an estimate of the risk of recurrence after surgery. Varying the cutoff level for the predicted probability of recurrence in the model from 50% to lower values increased the sensitivity of the model to detect recurrences but decreased the positive predictive value of the model to correctly predict failed repairs. There was a significant improvement in the mean WOSI and DASH scores at two years postoperatively (both p < 0.001), but the mean scores in the group with recurrence were significantly lower than those in the group without recurrence (both p < 0.001). Our study identified factors that are independently associated with a higher risk of recurrence following arthroscopic Bankart repair and capsular shift. These data can be useful for counseling patients undergoing this procedure for the treatment of recurrent glenohumeral instability and individualizing treatment options for particular groups of patients. Prognostic level I. See Instructions for authors for a complete description of levels of evidence.

Surgical treatment of anterior instability in rugby union players: clinical and radiographic results of the Latarjet-Patte procedure with minimum 5-year follow-up

Anterior instability in rugby players is characterized by the common finding of a bony lesion, which has been identified as a potential cause of recurrence after soft-tissue reconstruction. The Latarjet-Patte procedure is effective in the treatment of recurrent anterior instability in collision sports such as rugby union. We retrospectively assessed 34 rugby players (37 shoulders) stabilized with the Latarjet-Patte procedure. The mean follow-up was 12 years. All patients underwent clinical and radiographic assessment preoperatively and at final follow-up. Functional evaluation was performed with the Walch-Duplay and Rowe scores. A visual analog scale score for the evaluation of pain and the subjective shoulder value were recorded. In addition, all patients completed a questionnaire regarding the return to playing rugby. No recurrence of either dislocation or subluxation occurred. Persistent apprehension on clinical examination was present in 5 patients (14%). A bony lesion of the glenoid was present in 73% and a Hill-Sachs lesion in 68%. Sixty-five percent of the patients returned to playing rugby; only 1 patient did not return to playing rugby because of his shoulder. The mean Walch-Duplay and Rowe scores were 86 and 93 points, respectively. The mean subjective shoulder value was 90%. Radiographic healing of the bone block was observed in 89% of cases. At final follow-up, 11 patients (30%) had minor arthritic changes, with no cases of moderate or severe arthritis. The Latarjet-Patte procedure provides a reliable method for stabilizing the shoulder, resulting in a return to playing rugby in a high number of cases without increasing the risk of long-term arthritic degradation.

Anterior Shoulder Instability Associated with Coracoid Nonunion in Patients with a Seizure Disorder

An association between coracoid fracture and glenohumeral instability with both a seizure disorder and the subsequent development of coracoid nonunion has not previously been recognized. This is clinically important as patients with a seizure disorder and glenohumeral instability frequently require a primary osseous reconstructive procedure, such as coracoid osteotomy and transfer to the anterior glenoid rim (the Bristow-Latarjet procedure), to address glenoid osseous deficiency. We report on coracoid fracture nonunion in five patients with a seizure disorder and anterior glenohumeral instability and discuss the implications for surgical treatment. Coracoid fracture was specifically sought on three-dimensional reconstructions of computed tomography scans in a consecutive series of 234 patients presenting to our unit with recurrent anterior instability. In addition to demographic data, we specifically sought information on any history of shoulder injury, the mechanism of injury, or previous seizure activity in these patients. In patients with a coracoid fracture or nonunion viewed to be at high risk of failure with a soft-tissue procedure, an open osseous reconstructive procedure was performed. The type of operative procedure was determined by the location of the nonunion. We identified six coracoid fracture nonunions in association with anterior glenohumeral instability in five patients (mean age, 26.8 years; range, twenty-four to thirty years). All patients had instability occurring in association with seizures. In the four shoulders with the anatomic location of the coracoid nonunion at its so-called elbow, a standard Bristow-Latarjet procedure was performed. In the two shoulders in which the nonunion was more distal, an Eden-Hybbinette procedure was performed. We recommend having a high index of suspicion of coracoid fracture when treating patients with a seizure disorder who have anterior glenohumeral instability. In these patients, preoperative computed tomographic images allow the diagnosis of a coracoid nonunion to be made prior to surgery and help to determine whether there is sufficient intact coracoid bone to allow a Bristow-Latarjet procedure to be performed.

Force isocinétique des muscles rotateurs de l’épaule dans l’instabilité chronique antérieure

Given the role of dynamic stabilization means in shoulder recurrent anterior instability, due to the failure of passive stabilization means, a better understanding of the role of internal (IR) and external (ER) rotators muscle strength, and their agonist/antagonist balance, could be of interest in the therapeutic arsenal around this disease. In the light of the literature, a deficit of IR and ER muscle strength seems associated with unoperated recurrent anterior instability. After surgical stabilization using the Bristow-Latarjet procedure, there appears a transitional post-surgical deficit of the IR and ER muscle strength compared to preoperative values during 3 to 6 months post-surgery, but the preoperative deficit compared to contralateral shoulder seems to persist despite the surgical procedure and the postoperative rehabilitation care. Evaluation of IR and ER isokinetic muscle strength is relevant in monitoring patients with shoulder recurrent anterior instability, unoperated and post-surgery, in order to determine the orientation of rehabilitation, to help the decision for continuing or not strength rehabilitation, and to help the decision when deciding upon an appropriate time for return to sports.

Spontaneous healing of Hill-Sachs lesion after arthroscopic bony Bankart repair

Hill-Sachs lesions are impression fractures of the humeral head due to impaction of the posterolateral aspect of an anteriorly dislocated humeral head with the anterior rim of the glenoid. They are found in most patients with recurrent shoulder dislocation, and 20% to 45% of the articular surfaces are known to require additional repair procedures due to the high risk of dislocation recurrence after conventional Bankart repair. 1 Baker C.L. Intraarticular pathology in acute, first-time anterior shoulder dislocation: an arthroscopic study. Arthroscopy. 1994; 10: 478-479 Abstract Full Text PDF PubMed Scopus (12) Google Scholar , 3 Chen A.L. Hunt S.A. Hawkins R.J. Zuckerman J.D. Management of bone loss associated with recurrent anterior glenohumeral instability. Am J Sports Med. 2005; 33: 912-925https://doi.org/10.1177/0363546505277074 Crossref PubMed Scopus (154) Google Scholar , 5 Rowe C.R. Zarins B. Ciullo J.V. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am. 1984; 66: 159-168 PubMed Google Scholar

腱板断裂に大きなHill-Sachs病変を伴った反復性肩関節前方脱臼に対して，骨移植術を併用した鏡視下修復術の1例

【症例】81歳，女性．3年前に転倒後右肩関節前方脱臼し，骨頭と関節窩の嵌合が認められた．外来にて徒手整復不能であったため全身麻酔下に徒手整復した．上腕骨頭部陥凹を認めたが保存的治療にて経過観察した．1週間前，転倒しそうになり右手で壁についた際に右肩疼痛が出現した．1週後来院しX線所見で骨頭と関節窩が嵌合した肩関節前方脱臼を認めた．全身麻酔下に整復したが容易に再脱臼した．MRIでBankart lesionと腱板断裂と大きな上腕骨頭部陥凹を認めた．翌日関節鏡下にBankart lesionを修復し，上腕骨頭陥凹部に腸骨から採取した骨片（1.5×1.0×1.0cm）と海綿骨を移植した．腱板修復のため上腕骨頭陥凹部の四隅にsuture anchorを刺入し腱板を修復しながら同時に移植骨を修復腱板にて圧迫固定した．術翌日から右肩安静時痛は著明に改善した．術後6カ月でJOAスコア85点で，再脱臼を認めない．

Arthroscopic stabilization for recurrent anterior glenohumeral instability in competitive baseball players

Arthroscopic stabilization for recurrent anterior glenohumeral instability in competitive baseball players

Arthroscopic stabilization for recurrent anterior glenohumeral instability in basketball players Author

Arthroscopic stabilization for recurrent anterior glenohumeral instability in basketball players Author

Arthroscopic stabilization for recurrent anterior glenohumeral instability in martial arts players

Arthroscopic stabilization for recurrent anterior glenohumeral instability in martial arts players

Arthroscopic stabilization for recurrent anterior glenohumeral instability in the dominant of overhead athletes

Arthroscopic stabilization for recurrent anterior glenohumeral instability in the dominant of overhead athletes

A Rare Complication of Tuberculous Meningitis Pediatric Anterior Glenohumeral Instability

Dislocation and instability of the shoulder joint are rare occurrences in childhood. Traumatic, infectious, congenital, and neuromuscular causes of pediatric recurrent shoulder dislocations are reported before. Central nervous system infection in infancy may be a reason for shoulder instability during childhood. This situation, which causes a disability for children, can be treated successfully with arthroscopic stabilization of the shoulder and postoperative effective rehabilitation protocols. Tuberculous meningitis may be a reason for neuromuscular shoulder instability. We describe a 12-year-old child with a recurrent anterior instability of the shoulder, which developed after tuberculous meningitis at 18 months of age. We applied arthroscopic treatment and stabilized the joint.

鏡視下Bankart修復術後外旋制限の病態と鏡視下手術の有用性 －鏡視下RATS（Restoration of Anterior Transverse Sliding）法 －

鏡視下Bankart修復術後外旋制限の病態と鏡視下手術の有用性 －鏡視下RATS（Restoration of Anterior Transverse Sliding）法 －

Arthroscopic Remplissage With Bankart Repair for the Treatment of Glenohumeral Instability With Hill-Sachs Defects

To determine whether arthroscopic remplissage with Bankart repair is an effective treatment strategy for patients with Bankart lesions and large Hill-Sachs defects. Between 2006 and 2008, 20 patients underwent arthroscopic Bankart repair with remplissage for the treatment of recurrent anterior glenohumeral instability and large Hill-Sachs defects. Preoperative imaging in all patients identified avulsion of the anterior inferior glenohumeral ligament with an associated Hill-Sachs defect that involved greater than 25% of the humeral head. Patients were followed up postoperatively with the Western Ontario Shoulder Instability score, the American Shoulder and Elbow Surgeons score, and the Penn Shoulder Score. Recurrent subluxation or dislocation was documented. There were 15 male patients and 5 female patients. The mean age of the patients was 27.3 years. The mean length of follow-up in this series was 29.2 months (range, 24.3 to 37.7 months). At final follow-up, 3 patients reported recurrence of instability, which spontaneously reduced in all cases. The mean American Shoulder and Elbow Surgeons score was 92.5 (pain, 47.3; function, 45.3). The mean Penn score was 90 of 100 (pain, 27.3 of 30; satisfaction, 8.5 of 10; function, 54.3 of 60). The mean total Western Ontario Shoulder Instability score was 72.74% (mean physical symptom score, 77.10%; mean sports and recreation score, 70.25%; mean lifestyle score, 75%; mean emotions score, 58.50%). Using an all-arthroscopic remplissage technique with Bankart repair, we were able to restore function, diminish pain, and yield satisfaction in 85% of the patients in this study. Our results compare favorably with historic controls with similar pathology at early- to intermediate-term follow-up in terms of recurrence. Level IV, therapeutic case series.

Long-term Results After Arthroscopic Shoulder Stabilization Using Suture Anchors

Background: Arthroscopic stabilization using suture anchors is widely used to restore stability after anterior shoulder dislocations and is associated with low recurrence rates in short-term follow-up studies. Purpose: To evaluate the long-term follow-up after arthroscopic stabilization for traumatic recurrent anterior instability using suture anchors with emphasis on both redislocations and subjective shoulder function. Study Design: Case series; Level of evidence, 4. Methods: We included 67 consecutive patients with 70 affected shoulders. After 8 to 10 years, patients were asked to report the presence and course of their redislocations. Subjective shoulder function was addressed using the Oxford Instability Score (OIS), the Western Ontario Shoulder Instability Index (WOSI), and the Simple Shoulder Test (SST). Patients rated their health status using the Short Form-36 (SF-36). Results: Sixty-five patients with 68 affected shoulders (97%) were evaluated for follow-up; 35% reported a redislocation. Median shoulder function scores were 16 of 12 to 60, 22 of 0 to 210, and 12 of 0 to 12 for the OIS, WOSI, and SST, respectively. There was a significant difference in subjective function between patients with and without recurrent instability, respectively, 16 versus 24 for the OIS (P = .004), and 16 versus 47 for the WOSI (P = .05). We found a trend for an inverse relationship between the number of suture anchors and recurrent instability, with 2 having a higher recurrence rate than 3 or more (P = .06). Another trend was found with the presence of a Hill-Sachs defect slightly increasing the risk of a redislocation (P = .07). Conclusion: With a follow-up of 97%, about one third of the stabilized shoulders experienced at least one redislocation after 8 to 10 years. The presence of a Hill-Sachs defect and the use of less than 3 suture anchors might increase the chance of a redislocation. Patients without a redislocation have a significantly better shoulder function compared with patients with a redislocation.

Instabilità antero-inferiore: l’intervento di Latarjet modificato

Shoulder instability is one of most controversial joint diseases in terms of diagnosis and treatment. Several open surgical treatments for primary anterior glenohumeral instability have been published, including long-term follow-up of these methods, which are reliable and time-tested and can yield excellent clinical results. The use of arthroscopy has improved the recognition of pathologic findings in shoulder instability and allowed a better understanding of the anatomopathology of instability and the correlation between symptoms and lesions. The arthroscopic technique allows reparative and reconstructive surgical procedures aimed at selective treatment of the injured structures, obviating tenotomy or splitting of the subscapularis, thus reducing the risk of iatrogenic damage. In international literature, some studies demonstrate the results of arthroscopic treatment of recurrent traumatic anterior instability comparable with those achieved historically with open procedures. Despite these exciting advances, open surgery remains an acceptable method of treatment, particularly when a surgeon lacks the equipment, experience, or technical skills needed to perform an arthroscopic repair. Moreover, open surgery remains the preferred method of treatment in situations in which arthroscopic techniques cannot adequately address the anatomic lesion, such as anterior instability in the presence of glenoid and/or humeral bony defects or soft tissue deficiencies. The Latarjet procedure, first described in 1958 and used to address anteroinferior shoulder instability, involves using coracoid transfer to stabilize the shoulder by the static action of the transferred bone block and by the dynamic action of the attached conjoined tendon sling (short head of biceps and coracobrachialis) in patients who present anteroinferior shoulder instability. There are different effects by which to achieve shoulder stability with the Latarjet procedure: a) bone effect: bone graft can prevent engagement of a humeral bone lesion because the graft extends the glenoid arch to such a degree that the shoulder cannot externally rotate far enough to engage the Hill-Sachs lesion over the front of the graft; b) muscle effect: transfer of a coracoid graft and conjoined tendon over the top of the lower subscapularis tendon results in increased tension in the inferior fibers of the subscapularis, enhancing anterior stability; c) sling effect: conjoined tendon forms a sling across the anterior-inferior capsule when the shoulder is in 90° abduction and 90° external rotation, providing additional soft tissue restraint anteriorly, all of which act to prevent engagement of the Hill-Sachs lesion even before the anterior capsule is repaired; d) capsular effect: follows capsular restoration.

Recurrent anterior shoulder instability: accuracy of estimations of glenoid bone loss with computed tomography is insufficient for therapeutic decision-making

To evaluate the reliability of glenoid bone loss estimations based on either axial computed tomography (CT) series or single sagittal ("en face" to glenoid) CT reconstructions, and to assess their accuracy by comparing with actual CT-based bone loss measurements, in patients with anterior glenohumeral instability. In two separate series of patients diagnosed with recurrent anterior glenohumeral instability, glenoid bone loss was estimated on axial CT series and on the most lateral sagittal (en face) glenoid view by two blinded radiologists. Additionally, in the second series of patients, glenoid defects were measured on sagittal CT reconstructions by an independent observer. In both series, larger defects were estimated when based on sagittal CT images compared to axial views. In the second series, mean measured bone loss was 11.5% (SD = 6.0) of the total original glenoid area, with estimations of 9.6% (SD = 7.2) and 7.8% (SD = 4.2) for sagittal and axial views, respectively. Correlations of defect estimations with actual measurements were fair to poor; glenoid defects tended to be underestimated, especially when based on axial views. CT-based estimations of glenoid bone defects are inaccurate. Especially for axial views, there is a high chance of glenoid defect underestimation. When using glenoid bone loss quantification in therapeutic decision-making, measuring the defect instead of estimating is strongly advised.