Traumatic Instability Research Articles

New concepts of radiologic preoperative evaluation of anterior shoulder instability: on-track and off-track lesions.

The shoulder is the most frequently dislocated joint in the body due to a larger range of motion and a small area of articulation between the humeral and glenoid surfaces. Traumatic shoulder dislocations, especially those associated with injury to the labroligamentous or bony stabilizers of the joint, lead to further reduction of articular surface contact with resultant glenohumeral instability and recurrent shoulder dislocations. Imaging plays an increasingly important role in the preoperative evaluation of patients with traumatic shoulder instability by evaluating glenohumeral bone loss (uni- or bipolar), assessing soft tissue injuries and identifying patients at risk of postoperative recurrence. Quantification of bone loss is key to differentiate engaging vs. non-engaging Hill-Sachs lesions, while newer concepts of "on-track" vs. "off-track" lesions are being discussed that can determine the required surgical approaches. In this article, we review the preoperative imaging approaches, traditional treatments, outline the bone loss measurement strategies and review these new tracking concepts with relevant case examples.

Managing Bony Defects of the Shoulder Joint that Occur in Association with Dislocation.

Background:Defects to the articular surface of the humeral head have been known to be associated with shoulder dislocation since the 19th century. It wasn't until 1934 that the first description of the ubiquitous compression fracture of the posterolateral humeral head that occurs with traumatic anterior instability appeared. From 1940, this defect became referred to as a Hill-Sachs lesion after the investigators who reported the condition. The significance of, and therefore treatment of, these and other such bony defects around the shoulder joint has been hotly debated.Methods:We reviewed the available current literature to determine and report on the most up to date concepts and treatment techniques being used to manage bony defects of the shoulder.Results:Numerous surgical options have been proposed to manage bony defects of the shoulder, including a variety of defect-filling procedures, with good outcomes. However, the small numbers and diversity of case mix makes for difficult comparisons.Conclusion:We are currently developing a greater appreciation of how both the humeral and glenoid defects interact and therefore should be assessed and addressed simultaneously in order to improve patient outcomes. More research and collaboration is needed to determine the optimal method of assessing and managing these patients.

Modified Eaton-Littler's Reconstruction for Traumatic Thumb Carpometacarpal Joint Instability: Operative Technique and Clinical Outcomes.

Background Injuries to thumb carpometacarpal joint ligaments lead to instability. Eaton-Littler's ligament reconstruction traditionally uses a strip of flexor carpi radialis to stabilize the CMC joint. Study Description We have modified this technique to reproduce the direction of active action of the anterior oblique ligament by reconstructing both the volar and dorsoradial ligaments. In this prospective study, we evaluated patients with confirmed traumatic thumb CMC joint instability who underwent modified Eaton-Littler's reconstruction. Strength analysis, Michigan Hand Outcome Questionnaire, QuickDASH, and subjective outcome measures were collected pre- and postoperatively with minimum 3 years of follow-up. Eleven patients were included in the final analysis, with mean age of 29 years (range: 16-52) and average follow-up of 6.2 years (range: 3-11). There was a statistically significant improvement in all outcome measures. Clinical Relevance Our modified technique helps to simultaneously address both volar and dorsal ligaments and yields satisfactory clinical outcomes at medium term follow-up. Level of Evidence Level IV, case series.

Return to Sports After Shoulder Stabilization Surgery for Anterior Shoulder Instability.

Young athletes continue to experience traumatic shoulder instability and are often plagued by recurrent instability, limiting their return to sport. The purpose of this paper was to review return to sport in athletes after shoulder stabilization surgery for anterior shoulder instability. Athletes managed nonoperatively demonstrate unacceptably high rates of recurrent instability and are less likely to successfully return to sport. Operative management includes capsuloligamentous repair (arthroscopic versus open) and bone augmentation techniques. While modern arthroscopic techniques have provided favorable outcomes, open techniques have demonstrated lower recurrence rates among young collision athletes. A subset of athletes continue to experience recurrent instability, leading to further investigation of concomitant pathologies, which may put patients at risk of failure following Bankart repair. Bony augmentation procedures remain favorable for patients with glenoid bone loss; however, what constitutes critical bone loss in the decision between anterior labral repair versus bone augmentation has recently been questioned. Operative management of anterior shoulder instability provides superior results, including lower recurrent instability and return to sport. Future research on patient-specific risk factors may aid surgical decision-making and optimization of outcomes.

Partial Resurfacing for Humeral Head Defects Associated With Recurrent Shoulder Instability.

Recurrent traumatic shoulder instability is a complex clinical entity that commonly affects young, active patients. Humeral head defects are frequently associated with this condition, but specific treatment to stabilize the shoulder is rarely needed. Management options for defects of the humeral head that do necessitate treatment carry various risks and disadvantages, including the need for bone or soft tissue healing, complications related to hardware, and loss of motion. Partial prosthetic resurfacing has been reported as a treatment option. The current study retrospectively reviewed a cohort of patients with recurrent or locked anterior and posterior instability who underwent partial prosthetic humeral head resurfacing for significant Hill-Sachs and reverse Hill-Sachs lesions. At an average of 36.4 months after the index procedure, 16 patients were contacted by mail and telephone. Of the study group, 13 patients underwent partial resurfacing for anterior instability and 3 patients underwent partial re-surfacing for posterior instability. No patient had a repeat dislocation. In addition, 77% of patients in the anterior instability cohort and all of the patients in the posterior instability cohort returned to their full preinjury activity level. For the anterior instability cohort, significant improvements from preoperatively to final follow-up occurred for mean Musculoskeletal Review of System score (4.54, P<.0001) and Short Form-12 physical component score (9.52, P=.002). For the combined cohort, the Penn Shoulder Score improved by 36.4 points (P=.059). This study showed the effectiveness of partial humeral head resurfacing for preventing redislocation for patients with significant Hill-Sachs and reverse Hill-Sachs lesions. [Orthopedics. 2017; 40(6):e996-e1003.].

Current Concepts in the Management of Shoulder Instability

Shoulder instability ranges from subtle instability to frank dislocation. Our understanding on the subject is getting better. Patient lifestyle, increased awareness/expectations, better availability of information, improved imaging modalities, and increased awareness about the previously less known concepts in instability all add to the challenges of managing the problem. History and clinical examination without over reliance on imaging remain essential. We used Embase, PubMed, Medline, CINAHL, Cochrane Library, Scottish Intercollegiate Guidelines Network and Google Scholar search for published literature in English. We used various combinations of the keywords, namely, human shoulder instability, sports injuries, dislocation, surgery, latarjet, glenohumeral, glenoid, and arthroscopy from 1980 to March 2017. The systematic search captured 310 publications. After applying initial exclusion criteria, 41 abstracts were assessed for eligibility. Of these, we selected 20 full-text articles with the majority of focus primarily on surgical management of traumatic shoulder instability. A tailor-made approach for the management of the individual patient is essential and should involve shared decision making. In this article, we have tried to simplify and present the current evidence in the management of traumatic shoulder instability, particularly in sportsperson.

Indication for Computed Tomography Scan in Shoulder Instability: Sensitivity and Specificity of Standard Radiographs to Predict Bone Defects After Traumatic Anterior Glenohumeral Instability.

Background:Quantifying glenohumeral bone loss is key in preoperative surgical planning for a successful Bankart repair.Hypothesis:Simple radiographs can accurately measure bone defects in cases of recurrent shoulder instability.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A true anteroposterior (AP) view, alone and in combination with an axillary view, was used to evaluate the diagnostic properties of radiographs compared with computed tomography (CT) scan, the current gold standard, to predict significant bone defects in 70 patients. Sensitivity, specificity, and positive and negative predictive values were evaluated and compared.Results:Detection of glenoid bone loss on plain film radiographs, with and without axillary view, had a sensitivity of 86% for both views and a specificity of 73% and 64% with and without the axillary view, respectively. For detection of humeral bone loss, the sensitivity was 8% and 17% and the specificity was 98% and 91% with and without the axillary view, respectively. Regular radiographs would have missed 1 instance of significant bone loss on the glenoid side and 20 on the humeral side. Interobserver reliabilities were moderate for glenoid detection (κ = 0.473-0.503) and poor for the humeral side (κ = 0.278-0.336).Conclusion:Regular radiographs showed suboptimal sensitivity, specificity, and reliability. Therefore, CT scan should be considered in the treatment algorithm for accurate quantification of bone loss to prevent high rates of recurrent instability.

Initial management of traumatic ventral shoulder dislocation

In the current literature aconsensus on the specific management of primary anterior traumatic shoulder instability has not been reached. While the steps of the initial diagnostic and therapeutic procedures are mostly well-defined, avariety of factors need to be considered for the planning of further treatment. This article aims at giving an overview of the essential aspects of the initial management in the rescue center, clinical and radiological diagnostic procedures and the subsequent treatment options. The content of this article is based on our own clinical experiences in combination with asystematic literature search for relevant clinical and baseline studies. Besides adetailed anamnesis and clinical examination, X‑rays in two planes are important for the diagnosis. Potential nerve injuries or fractures need to be borne in mind before and after reduction of the joint and documented accordingly. The Matsen's maneuver can be recommended as it enables acareful repositioning. In rare cases of an irreducible shoulder dislocation due to soft tissue or bony articular interpositions, an open reduction might be necessary. Further therapeutic concepts should be adapted to patient age, activity level and accompanying pathologies, which determine the risk of arecurrent dislocation. Asurgical approach for stabilization of the shoulder is highly recommended in cases of concomitant bony defects as well as in young and physically active patients. Awell-structured treatment plan is essential for the initial management of primary anterior traumatic shoulder instability. Agenerally applicable algorithm for further management is not yet established. The treatment should therefore be individually planned based on patient-specific characteristics.

The Epidemiology of Glenohumeral Joint Instability: Incidence, Burden, and Long-term Consequences.

Acute traumatic glenohumeral joint instability is common within the general population and endemic in young athletes and physically active populations. Individuals who experience acute traumatic glenohumeral joint instability events are at high risk of recurrent injury. In addition, glenohumeral joint instability results in substantial short-term and long-term consequences, including significant time loss from activity, degenerative joint changes, and reduced quality of life. This review provides an overview of the epidemiology of glenohumeral joint instability, reviews the modifiable and nonmodifiable risk factors for glenohumeral joint instability identified in the literature, and discusses the need for developing and implementing effective multilevel strategies for the primary, secondary, and tertiary prevention of glenohumeral joint instability and the long-term consequences associated with injury.

Glenohumeral Instability Related to Special Conditions: SLAP Tears, Pan-labral Tears, and Multidirectional Instability.

Glenohumeral instability is one of the more common conditions seen by sports medicine physicians, especially in young, active athletes. The associated anatomy of the glenohumeral joint (the shallow nature of the glenoid and the increased motion it allows) make the shoulder more prone to instability events as compared with other joints. Although traumatic dislocations or instability events associated with acute labral tears (ie, Bankart lesions) are well described in the literature, there exists other special shoulder conditions that are also associated with shoulder instability: superior labrum anterior/posterior (SLAP) tears, pan-labral tears, and multidirectional instability. SLAP tears can be difficult to diagnose and arthroscopic diagnosis remains the gold standard. Surgical treatment as ranged from repair to biceps tenodesis with varying reports of success. Along the spectrum of SLAP tears, pan-labral tears consist of 360-degree injuries to the labrum. Patients can present complaining of either anterior or posterior instability alone, making the physical examination and advanced imaging a crucial component of the work up of the patients. Arthroscopic labral repair remains a good initial option for surgical treatment of these conditions. Multidirectional instability remains one of the more difficult conditions for the sports medicine physician to diagnose and treat. Symptoms may only be reported as vague pain versus frank instability making the diagnoses particularly challenging, especially in a patient with overall joint laxity. Conservative management to include physical therapy is the mainstay initial treatment in patients without an identifiable structural abnormality. Surgical management of this condition has evolved from open to arthroscopic capsular shifts with comparable results.

Traumatic anterior instability of the shoulder

The shoulder is the most unstable joint in the human body. Traumatic anterior instability of the shoulder is a common condition, which, especially in young patients, is associated with high recurrence rates. The effectiveness of non-surgical treatments when compared to surgical ones is still controversial. The purpose of this study was to review the literature for current concepts and updates regarding the treatment of this condition.

Management of Glenoid Defects in Anterior Shoulder Instability: A Review of Current Concepts.

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

Controversies in the Surgical Management of Shoulder Instability: Open vs Arthroscopic Procedures.

Background:Traumatic anterior instability of the shoulder is a common condition associated with a high recurrence rate in young adults. Operative treatment reduces the risk of recurrence. Several studies have compared arthroscopic and open shoulder instability repair. The purpose of this paper is to perform a review of the literature where both techniques are compared in the repair of the anterior shoulder instability without bone loss.Methods:Prior to arthroscopy, recurrent dislocations were managed by open repair. There have been many studies documenting low recurrence rates after open Bankart stabilization.Initially, arthroscopic fixation reported high failure rates.Results:In the last 20 years, the development of arthroscopic stabilization for recurrent anterior instability has improved failure rates. In comparison with open techniques, arthroscopic procedures have the advantages of decreased morbidity rate, early functional rehabilitation and improved range of motion.Conclusion:The available evidence does not show a statistically significant difference in outcome measures between arthroscopic and open repair for the treatment of recurrent anterior shoulder instability. Given the similar results between the 2 groups, differences in length of hospital stay and cost to the patient and society point to arthroscopic repair as the more judicious treatment approach.

Instabilidade anterior traumática do ombro

The shoulder is the most unstable joint in the human body. Traumatic anterior instability of the shoulder is a common condition, which, especially in young patients, is associated with high recurrence rates. The effectiveness of non‐surgical treatments when compared to surgical ones is still controversial. The purpose of this study was to review the literature for current concepts and updates regarding the treatment of this condition.

Radial head prosthesis: results overview

Background/purposeRadial head replacement is frequently used in treatment of radial head fractures or sequela. Impossibility to restore a correct anatomy, acute elbow traumatic instability and failure of osteosynthesis hardware are the most common indications. The authors describe their case studies and results on the implantation of various radial head prostheses.MaterialsBetween June 2005 and June 2016, 28 radial head prostheses were implanted in the same number of patients with an average follow-up of 49 months (6–104). Indications for implantation were: Mason type III and IV radial head fractures and post-traumatic arthritis due to failure of previous treatments. Monopolar prostheses were used and were press-fit implanted via Kaplan’s lateral access and Kocher’s anconeus approach to the humeroradial joint. At the follow-up, assessments were made of the pain, according to the visual analogic scale, range of motion (ROM), stability and functionality according to the Mayo Elbow Performance Score, presence of osteolysis and mobilization during radiography tests, personal satisfaction of the patients, Disabilities of the Arm, Shoulder and Hand and Patient-Rated Wrist Evaluation outcomes measurements.ResultsAt the follow-up, we recorded an average level of pain of 1.8 in patients under acute treatments for radial head fractures and a marked reduction in the remaining cases from 6.7 to 2.1. ROM was found on average to be 107° of flexion–extension and 159° of pronosupination. Personal satisfaction was good–excellent in 23 cases. There was no case of infection; removal of the implant was necessary in three cases due to mobilization of the stem and oversized implants. In six cases, bone resorption was seen at the level of the prosthetic collar and it was in all cases asymptomatic.ConclusionsThe results of this study suggest that the use of prostheses, if well positioned, is a valid solution in the treatment of secondary arthritis and fractures of the radial head with poor prognosis, with good results in the reduction of pain, recovery of movement and improved quality of life.

Imaging of shoulder instability.

This extended review tries to cover the imaging findings of the wide range of shoulder injuries secondary to shoulder joint instability. Usefulness of the different imaging methods is stressed, including radiography, computed tomography (CT) and magnetic resonance. The main topics to be covered include traumatic, atraumatic and minor instability syndromes. Radiography may show bone abnormalities associated to instability, including developmental and post-traumatic changes. CT is the best technique depicting and quantifying skeletal changes. MR-arthrography is the main tool in diagnosing the shoulder instability injuries.

The Shoulder Instability-Return to Sport after Injury (SIRSI): a valid and reproducible scale to quantify psychological readiness to return to sport after traumatic shoulder instability

The main goal of this study was to propose and validate a tool to quantify the psychological readiness of athletes to return to sport following traumatic shoulder instability and conservative or surgical management. «Knee» was replaced by the term «shoulder» in the Anterior Cruciate Ligament-Return to Sport after Injury scale. This pilot test of the Shoulder Instability-Return to Sport after Injury scale (SIRSI) was performed in a group of athletes who underwent surgery for post-traumatic chronic anterior shoulder instability. The final version was then validated according to the international COSMIN methodology. A retrospective study was performed including all rugby players who had reported an episode of instability between 2012 and 2013. The WOSI and the Walch-Duplay scales were used as reference questionnaires. Sixty-two patients were included, mean age 26±5.2years old, 5 women/57 men. Patients were professional or competitive athletes (70.9%) and followed-up for 4.6±1.6years after the first episode of shoulder instability. Shoulder surgery was performed in 30/62 (48.4%) patients, a mean 1.6±1.2years after the first episode of instability. The SIRSI was strongly correlated with the reference questionnaires (r=0.80, p<10-5). The mean SIRSI score was significantly higher in patients who returned to play rugby (60.9±26.6% vs 38.1±25.6%, p=0.001). The internal consistency of the scale was high (α=0.96). Reproducibility of the test-retest was excellent (ρ=0.93, 95% CI [0.89-0.96], p<10-5). No ceiling/floor effects were found. The SIRSI is a valid, reproducible scale that identifies patients who are ready to return to the same sport after an episode of shoulder instability, whether they undergo surgery or not. III.

Arthroscopic repair of bony Bankart lesions in collision athletes.

The present study aimed to report the outcomes of acute and subacute arthroscopic bony Bankart repairs in collision athletes. We reviewed 22 consecutive rugby players with traumatic anterior glenohumeral instability who underwent arthroscopic bony Bankart repair within 4 months of injury over a 2-year period. All lesions were less than 25% of the glenoid bony area. A significant improvement was noted at three months and was maintained at 28 months postoperatively. The mean Constant score improved from 61.5 to 84.1, the mean Oxford shoulder score decreased from 26.3 to 13.6 and the mean Oxford instability score decreased from 42.9 to 13.5. The mean satisfaction score was 8.3 out of 10 at final follow-up. All patients returned to their pre-injury sporting level. Twenty patients (91%) remained stable and asymptomatic, although two (9%) had recurrent instability after further traumatic sports injuries. One required a modified Latarjet procedure, whereas the other patient sustained a soft tissue Bankart lesion and had a revision arthroscopic repair. Acute and sub-acute bony Bankart lesions in collision athletes can be addressed through arthroscopic repair with a satisfactory outcome and return to pre-injury level of sport.

Diagnosis and Management of Traumatic Patellar Instability in the Pediatric Patient.

Instability of the patella is a common cause of knee pain and dysfunction in pediatric and adolescent patients and can be due to several factors. Although some patients will recall a specific traumatic event others may not, requiring the diagnosis to be made on the basis of physical examination and imaging. Congenital dislocation and connective tissue disorders should also be considered, even in the setting of trauma. There are radiographic parameters that may identify causes of instability such as trochlear and patellar abnormalities, and magnetic resonance imaging can identify signs of trauma such as bony edema, loose osteochondral fragments, and increased tibial tubercle-trochlear groove distance. The first line of treatment for instability is most commonly nonoperative in nature; however, there are many options for operative management in the event of severe chondral injury or recurrent dislocation. Surgical management to best restore stability of the patellofemoral joint varies depending on the skeletal maturity of the patient and the source of instability (ligamentous, osteocartilaginous, or both). A combination of soft tissue, bony, and anatomic ligamentous repair or reconstruction is used to best augment patellar tracking and optimize patient outcome. [Orthopedics. 2017; 40(5):e749-e757.].

Operação de Bristow‐Latarjet modificada no tratamento na luxação glenoumeral anterior traumática recidivante

ObjectiveRetrospective case‐control study of authors experience in the modified Bristow‐Latarjet procedure for treatment of recurrent traumatic anterior glenohumeral dislocation with glenoid bone injury. MethodsSample with 102 recurrent glenohumeral dislocation cases submitted to modified Bristow‐Latarjet procedure. Indications included situations of recurrent traumatic anterior glenohumeral instability with more than two dislocation episodes and with glenoid bone attritional or fragmentary injuries, without possibility of reconstruction. Mean follow‐up time was 5.33±2.74 years (minimum 1; range 1‐13). ResultsThe mean Walch‐Duplay Score at the last evaluation was 91.23±11.46 (range 15‐100). The functional score of patients with glenoid bone loss greater than 20% did not show a significant difference in comparison with patients with glenoid bone loss lower than 20% (90 vs. 92, respectively). The functional score also did not show a significant difference between sports practice categories and between recreational and competitive practice, being excellent (greater than 90) in every category. There were no dislocation recurrences and the only complications were a case of persistent instability and a screw revision. Mild glenohumeral osteoarthrosis imaging signs were identified in 7.84% of the patients; however, their functional scores were not significantly different in comparison to other patients. ConclusionThe modified Bristow‐Latarjet procedure is a very effective procedure with few complications in the medium‐term, showing very satisfactory functional outcomes in the treatment of recurrent traumatic anterior glenohumeral dislocation associated with glenoid bone injury.