Shoulder and Elbow cases anterior instability

A 28-year-old, recreational athlete presents to your clinic with shoulder pain and a history of multiple subluxations in the past. He describes a recent frank dislocation that had to be “popped” back in place on the field. His imaging is shown below (Fig. 2–34).

 

 

 

Figure 2–34

What treatment is most appropriate?

1. Capsulolabral repair

2. Latarjet

3. Remplissage

4. Remplissage and Bankart procedures

5. Putti–Platt procedure

 

Discussion

The correct answer is (A). The question describes a young, athletic patient with a history of multiple instability events, and as such, he is very prone to subsequent instability events. Although the initial treatment involves physical therapy, it is likely that this patient will require surgical stabilization. The image demonstrates a located shoulder with a small Hill–Sachs lesion and no significant glenoid bone loss, making capsulolabral repair the appropriate treatment option. For a patient with a failed capsulolabral repair or significant anterior bone loss (>20%), a Latarjet procedure is employed. A Remplissage (Answer C) is indicated for a large Hill–Sachs lesion, which is not seen on the image provided. A Putti–Platt procedure (Answer E) involves a vest-over-pants imbrication with the goal of shortening the subscapularis and anterior capsule. This procedure was historically used for anterior instability but has been replaced by more modern techniques as it causes a significant restriction of external rotation.

Following a single, traumatic, anterior dislocation, several factors may contribute to a patient developing recurrent anterior instability. The most common of these is an anteroinferior capsulolabral avulsion. Other contributing factors include glenoid bone loss (which may be in the form of an identifiable fragment or attritional loss), a Hill–Sachs lesion, generalized hyperlaxity, younger age, and damage to static shoulder stabilizers. These include:

 

Anterior band of IGHL—provides restraint to anterior and inferior subluxation with the arm in 90 degrees of abduction and external rotation (late cocking phase)

 

MGHL provides restraint to anterior and posterior subluxation with arm in 45 degrees of abduction and external rotation

 

SGHL provides restraint to inferior subluxation with arm at the side

On evaluation, a thorough history and physical examination should be performed. Understanding the patient’s functional demands and the activities and positions that are associated with instability events will be helpful in guiding treatment and formulating a rehab strategy. The physical examination begins with a

visual examination followed by range of motion, strength testing, and a thorough neurovascular examination; these are usually unremarkable. Specific tests and signs include the load and shift test, sulcus sign, and apprehension/relocation test. The load and shift test is performed in both the standing and supine position. The examiner stands to the side of the patient and stabilizes the shoulder girdle with one hand while grasping and pushing the humeral head anteriorly and posteriorly with the other hand. A grade is assigned to the degree of humeral head translation.

Grade 0—minimal translation

Grade 1—humeral head translates to the glenoid rim

Grade 2—humeral head translates over the glenoid rim but spontaneously reduces Grade 3—humeral head dislocates and does not spontaneously reduce

The sulcus sign is elicited by pulling straight down on the humerus of a standing, relaxed patient. A positive test is marked by a divot between the acromion and humeral head that is 2 cm or greater. The apprehension–relocation test is performed by placing the arm in 90 degrees of abduction and external rotation; passive external rotation beyond this associated with pain or a sensation of impending dislocation is indicative of a positive test. The examiner’s second hand is then placed anteriorly and used to push the humeral head posteriorly; this describes the relocation test, and patients will report an alleviation of the sensation of impending dislocation.

Treatment usually begins with conservative measures including physical therapy to work on strengthening of the dynamic shoulder stabilizers and activity modification to avoid proactive positions. Patients will frequently require surgical treatment, particularly those with a history of significant trauma. Broadly speaking, there are two surgical options: those that deal primarily with soft tissue and those that involve bony reconstruction of the anterior glenoid. The type of surgical treatment employed is based on the degree of glenoid bone loss. For bone loss

<15%, a standard arthroscopic capsulolabral repair can be utilized. For bone loss

>25%, a bony stabilization procedure is necessary. In the 15% to 25% range, opinions vary, and one must exercise clinical judgment. Specific treatment options are further discussed in Table 2–1.

Additional Questions

An 18-year-old male with a history of recurrent anterior instability is seeking surgical treatment after having failed a course of extensive PT. His examination demonstrates a Grade 2 load and shift test and positive sulcus sign. His MRA is

shown in Fig. 2–35.

 

 

 

Figure 2–35

 

What is the best treatment option?

1. Putti–Platt procedure

2. Bristow coracoid transfer

3. Meyer–Burgdorff procedure

4. Isolated Bankart repair

5. Bankart repair with capsular shift

 

Discussion

The correct answer is (E). The question stem describes recurrent anterior instability that has failed conservative treatment and hence necessitates surgical intervention. Several surgical procedures have been described for anterior instability. In the absence of significant bone loss, the most common procedure utilized is an arthroscopic Bankart repair and capsular shift. The image provided does not demonstrate any significant bone loss, making this the correct answer. An isolated Bankart repair (Answer D) will restore the bumper effect that an intact labrum provides but will not restore the sling effect of the normal anterior capsule. A Bristow procedure (Answer B) would be appropriate in the setting of significant anterior glenoid bone loss. The other procedures represent nonanatomic procedures that are largely historical.

The various procedures described for anterior instability are listed in Table 2–4.

 

Table 2–4 DESCRIBED PROCEDURES FOR SHOULDER INSTABILITY

 

Procedure	Description
Putti–Platta	Vest-over-pants imbrication with the goal of shortening the subscapularis and anterior capsule. Leads to over-constraint and stiffness
Magnuson–Stacka Subscapularis transfer to a more lateral position. Leads to over-constraint and stiffness Webera Humeral rotational osteotomy Meyer–Burgdorff a Glenoid anteverting osteotomy Boyd–Siska Transfer of biceps laterally and posteriorly Arthroscopic Bankart Bone anchors and sutures are used to reattach the anterior labrum to the glenoid repair Open Bankart repair Largely being replaced by arthroscopic techniques, however, may be used in the setting of large associated Hill–Sachs lesions or HAGL lesions Capsular shift Frequently done in conjunction with a Bankart repair. Together these are referred to as a capsulolabral repair Du-Toit A Bankart repair using staples instead of suture—uncommonly used secondary to a high complication rate Bristow coracoid Used for anterior glenoid bone loss. Transfer of coracoid bone and strap transfer muscles for a sling effect. The coracoid is transferred and fixed perpendicular to the base of the anterior glenoid Latarjet Compared to the Bristow a larger piece of coracoid is transferred and placed parallel to the anterior glenoid. This procedure is generally favored over the Bristow Bone graft Bone graft to the anterior glenoid is often employed in revision situations with significant anterior glenoid bone loss. The inner table of the iliac crest has a contour that matches the anterior glenoid with the concave inner table facing laterally and the cancellous bone sitting on the glenoid rim
Glenoid ORIF	If a large anterior glenoid fragment is evident as may be the case after a single acute dislocation event re-fixating with anchors or screws can often restore anterior stability

aHistoric procedures that have been replaced by more “anatomic” reconstructions.

 

A 22-year-old male with a history of multiple shoulder dislocations was treated with an arthroscopic Bankart repair 9 months ago. Over the last 3 months, he has tried returning to sports but reports continued anterior subluxation events. Revision surgery has been recommended, and he comes to you for a second opinion. His CT

scan is shown above (Fig. 2–36).

 

 

 

Figure 2–36

 

What is the most appropriate treatment option?

1. Continue with physical therapy and focus on dynamic stabilizer strengthening

2. Latarjet procedure

3. ORIF of bony fragment

4. Repair of Hill–Sachs lesion

5. Boyd–Sisk procedure

 

Discussion

The correct answer is (B). In patients who have undergone a capsulolabral repair for instability and continue to be symptomatic, it is important to carefully assess the degree of glenoid bone loss. This is best done with a 3D CT scan. When viewing sagittal images, the inferior two-thirds of the glenoid should be a perfect circle. Bony defects can be appreciated by loss of this circle with bone missing from the 230 to 430 position. This may result in the glenoid taking on the classic inverted pear-shaped configuration that is associated with recurrent anterior instability (see Fig. 2–37). The average circle diameter is 24 mm and the average bone loss associated with a pear-shaped glenoid is 35% or 7.5 mm off the anterior rim. The critical amount of bone loss that destabilizes the shoulder is between 15% and 25% hence bone loss at or above this level must be treated with a bony procedure rather than capsulolabral repair.

 

 

 

Figure 2–37 Sagittal depiction of the glenoid. Bone loss of 8 mm in the AP direction corresponds to approximately 35% and will likely require bony reconstruction. (Reproduced with permission from Piasecki DP, Verma NN, Romeo AA, et al. Glenoid Bone Deficiency in Recurrent Anterior Shoulder Instability: Diagnosis and Management. JAAOS 2009;17(8):482–493.)

 

Answer A is incorrect as additional PT after a year is not going to make a difference especially given the degree of bone loss. Answer C is incorrect as no fixable bony fragment is seen. Answer D is incorrect as no significant Hill–Sachs lesion is seen on imaging; however, a Hill-Sachs lesion, if present, would contribute to ongoing instability. A Boyd–Sisk (Answer E) procedure was historically described for anterior instability but is no longer used.

 

Objectives: Did you learn...?

 

The physical examination findings associated with anterior instability?

 

The current and historical surgical procedures used to treat anterior instability and the indications for their use?

 

How to quantify and treat glenoid bone defects?