Long-term results with the Bankart and Bristow-Latarjet procedures: recurrent shoulder instability and arthropathy

Bankart repair for recurrent anterior glenohumeral instability: results at twenty-nine years' follow-up

The aim of the study was to evaluate the long-term results of the open surgical technique of Bankart repair for glenohumeral instability, a procedure that is still widely used. Thirty-nine patients were operated on at our institution by use of the Bankart technique for traumatic anterior glenohumeral instability. Thirty patients were reviewed, with a mean follow-up of 29.0 years (range, 20.3-41.0 years). After surgery, all patients recovered the pretraumatic level of sporting and professional activities. Three (ten percent) had recurrence of dislocation, one of whom underwent reoperation. Between surgery and review, 5 patients needed a total shoulder arthroplasty because of symptomatic osteoarthritis. Among the 25 remaining patients, 20 had a good subjective result, 4 had a fair result, and 1 had a poor result. The mean loss of external rotation was 24 degrees, and the mean loss of internal rotation was 19 degrees. Compared with the contralateral intact shoulder, the scores measured in the operative shoulder were significantly lower (13 points less for the Constant score, 19.8 points less for the Rowe score, and 1.4 points less for the American Shoulder and Elbow Surgeons score). As seen on the radiographs, there were some signs of osteoarthritis in 7 patients. Including the 5 patients who needed shoulder prosthetic replacement, the global rate of osteoarthritis of the study was 40%. All of the patients said that they would recommend this surgery. The Bankart technique, when used for traumatic anterior glenohumeral instability, gives reliable long-term results. However, it does not prevent the development of shoulder osteoarthritis.

Histologic analysis of bony Bankart lesions in recurrent anterior instability of the shoulder

The histologic examination of bony Bankart lesions was performed with hematoxylin-eosin staining of specimens obtained intraoperatively from 27 patients. We assessed the incidence and extent of degeneration in the bony fragment and the surrounding ligament and the relationship of such pathologic changes to several clinical and radiologic factors. Loss of osteocytes in the bony fragment was defined as osteonecrosis, and loss of fibroblasts in the surrounding ligament was defined as ligament degeneration. Although extensive ligament degeneration was noted in 8 patients (29.6%) (degeneration group), no bony fragment with extensive osteonecrosis was found. The degeneration group showed a statistically higher frequency of dislocation than the other group (P = .045). All bony fragments in the bony Bankart lesion seemed to be viable and could be used to treat the fractured glenoid defect. The surrounding ligaments in cases with a higher frequency of dislocation were often degenerative and might not be good for repair.

Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft

BACKGROUND

Anterior shoulder instability associated with severe glenoid bone loss is rare, and little has been reported on this problem. Recent biomechanical and anatomical studies have suggested guidelines for bony reconstruction of the glenoid.

HYPOTHESIS

Anatomical glenoid reconstruction will restore stability in shoulders with recurrent anterior instability owing to glenoid bone loss.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Eleven cases of traumatic recurrent anterior instability that required bony reconstruction for severe anterior glenoid bone loss were reviewed. In all cases, the length of the anterior glenoid defect exceeded the maximum anteroposterior radius of the glenoid based on preoperative assessment by 3-dimensional CT scan. Surgical reconstruction was performed using an intra-articular tricortical iliac crest bone graft contoured to reestablish the concavity and width of the glenoid. The graft was fixed with cannulated screws in combination with an anterior-inferior capsular repair.

RESULTS

At mean follow-up of 33 months, the mean American Shoulder and Elbow Surgeons score was 94, compared with a preoperative score of 65. The University of California, Los Angeles score improved to 33 from 18. The Rowe score improved to 94 from a preoperative score of 28. The mean motion loss compared with the contralateral, normal shoulder was 7 degrees of flexion, 14 degrees of external rotation in abduction, and one spinous process level for internal rotation. All patients returned to preinjury levels of sport, and only 2 complained of mild pain with overhead sports activities. No patients reported any recurrent instability (dislocation or subluxation). The CT scans with 3-dimensional reconstructions obtained 4 to 6 months postoperatively demonstrated union of the bone graft with incorporation along the anterior glenoid rim and preservation of joint space.

CONCLUSION

Anatomical reconstruction of the glenoid with autogenous iliac crest bone graft for recurrent glenohumeral instability in the setting of bone deficiency is an effective form of treatment for this problem.

Long-term results and arthropathy following the modified Bristow-Latarjet procedure

The incidence of early osteoarthritis after the modified Bristow procedure has been the subject of several articles during the last decade. Recurrent dislocation, recurrent subluxation after surgery or the procedure itself have been suggested as the main causes of degenerative changes. We assessed 19 patients who underwent the Bristow procedure for recurrent anterior dislocations of the shoulder retrospectively. Only one redislocation occurred in 20 shoulders (six women and 13 men) with an average follow-up of 7.7 years. All patients were satisfied and experienced improved stability. Three patients showed arthritic changes (two mild and one moderate), which, surprisingly, were also seen in the opposite shoulder. We therefore conclude that the occurrence of arthropathic changes after surgical stabilisation is based on multiple factors, with the initial dislocation playing a major role.

The unstable shoulder

Not all unstable shoulders are the same, and careful patient selection ensures proper treatment. Improved understanding of the mechanisms of stability, advances in imaging and arthroscopic technology mean that repeated visits to the emergency department with a painful dislocated shoulder should be a thing of the past.

Active stability of the glenohumeral joint decreases in the apprehension position

BACKGROUND

Muscle forces that compress the glenohumeral joint during mid-ranges of motion may lead to increased translational forces in end-range positions, such as the apprehension position, where symptoms of anterior instability occur.

OBJECTIVE

The objective of this study was to quantify active stability provided by eight shoulder muscles in mid-range and end-range positions through muscle force vector analysis.

METHODS

Lines of action were derived from a geometric model and muscle force magnitudes were estimated with electromyography-based techniques. Resultant muscle force vectors were calculated by summing individual muscle force vectors.

RESULTS

Compared to mid-range positions, lines of action of resultant force vectors were more anteriorly directed in end-range positions compared to 15 degrees of abduction, up to 26 degrees. Consequently, anterior stability was lowest in the apprehension position. The magnitudes of the resultant force vectors were comparable to other studies. Based on a sensitivity analysis, lines of action of resultant force vectors vary up to 6 degrees within the population.

CONCLUSIONS

Data obtained from this model will improve conservative management, post-surgical rehabilitation, and strength training protocols.

One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I--clinical results

In this prospective study on the Bristow-Latarjet repair, which started in 1980 and ended in 2001, we report the outcome in 118 shoulders where the patients have been followed up for 15 years (mean, 15.2 years; range, 14.3-20.8 years). The study was based on a physical examination, scoring with the system of Rowe et al, and the patients' subjective assessment of the operative result. After 2 years, 1 of 118 shoulders had redislocated and 98% of patients were satisfied with the operative repair. At 15 years' follow-up, 1 patient had undergone revision surgery as a result of recurrence of instability. One patient had had one redislocation during the follow-up period, and one patient reported three recurrences 3 years postoperatively. This patient has had no redislocations during the last 12 years. Furthermore, one more patient had had two recurrences 9 and 12 years after surgery but was very satisfied at follow-up. Subluxations occurred once in 4 patients and several times in 7 patients. These patients were, however, satisfied with the procedures at follow-up. One patient reported posterior subluxations at follow-up. Apprehension was significantly more common in patients with bilateral instability (P =.04) and was found in 19 of 109 shoulders. Of the patients, 90 (76%) were very satisfied with the operative result, 26 were satisfied (22%), and 1 did not know. The patient with revision surgery was considered to be dissatisfied. The incidence of bilateral shoulder instability increased from 22 of 118 (19%) at the time of surgery to 41 of 117 (35%) at 15 years after surgery. We conclude that the overall clinical results, with a satisfaction rate of 98% 15 years after the Bristow-Latarjet repair, were as good as the results reported after any operative method for recurrent anterior shoulder dislocation. However, until the radiologic part of this study is completed, we recommend the procedure only for shoulders with revision because of failed previous surgery and to surgeons familiar with the method.

Glenohumeral arthritis and its management

Glenohumeral arthritis has many different etiologies, including osteo-arthritis, secondary degenerative joint disease, rheumatoid arthritis,avascular necrosis, cuff tear arthropathy, and capsulorrhaphy arthropathy. Each of these diagnoses may have different underlying pathoanatomy and pathomechanics. The treating physician must recognize how these characteristics impair shoulder function so that the prescribed course of treatment addresses the root causes of shoulder dysfunction. The patient's age. level of physical activity, and comorbidities should be taken into account, and the intended management should be weighed against how these factors may interfere with treatment efficacy over the long-term. The goal of treatment is to restore comfort, motion, strength, and stability to the shoulder in a safe and reliable manner. Conservative treatments should aim to optimize shoulder flexibility, maintain muscle function, and reduce inflammation. Activity modification is crucial but often unreasonable to the active patient. Temporary surgical approaches include arthroscopic debridement and synovectomy. These approaches may be appropriate for a younger patient with some remaining joint space and a functional rotator cuff. Definitive surgical treatment typically involves either a proximal humerus replace mentor a total shoulder replacement. The decision to resurface the glenoid should be based on the patient's age, diagnosis, available bone stock, and physical demands. The surgeon must be familiar with the options provided by the given implant system so that the proper balance of motion and stability can be restored with a close approximation of the native anatomy. Inexperienced hands, good-to-excellent results can be achieved in greater than 90% of properly selected patients. Glenoid component failure is one of the most common complications of shoulder arthroplasty, highlighting the need to select carefully patients in whom glenoid resurfacing is warranted.

Glenohumeral arthrosis in anterior instability before and after surgical treatment: incidence and contributing factors

BACKGROUND

Few large series of arthropathy related to anterior glenohumeral instability are available in the orthopaedic literature, preventing analysis of the incidence and the risk factors of preoperative and postoperative glenohumeral arthritis.

HYPOTHESIS

Anterior stabilization surgery influences the risk factors of glenohumeral arthritis.

STUDY DESIGN

Retrospective review.

METHODS

There were 570 patients who underwent an instability procedure. Clinical and radiographic preoperative data were collected for these patients. Arthritis was evaluated preoperatively and postoperatively with the Samilson classification. The mean age at surgery was 31.9 years. Follow-up averaged 6.5 years.

RESULTS

The preoperative incidence of arthritis was 9.2%. Arthritic risk factors were older age at the initial dislocation and at surgery, increased length of time from the initial dislocation until surgery, and the presence of osseous glenoid rim lesions. Postoperative arthritis in patients without any preoperative arthritis occurred in 19.7% and was correlated with older age at the initial dislocation and at surgery, increased number of dislocations, and longer follow-up. Decreased external rotation at latest follow-up correlated with arthritis, although whether this was the cause or the effect was unclear.

CONCLUSIONS

Similar factors contribute to preoperative and postoperative arthritis in patients with anterior glenohumeral instability, suggesting that surgery does not influence the risk factors of arthritis. Although decreased external rotation with the arm at side statistically correlated with arthritis in this study, the authors were unable to establish this as an effectual relationship because nearly all patients with glenohumeral osteoarthritis, whether instability related or not, have decreased external rotation.

Diagnosis and Management of the Painful Shoulder. Part 2: Examination, Interpretation, and Management

Diagnosis, interpretation and subsequent management of shoulder pathology can be challenging to clinicians. Because of its proximal location in the schlerotome and the extensive convergence of afferent signals from this region to the dorsal horn of the spinal cord, pain reference patterns can be broadly distributed to the deltoid, trapezius, and or the posterior scapular regions. This pain behavior can make diagnosis difficult in the shoulder region, as the location of symptoms may or may not correspond to the proximity of the pain generator. Therefore, a thorough history and reliable physical examination should rest at the center of the diagnostic process. Effective management of the painful shoulder is closely linked to a tissue-specific clinical examination. Painful shoulder conditions can present with or without limitations in passive and or active motion. Limits in passive motion can be classified as either capsular or noncapsular patterns. Conversely, patients can present with shoulder pain that demonstrates no limitation of motion. Bursitis, tendopathy and rotator cuff tears can produce shoulder pain that is challenging to diagnose, especially when they are the consequence of impingement and or instability. Numerous nonsurgical measures can be implemented in treating the painful shoulder, reserving surgical interventions for those patients who are resistant to conservative care.