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Management of Shoulder Instability in Patients with Underlying Hyperlaxity. Curr Rev Musculoskelet Med 2023; 16:123-144. [PMID: 36821029 PMCID: PMC10043087 DOI: 10.1007/s12178-023-09822-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD). RECENT FINDINGS Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.
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Hurley ET, Matache BA, Wong I, Itoi E, Strauss EJ, Delaney RA, Neyton L, Athwal GS, Pauzenberger L, Mullett H, Jazrawi LM. Anterior Shoulder Instability Part I-Diagnosis, Nonoperative Management, and Bankart Repair-An International Consensus Statement. Arthroscopy 2022; 38:214-223.e7. [PMID: 34332055 DOI: 10.1016/j.arthro.2021.07.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/06/2021] [Accepted: 07/13/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability. METHODS A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors. CONCLUSION Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
- Eoghan T Hurley
- NYU Langone Health, New York, New york, USA; Sports Surgery Clinic, Dublin, Ireland.
| | | | - Ivan Wong
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Eiji Itoi
- Tohoku University School of Medicine, Sendai, Japan
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Hoshika S, Sugaya H, Takahashi N, Matsuki K, Tokai M, Morioka T, Ueda Y, Hamada H, Takeuchi Y. Arthroscopic Soft Tissue Stabilization With Selective Augmentations for Traumatic Anterior Shoulder Instability in Competitive Collision Athletes. Am J Sports Med 2021; 49:1604-1611. [PMID: 33844602 DOI: 10.1177/03635465211003091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many surgeons prefer bony stabilization including Bristow or Latarjet procedures for shoulder instability in collision athletes, even though several potential complications have been reported. There has been a limited number of studies on the midterm outcomes of arthroscopic soft tissue stabilization for anterior shoulder instability in competitive collision athletes. PURPOSE To assess the outcomes of arthroscopic soft tissue stabilization in combination with selective augmentation procedures for collision athletes with traumatic anterior shoulder instability. STUDY DESIGN Case series; Level of evidence, 4. METHODS We retrospectively assessed rugby or American football players (<40 years old) who underwent arthroscopic Bankart or bony Bankart repair with selective augmentations (rotator interval closure and/or Hill-Sachs remplissage) for traumatic anterior shoulder instability between January 2012 and March 2017. Shoulders that required other bony procedures were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score and Subjective Shoulder Value sports score) were investigated. RESULTS This study included 113 shoulders in 100 patients with a mean age of 20 years (range, 15-36 years) at surgery. Rotator interval closure was performed on 36 shoulders in addition to Bankart repair, and rotator interval closure and Hill-Sachs remplissage were performed on 77 shoulders. The mean follow-up period was 44 months (range, 24-72 months). Of the 113 shoulders, 4 (3.5%) experienced postoperative dislocation, but there were no complications. A total of 93 athletes (93%) attained complete or near complete preinjury sports activity levels. The mean Rowe score significantly improved from 36 (range, 10-75) at presurgery to 96 (range, 35-100; P = .003) at postsurgery. The mean Subjective Shoulder Value sports score significantly improved after surgery, from a mean preoperative score of 22 (range, 0-50) to a postoperative score of 92 (range, 64-100; P = .002). CONCLUSION Our treatment strategy, where arthroscopic soft tissue stabilization was combined with selected augmentations, provided good clinical outcomes for competitive collision athletes in terms of low rates of recurrence and complication, a high rate of return to sports, and good shoulder function.
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Affiliation(s)
- Shota Hoshika
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | | | - Norimasa Takahashi
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | - Keisuke Matsuki
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | | | - Takeshi Morioka
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | - Yusuke Ueda
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | - Hiroshige Hamada
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
| | - Yasutaka Takeuchi
- Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine and Joint Center, Funabashi, Japan
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Ruzbarsky JJ, Haber D, Arner JW, Hackett TR. The Saber Technique for Biceps Tenotomy. Arthrosc Tech 2020; 9:e965-e968. [PMID: 32714806 PMCID: PMC7372501 DOI: 10.1016/j.eats.2020.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/15/2020] [Indexed: 02/03/2023] Open
Abstract
Long head of the biceps (LHB) pathology is a prevalent cause of shoulder pain. Arthroscopic tenotomy and tenodesis are performed for treatment at increasing frequency. When LHB pathology is the only glenohumeral intra-articular pathology that needs to be addressed, and an LHB tenotomy or subpectoral LHB tenodesis is planned, it is unnecessary and potentially harmful to establish an anterior rotator interval portal. The objective of this Technical Note is to describe a minimally invasive technique for LHB tenotomy at the supraglenoid tubercle without the need for establishing an accessory portal.
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Affiliation(s)
- Joseph J. Ruzbarsky
- Address correspondence to Joseph J. Ruzbarsky, Steadman Philippon Research Institute, 181 W Meadow Dr., Vail, CO 81657.
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Komplikationsmanagement in der operativen Versorgung der glenohumeralen Schulterinstabilität. ARTHROSKOPIE 2020. [DOI: 10.1007/s00142-020-00358-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Smith JR, Field LD. Rotator Interval Plication: The "Seamster" Technique. Arthrosc Tech 2019; 8:e1099-e1104. [PMID: 31921580 PMCID: PMC6948111 DOI: 10.1016/j.eats.2019.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/20/2019] [Indexed: 02/03/2023] Open
Abstract
The indications and best technique for plication of the rotator interval capsule, performed as a supplemental procedure at the time of arthroscopic shoulder stabilization, remain a controversial topic. There are currently no well-accepted surgical indication guidelines that have been established. Several biomechanical studies, however, have demonstrated the important contribution of the rotator interval capsule to stability of the glenohumeral joint, and the utilization of rotator interval plication in patients with glenohumeral instability has been supported in several publications. The indications for and surgical steps to accomplish the arthroscopic "seamster" technique for rotator interval plication, used by the authors for >20 years, is described.
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Affiliation(s)
| | - Larry D. Field
- Address correspondence to Larry D. Field, M.D., Upper Extremity Service, Sports Medicine and Arthroscopy Fellowship, Mississippi Sports Medicine and Orthopaedic Center, 1325 East Fortification Street, Jackson, MS 39202, U.S.A.
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Peebles LA, Aman ZS, Preuss FR, Samuelsen BT, Zajac TJ, Kennedy MI, Provencher MT. Multidirectional Shoulder Instability With Bone Loss and Prior Failed Latarjet Procedure: Treatment With Fresh Distal Tibial Allograft and Modified T-Plasty Open Capsular Shift. Arthrosc Tech 2019; 8:e459-e464. [PMID: 31194075 PMCID: PMC6551465 DOI: 10.1016/j.eats.2019.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/06/2019] [Indexed: 02/03/2023] Open
Abstract
Recurrent multidirectional shoulder instability (MDI) is a challenging clinical problem, particularly in the setting of connective tissue diseases, and there is a distinct lack of literature discussing strategies for operative management of this unique patient group. These patients frequently present with significant glenoid bone loss, patulous and abnormal capsulolabral structures, and a history of multiple failed arthroscopic or open instability procedures. Although the precise treatment algorithm requires tailoring to the individual patient, we have shown successful outcomes in correcting recurrent MDI in the setting of underlying connective tissue disorders by means of a modified T-plasty capsular shift and rotator interval closure in conjunction with distal tibial allograft bony augmentation. The purpose of this Technical Note was to describe a technique that combines a fresh distal tibial allograft for glenoid bony augmentation with a modified T-plasty capsular shift and rotator interval closure for the management of recurrent shoulder MDI in patients presenting with Ehlers-Danlos syndrome or other connective tissue disorders after failed Latarjet stabilization.
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Affiliation(s)
- Liam A. Peebles
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Zachary S. Aman
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Fletcher R. Preuss
- University of Virginia School of Medicine, Charlottesville, Virginia, U.S.A
| | | | | | | | - Matthew T. Provencher
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Matthew T. Provencher, M.D., C.A.P.T., M.C., U.S.N.R., The Steadman Clinic, 181 W Meadow Dr, Ste 400, Vail, CO 81657, U.S.A.
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