Association Between Excessive Joint Laxity and a Wider Hill-Sachs Lesion in Anterior Shoulder Instability

Native Glenoid Depth and Hill-Sachs Lesion Morphology in Traumatic Anterior Shoulder Instability

BACKGROUND

Although Hill-Sachs lesions (HSLs) are assumed to be influenced by glenoid characteristics in the context of bipolar bone loss, little is known about how glenoid concavity influences HSL morphology.

PURPOSE

To investigate the relationship between the native glenoid depth and HSL morphological characteristics.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Computed tomography images of bilateral shoulders from 151 consecutive patients with traumatic unilateral anterior shoulder instability were retrospectively reviewed. Patients were categorized into flat (<1 mm), moderate (1-2 mm), and deep (>2 mm) groups based on the native glenoid depth measured from the contralateral unaffected shoulder. The HSL morphological characteristics included size (depth, width, length, and volume), location (medial, superior, and inferior extent), and orientation (rim and center angle). The glenoid characteristics included diameter, depth, version, and bone loss. The patient, glenoid, and HSL morphological characteristics were compared among the 3 depth groups. Subsequently, the independent predictors of some critical HSL morphological characteristics were determined using multivariate stepwise regression.

RESULTS

After exclusion of 55 patients, a total of 96 patients were enrolled and classified into the flat group (n = 31), moderate group (n = 35), and deep group (n = 30). Compared with those in the flat group, patients in the deep group were more likely to have dislocation (38.7% vs 93.3%; P = .009) at the primary instability and had a significantly larger number of dislocations (1.1 ± 1.0 vs 2.2 ± 1.8; P = .010); moreover, patients in the deep group had significantly deeper, wider, larger volume, more medialized HSLs and higher incidences of off-track HSLs (all P≤ .025). No significant differences were detected among the 3 groups in HSL length, vertical position, and orientation (all P≥ .064). After adjustment for various radiological and patient factors in the multivariate regression model, native glenoid depth remained the strongest independent predictor for HSL depth (β = 0.346; P < .001), width (β = 0.262; P = .009), volume (β = 0.331; P = .001), and medialization (β = -0.297; P = .003).

CONCLUSION

The current study sheds light on the association between native glenoid depth and the morphology of HSLs in traumatic anterior shoulder instability. Native glenoid depth was independently and positively associated with HSL depth, width, volume, and medialization. Patients with deeper native glenoids were more likely to have off-track HSLs and thus require more attention in the process of diagnosis and treatment.

Management of Shoulder Instability in Patients with Underlying Hyperlaxity

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.

Suspension fixation of iliac bone grafts under arthroscopy is an effective method for the treatment of unstable bony Bankart disease of the shoulder joint in patients with joint relaxation

PURPOSE

To evaluate the results of arthroscopic autologous iliac bone graft suspension fixation combined with the Remplissage procedure in the treatment of recurrent shoulder dislocation with bony Bankart lesions and joint hyperlaxity.

METHODS

From 2018 to 2020, 22 patients with joint laxity underwent arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure due to recurrent shoulder dislocation. Clinical assessment included range of motion (forward flexion, abduction, 90° external rotation, conventional external rotation, adduction, and internal rotation), visual analog scale (VAS) score, Rowe score, University of California Los Angeles (UCLA) score, and Western Ontario Shoulder Instability Index (WOSI) score. Post-operatively, the healing of the bone graft was evaluated with computed tomography (CT) scanning.

RESULTS

All 22 patients were followed up for a mean of 19.3 ± 4.1 months. CT imaging showed that the healing time of the bone graft was 6-8 weeks. The patient satisfaction rate was 100%, there were no cases of redislocation, all patients returned to their preinjury training state, and the fear test was negative. At the final follow-up, the UCLA, VAS, Rowe, and WOSI scores were 29.8 ± 2.1, 2.2 ± 0.8, 89.4 ± 4.2, and 482.3 ± 46.2, respectively (p < 0.001).

CONCLUSION

Arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure are effective in preventing recurrent instability with joint hyperlaxity. Furthermore, no patient had redislocation.

LEVEL OF EVIDENCE

IV.

The anterior talofibular ligament ratio was greater in young men with generalized joint laxity than in those without generalized joint laxity

PURPOSE

This study aimed to evaluate the relationship between generalized joint laxity (GJL) and stress ultrasonographic (US) findings of the anterior talofibular ligament (ATFL) of healthy young men.

METHODS

The ATFL lengths of healthy young men were consecutively measured in the stress and nonstress positions. The ATFL ratio was calculated as an indicator of lateral ankle laxity. GJL was evaluated using the Beighton score (BS), and a BS of ≥ 5 was considered GJL. The manual anterior drawer test (ADT) was also performed. The results of stress US and ADT were compared between subjects with and without GJL, and the correlation between GJL and US findings was examined.

RESULTS

A total of 13 subjects with GJL and 95 without GJL were included in the study. The mean BSs in the GJL and no-GJL groups were 5.9 ± 0.9 and 1.1 ± 1.3, respectively (p < 0.0001). The GJL group showed a higher grade of ADT than the no-GJL group (p < 0.0001). Significant differences were found in the stress ATFL length (23.6 ± 1.8 mm vs. 21.7 ± 1.8 mm, p = 0.002) and ATFL ratio (1.15 ± 0.06 vs. 1.07 ± 0.03, p < 0.0001) between the GJL and no-GJL groups. Spearman's correlation coefficients showed a moderate correlation between the BS and ATFL ratio (r = 0.45, p < 0.0001).

CONCLUSION

The present study showed significant differences in the ATFL ratio and stress ATFL length between young men with and without GJL. The BS was moderately correlated with the lateral ankle laxity in this population.

LEVEL OF EVIDENCE

Level IV.

Association between the Beighton Score and Stress Ultrasonographic Findings of the Anterior Talofibular Ligament in Healthy Young Women: A Cross-Sectional Study

The Beighton score (BS) is widely used to evaluate generalized joint laxity. However, the association between the BS and lateral ankle laxity is unclear. This study compared the ultrasonographic (US) findings of the anterior talofibular ligament (ATFL) between high- (≥6) and low- (≤3) BS groups of healthy young women. The ATFL lengths of healthy young women were measured in the stress and nonstress positions using the previously reported technique from March 2021 to January 2022. The ATFL ratio (ratio of stress to nonstress ATFL length) was used as an indicator of lateral ankle laxity. The anterior drawer test (ADT) was performed. The correlation between the BS and US findings was also examined. A total of 20 (high-BS group) and 61 (low-BS group) subjects with a mean age of 23.8 ± 1.0 years were included. The high-BS group showed a higher grade of ADT than the low-BS group. No significant differences were found in the nonstress and stress ATFL lengths and ATFL ratio (1.10 ± 0.05 vs. 1.09 ± 0.05, p = 0.19) between the groups. No correlation was found between the BS and US findings. In conclusion, this study did not detect significant differences in the US findings of the ATFL between the high- and low-BS groups.