Bankart repair for unstable dislocating shoulders: Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy can lessen pain and improve function for active individuals.
Edited By: Frederick A. Matsen III, M.D., Winston J. Warme, MD
Last updated Friday, October 16, 2009
|
Figure 1 - Shoulder dislocation – the humeral head is held in the glenoid socket by compression from the rotator cuff
Shoulder dislocation – A-P and Axillary x-ray views
Shoulder dislocation – apical oblique x-ray view
Shoulder dislocation – apical oblique view showing a Hill Sachs defect of the humeral head and a defect of the anterior inferior rim of the glenoid
Shoulder dislocation – Bankart lesion with repair sutures placed through the bone edge
Shoulder dislocation - Failed arthroscopic Bankart repair
Shoulder dislocation – fracture of the anterior inferior glenoid lip
Shoulder dislocation – bone graft held in place with screws to replace the anterior – inferior glenoid bony defect
Shoulder dislocation – bone block secured in place to replace glenoid bony defect
Figure 2 - Throwing may be difficult
Figure 3 - Traumatic anterior instability
Figure 4 - Exercises to strengthen the rotator cuff
Figure 5 - Axillary incision leaves a small scar
Figure 6 - Anatomical repair for ligaments and labrum
Figure 8 - Location of cosmetic incision
Figure 10 - Repaired capsule and labrum
Figure 12 - Example of shoulder exercise
Figure 13 - Examples of shoulder exercises
Summary
Overview
The normal shoulder
is a marvel of mobility and stability. It provides more motion than any other
joint in the human body, yet the humeral head (ball of the shoulder joint)
remains precisely centered in the glenoid (the socket of the joint) throughout
the wide range of shoulder activities. One of the main stabilizing mechanisms
is concavity compression, in which the head of the humerus is held into the
glenoid concavity by the action of the rotator cuff (much like a golf ball is
held into the concavity of a golf tee).
The figure shows the humeral head, the glenoid, and one of the muscles
of the rotator cuff. The concavity of the shoulder socket is deepened by a
fibrous ring, known as the glenoid labrum (see movie 1). The glenoid labrum
greatly increases the stability of the shoulder (see movies 2 and 3). Another
stabilizing mechanism is ligament restraint in which the motion of the shoulder
is kept within the proper range by ligaments that span the joint (see movie 4).
The glenoid labrum
and the ligaments can be torn when the arm is forced backwards, allowing the
humeral head to dislocate from the glenoid. If the labrum and the ligaments do
not heal, the shoulder may continue to be unstable, allowing the ball to slip
from the center of the glenoid, even with minimal force.
When recurrent shoulder dislocations or feeling of instability
interfere with the comfort and security of the shoulder, a repair of the
ligaments and labrum by an experienced shoulder surgeon can usually restore the
stability of the joint.
QuickTime movies
The patient with an
unstable shoulder requires a thorough history and physical examination along
with proper x-rays.
The most common
form of ligament injury is the Bankart lesion, in which the ligaments are torn
from the front of the socket. A solid surgical repair requires that the torn
tissue be sewn back to the rim of the socket. Failure to secure this lesion solidly
can result in failure of the repair.
If the glenoid bone is deficient, the
shoulder may benefit from a surgery to restore the lost bony anatomy.
Characteristics of shoulder dislocations
Instability is a common cause of shoulder injury; shoulder function
can usually be improved by a surgical repair. Individuals with shoulder
instability usually notice that the shoulder feels unsteady or the ball
may actually slip out of the joint in certain positions, such as when
the arm is out to the side or across the body. People with anterior
(frontward) instability of the shoulder, have difficulty throwing
because this action depends on normal ligaments across the front of the
joint, as shown in the figure and movie 5.
QuickTime movie
Types
The most common type of shoulder instability is traumatic anterior
instability. In this type, the ligaments and the labrum at the lower
front part of the shoulder are torn by an injury that occurred when the
arm was out to the side.
The figure on the left shows in cross section the capsule and labrum
torn from the edge of the glenoid socket. Note that the damaged socket
resembles a golf tee with one of its edges broken away so that the golf
ball will tend to roll off of it. The figure on the right shows the
same injury looking at the socket with the ball removed. The gap
between the glenoid and the torn capsule and labrum is where the ball
dislocates. The tear of the labrum and capsule from the glenoid is
called a "Bankart Lesion".
Common causes of this injury include a skiing fall with the arm out to the side, a clothesline
tackle, or a blocked spike in volleyball. The shoulder may not pop back
in the joint, but instead often needs to be put back in place by
experienced assistance, such as in an emergency room. The dislocated
shoulder is given a chance to heal; then the patient is started on a
rehabilitation program.
Not infrequently, the labrum and the ligaments do not heal
completely and the shoulder continues to feel unsteady (for example
when the arm is moved out to the side and backward). These injuries
seriously compromise the stability of the shoulder. An unhealed Bankart
Lesion can result in recurrent anterior shoulder instability. When
multiple dislocations have occurred, the chances of healing without
surgery become small.
A similar type of injury can occur to the back of the joint
(traumatic posterior shoulder instability), but it is much less common.
Traumatic posterior instability arises from mechanisms such as a fall
on the outstretched hand.
There is another type of instability which arises without an
injury--atraumatic instability. In this condition the shoulder loses
its normal ability to center the ball in the glenoid socket. Not
infrequently, atraumatic instability may allow the shoulder to slip in
different directions (multidirectional instability). In this condition
there is usually nothing torn, but rather the stabilizing structures of
the shoulder decompensate.
Diagnosis
Shoulder instability must be distinguished from other causes of
shoulder dysfunction, such as arthritis, rotator cuff tear and snapping
scapula. Arthritis usually results in shoulder stiffness and pain;
X-rays show the loss of the joint space. Rotator cuff tear results in
shoulder weakness. In snapping scapula, the shoulder pops when the
shoulder blade is moved on the chest wall.
Shoulder dislocations are among the most common conditions of the
shoulder. They are more likely to be found in people from 15 to 35
years of age. Individuals over the age of 40 who dislocate their
shoulders are likely to also have a tear of the rotator cuff. Those who
have instability of one shoulder are somewhat more likely to have
instability of the opposite shoulder. People with loose joints are more
likely to have atraumatic instability.
The experienced shoulder surgeon can make a diagnosis of shoulder
instability from the patient's history and from the physical
examination. In traumatic instability, X-rays may show damage to the
humeral head (ball of the shoulder) or the glenoid (socket). Complex
tests such as MRI or arthroscopy are rarely necessary to make the
diagnosis.
It is essential that the surgeon establish the diagnosis of shoulder instability before surgical treatment is considered.
Medications
Medications cannot help the healing of a torn labrum or ligament. Mild
pain-relieving medications can be used to make shoulders with
instability more comfortable.Exercises
Shoulder exercises
to strengthen the rotator cuff, such as those shown in the figure
above, may help control an unstable shoulder. Particularly in
atraumatic instability, rotator cuff strengthening and training the
shoulder for stability are the mainstays of treatment.
In traumatic instability, the repair of the labrum and the ligaments
can usually restore stability to the joint. The restoration of
stability often allows patients to return to their usual activities.
In atraumatic instability, there is no single lesion to repair.
Thus, if exercises do not restore joint stability, careful
consideration needs to be given to the advisability of any surgical
procedure. While tightening or burning the ligaments and capsule of the
joint have been used for this condition, it is recognized that these
procedures may not specifically address the cause of the instability.
Possible benefits of surgical repair for shoulder dislocations
The effectiveness of any surgical procedure depends on the health and
motivation of the patient, the condition of the shoulder and the
expertise of the surgeon. When performed by an experienced surgeon,
surgery for shoulder instability usually leads to improved shoulder
comfort and function. This is particularly the case for individuals
with traumatic instability where the injury can be specifically
repaired. The greatest improvements are in the ability of the patient
to sleep, to perform activities of daily living, and to engage in
recreational activities.
Who should consider surgical repair for shoulder dislocations?
Surgery is considered for patients with:
- recurrent instability or feelings of unsteadiness or apprehension after a traumatic shoulder dislocation, or
- atraumatic instability that has not responded to a well-conducted rehabilitation program.
What happens without surgery?
Surgical options
For traumatic anterior shoulder instability, the most dependable
results have been obtained with an open (not arthroscopic) repair that
securely restores the attachment of the labrum and the ligaments to the
edge of the glenoid socket, as shown in the figure.
While arthroscopic approaches to surgical repair have been
developed, the chance of persistent instability is less when the repair
is carried out by open surgery. This may be due to the increased
difficulty in restoring the normal anatomy and in achieving a secure
repair using arthroscopic surgery. The return to activities after open
surgery is at least as fast as with arthroscopic repair. The cosmetic
appearance of the shoulder after open surgery done through the natural
skin creases is at least as good as that after arthroscopic repair.
For shoulders in which the bone of the anterior (front) lip of the
glenoid socket is lacking, bone grafting can be used to restore the
configuration of the socket.
For shoulders in which the back of the socket is too flat, a
reshaping of the socket (posterior glenoid osteoplasty) can be used.
For shoulders in which the soft tissues provide insufficient
stability to the shoulder, procedures can be considered to tighten the
ligaments and capsule and to thicken the glenoid labrum (the "O" ring
that surrounds the surface of the socket).
Effectiveness
In the hands of an experienced surgeon, repair for recurrent
traumatic instability has an excellent chance of restoring much of the
lost comfort and function to the unstable shoulder. With a good
rehabilitation effort and with the avoidance of additional injuries,
the result of the surgery should last for a long time.
The results of surgery for the more unusual types of instability
depend on the specifics of the shoulder problem and the type of surgery
performed. Patients should discuss the details of the problem and the
proposed procedure with the surgeon.
Urgency
Surgery for instability is not an emergency. Such a repair is an
elective procedure that can be scheduled when circumstances are
optimal. The patient has time to become informed and to select an
experienced surgeon.
Before surgery is undertaken, the patient needs to:
- be in optimal health,
- understand and accept the risks and alternatives of surgery, and
- understand the post operative rehabilitation program.
Surgery for shoulder instability should be performed when conditions
are optimal. Particularly in the case of atraumatic instability, an
extended effort at non-operative management is suggested. This is
because there is not a specific surgical repair for a specific injury.
On the other hand, in the case of recurrent instability or apprehension
after an injury, surgery can be performed whenever it becomes evident
that exercises are not effective in restoring the shoulder's ability to
function. Usually a 6- to 12-week try at strengthening exercises is
sufficient to determine whether exercises are likely to be effective.
Risks
The risks of surgery for shoulder instability include but are not limited to the following:
- infection
- injury to nerves and blood vessels
- inability to carry out the planned repair
- stiffness of the joint
- tear of the rotator cuff
- pain
- persistent instability
- the need for additional surgeries
There are also risks associated with anesthesia, including death. An
experienced shoulder surgery team will use special techniques to
minimize these risks, but cannot totally eliminate them.
Managing risk
Many of the risks of surgery for instability can be effectively
managed if they are promptly identified and treated. Infections may
require a wash out in the operating room and subsequent
antibiotic treatment. Blood vessel or nerve injury may require repair.
Stiffness may require exercises or additional surgery. Persistent
instability may require the consideration of additional surgery.
If the patient has questions or concerns about the course after surgery, the surgeon should be informed as soon as possible.
Goal of surgery
Surgery to repair instability can help restore the function and
comfort of unstable and dislocating shoulders. The goal of surgery for
traumatic anterior instability is to repair the ligaments and the
labrum that are torn from the lower front part of the glenoid socket.
The opportunity for a secure and anatomic repair is best when the
repair is done through open (not arthroscopic) surgery. As shown in the
figure, the incision is made in the normal skin creases around the
shoulder, leaving a minimal surgical scar.
Surgery for traumatic vs. atraumatic instability
Figure 6 shows how ligaments and the labrum can be
anatomically repaired so that their function is restored. If there is a
substantial loss of the bone of the anterior glenoid lip, this can be
restored by fixing a bone graft from the iliac crest (hip bone at the
belt line) outside the shoulder joint capsule.
When performed by an experienced shoulder surgeon, surgery for
traumatic anterior instability has an excellent chance of restoring
stability to the shoulder.
For traumatic posterior instability, a similar repair can be carried out through an incision over the back of the shoulder.
For atraumatic instability, exercises are the first choice in
treatment. When these are not successful, the surgical approach needs
to be tailored to the specific circumstances. If the primary direction
of atraumatic instability is posterior, a posterior glenoid osteoplasty
provides a robust reconfiguration of the shape of the glenoid so that
it provides additional stability. For multidirectional instability, a
procedure to build up the glenoid labrum may increase the effective
concavity of the glenoid socket. For patients with ligamentous
hyperlaxity (excessive range of motion of the shoulder) a ligament and
capsule tightening procedure is considered. This has been done with
open surgery (known as a capsular shift) and by arthroscopic surgery
(for example by burning and scarring the capsule).
Preparation
Surgery for instability is considered for healthy and motivated
individuals in whom shoulder dislocations or apprehension interfere
with shoulder function. Successful surgery for instability depends on a
partnership between the patient and the experienced shoulder surgeon.
The patient's motivation and dedication are important elements of the
partnership. Patients should optimize their health so that they will be
in the best possible condition for this procedure. Smoking should be
stopped a month before surgery and not resumed for at least three
months afterwards--ideally never. This is because smoking interferes
with healing of the repair. All heart, lung, kidney, bladder, tooth, or
gum problems should be managed before surgery. Any infection may be a
reason to delay the operation.
The patient's shoulder surgeon needs to be aware of all health
issues, including allergies and non-prescription and prescription
medications being taken. Some of these may need to be modified or
stopped. For instance, aspirin and anti-inflammatory medication may
affect the way the blood clots. The skin around the shoulder must be
clean and free from sores and scratches.
Before surgery, patients should consider the limitations,
alternatives, and risks of surgery. Patients should also recognize that
the result of surgery depends in large part on their efforts in
rehabilitation after surgery.
The patient needs to plan on being less functional than usual for up
to twelve weeks after the shoulder repair. Lifting, pushing, pulling,
and some activities of daily living can place stresses on the repair.
Performing usual work or chores may be difficult during this time.
Plans for necessary assistance need to be made before surgery. For
people who live alone or those without readily available help,
arrangements for home help should be made well in advance.
The shoulder surgeon should answer any questions about the surgery or the recovery period.
Timing
Surgery for shoulder instability can be delayed until the time that is best for the patient's overall well-being.Costs
The surgeon's office should be able to provide a reasonable estimate of:
- the surgeon's fee, and
- the hospital fee.
Finding an experienced surgeon
Surgery for instability is a technically demanding procedure that is
ideally performed by an experienced shoulder surgeon in a medical
center accustomed to performing these procedures at least several times
a month. Patients should inquire as to the number of instability
repairs that the surgeon performs each year and the number of these
procedures performed in the medical center each year.
Surgeons specializing in shoulder instability surgery may be located
through university schools of medicine, county medical societies, state
orthopedic societies, or professional groups such as the American
Shoulder and Elbow Surgeons Society, which offers a worldwide directory of shoulder and elbow surgeons on its web site.
Facilities
Surgery for shoulder instability is often performed in a major
medical center that performs these procedures on a regular basis. These
centers have surgical teams and facilities specially designed for this
type of surgery. They also have nurses and therapists who are
accustomed to assisting patients in their recover from this type of
surgery.
Technical details
Shoulder instability surgery is a highly technical procedure; each
step plays a critical role in the outcome. After the anesthetic has
been administered and the shoulder has been prepared, a cosmetic
incision is made in a natural skin crease at the front of the shoulder
as shown in figure 8.
This incision allows access to the seam between the deltoid and the
pectoralis major muscles. Splitting this seam allows access to the
shoulder without detaching or damaging the important deltoid muscle,
which is responsible for a significant portion of the shoulder's power.
All scar tissue is removed from the space beneath the deltoid.
The tendon of the subscapularis muscle is incised (see movie 6),
providing excellent access to the interior of the shoulder joint and a
view of the detachment of the labrum and ligaments from the glenoid
socket (see movie 7), as shown in figure 9.
The goal of the repair is to reattach securely the labrum and
ligaments to the area from which they were torn. This is accomplished
by roughening the edge of the glenoid socket (see movie 8) and drilling
small holes through its lip in the area of the tear (see movie 9).
Passing suture (surgical thread) through these holes (see movie 10) and
then through the detached labrum and ligaments (see movie 11) restores
the anatomy of the shoulder and the depth of the glenoid socket when
the suture are tied, as shown in figure 10.
At the conclusion of the repair the subscapularis tendon is repaired anatomically, as shown in figure 11 and movie 12.
A cosmetic closure of the skin incision is carried out, dressings are applied, and the arm is placed in a sling.
QuickTime movies
Anesthetic
Shoulder instability surgery may be performed under a general
anesthetic or a brachial plexus nerve block. A brachial plexus block
can provide anesthesia for several hours after the surgery. The patient
may wish to discuss their preferences with the anesthesiologist before
surgery.Length of surgical repair for shoulder dislocations
The procedure usually takes approximately one hour, but the
preoperative preparation and the postoperative recovery may add several
hours to this time. Patients often spend two hours in the recovery room
and about two days in the hospital after surgery.
Pain and pain management
Recovery of comfort and function after shoulder instability surgery
continues for many months. Shoulder instability surgery is a major
surgical procedure that involves cutting of skin, removal of scar
tissue, as well as suturing of tendons and bone. The pain from this
surgery is managed by the anesthetic and by pain medications.
Immediately after surgery, strong medications (such as morphine or
Demerol) are often given by injection. Within a day or so, oral pain
medications (such as hydrocodone or Tylenol with codeine) are usually
sufficient.
Initially pain medication is administered usually intravenously or
intramuscularly. Sometimes patient controlled analgesia (PCA) is used
to allow the patient to administer the medication as it is needed.
Hydrocodone or Tylenol with codeine are taken by mouth. Intravenous
pain medications are needed usually for only the first day or two after
the procedure. Oral pain medications are needed usually for only the
first two weeks after the procedure.
Pain medications can be very powerful and effective. Their proper
use lies in the balancing of their pain relieving effect and their
other, less desirable effects. Good pain control is an important part
of the postoperative management.
Pain medications can cause drowsiness, slowness of breathing,
difficulties in emptying the bladder and bowel, nausea, vomiting, and
allergic reactions. Patients who have taken substantial narcotic
medications in the recent past may find that usual doses of pain
medication are less effective. For some patients, balancing the
benefits and side effects of pain medication is challenging. Patients
should notify their surgeon if they have had previous difficulties with
pain medication or pain control.
Hospital stay
After surgery the patient spends about an hour in the recovery room.
A drainage tube is sometimes used to remove excess fluid from the
surgical area. The drain is usually removed on the second day after
surgery. Bandages cover the incision. They are usually changed the
second day after surgery.
Hospital discharge
Patients are discharged as soon as:
- the incision is dry,
- the shoulder is comfortable with oral pain medications,
- the patient can perform the range of motion exercises,
- the patient feels comfortable with the plans for managing the shoulder, and
- the home support systems for the patient are in place.
Discharge is usually on the second day after surgery.
Patient limitations
Early protected motion after shoulder instability surgery is helpful
for achieving optimal shoulder function. Depending on the nature of the
procedure, the surgeon will often prescribe some gentle motion
exercises within a limited range of movement.
Walking and use of the arm for gentle activities (with the elbow at
the side) are often encouraged soon after surgery, but the surgeon
should be consulted for the specifics of each individual case.
Gentle activities of daily living are often permitted with the
operated arm; however, lifting anything heavier than a cup of coffee or
using the arm for forceful activities must avoided for six to twelve
weeks, depending on the procedure.
The surgeon often wishes to check the mobility of the shoulder two
or three weeks after surgery, to assure that the shoulder has not
become too stiff.
Management of the patient's limitations requires advance planning to
accomplish the activities of daily living during the recovery period.
Patients may require some assistance with self-care, activities of
daily living, shopping, and driving for about one month after surgery.
Recovery of comfort and function after shoulder instability surgery
continues for many months after the surgery. Improvement in some
activities may be evident as early as three months. With persistent
effort, patients make progress for as long as a year after surgery.
Physical therapy
A progressive rehabilitation program after instability surgery is critical for achieving optimal shoulder function.
Instable shoulders may become stiff after surgery, so early
protected motion is often suggested. However, the repair needs to be
protected from re-injury, especially during the healing period. Thus,
the surgeon will often prescribe limited early motion for three to six
weeks and then strengthening exercises for a second six-week period.
Rehabilitation options
It is often most effective for patients to carry out their own
exercises so that they are done frequently, effectively and
comfortably. Usually, a physical therapist or the surgeon instructs the
patient in the exercise program and advances it at a rate that is
comfortable for the patient.
For the first six weeks after surgery, emphasis is placed on
protected motion. For the second six weeks, emphasis is placed on
strengthening exercises to so that strong muscles will protect the
shoulder as it returns to normal activities.
The figures show examples of some of the exercises that may be used
to develop strength and flexibility after the first six weeks following
surgery; however, the surgeon must be consulted for the specifics on
each case.
Once the range of motion and strength goals are achieved, the
exercise program can be cut back to a minimal level. However, gentle
stretching is recommended on an ongoing basis.
Patients are almost always satisfied with the increases in range of
motion, comfort, and function that they achieve with the exercise
program. If the exercises are uncomfortable, difficult or painful, the
patient should contact the surgeon promptly.
Stressful activities and activities with the arm in extreme
positions must be avoided until healing is almost complete--often for
three months after the surgery.
In general the exercises are best performed by the patient at home.
Occasional visits to the surgeon or therapist may be useful to check
the progress and to review the program.
The surgeon and therapist should be able to provide the information
on the usual cost of the rehabilitation program. The program is quite
cost-effective, because it is heavily based on home exercises.
This is a safe rehabilitation program with little risk.
Returning to ordinary daily activities
In general, patients are able to perform gentle activities of daily
living with the operated arm at the side starting two to three weeks
after surgery. Walking with the arm protected is strongly encouraged.
Driving should wait until the patient can perform the necessary
functions comfortably and confidently. This may take up to one month if
the surgery has been performed on the right shoulder, because of the
increased demands on the right shoulder for shifting gears.
With the consent of their surgeon, patients can often return to
activities such as swimming, golf and tennis at six weeks after their
surgery.
Patients should avoid activities that involve major impact (chopping
wood, contact sports, sports with major risk of falls) or heavy loads
(lifting of heavy weights, heavy resistance exercises) until three
months after surgery., and until the shoulder has excellent strength
and range of motion--essentially equivalent to the opposite side. In
this way the risk of re-injury is minimized.
Summary of surgical repair for shoulder dislocations for shoulder dislocations
Shoulder instability surgery can help restore comfort and function to
shoulders with dislocations, instability or apprehension. In the hands
of an experienced surgeon, shoulder instability surgery can be a most
effective method for restoring comfort and function to a shoulder with
recurrent instability, dislocations, or apprehension in a healthy and
motivated patient. The best results are obtained when the surgery
repairs a shoulder injury which resulted a tear of the labrum and
ligaments from the glenoid socket. In this situation the surgeon has a
good opportunity to restore the normal anatomy of the shoulder.
Pre-planning and persistent rehabilitation efforts will help assure an
optimal result for the patient.
References:
Churchill, R. S., M. Moskal, et al. (2001) "Extracapsular Anatomically Contoured Anterior Glenoid Bone Grafting for Complex Glenohumeral Instability." Techniques in Shoulder & Elbow Surgery. 2(3):210-218.
Gibb, T. D., J. A. Sidles, et al. (1991). "The effect of capsular venting on glenohumeral laxity." Clin Orthop Relat Res(268): 120-7.
Harryman, D. T., 2nd, J. A. Sidles, et al. (1990). "Translation of the humeral head on the glenoid with passive glenohumeral motion." J Bone Joint Surg Am 72(9): 1334-43.
Harryman, D. T., 2nd, J. A. Sidles, et al. (1992). "The role of the rotator interval capsule in passive motion and stability of the shoulder." J Bone Joint Surg Am 74(1): 53-66.
Jackins, S. and F. A. Matsen, 3rd (1994). "Management of shoulder instability." J Hand Ther 7(2): 99-106.
Lazarus, M. D., J. A. Sidles, et al. (1996). "Effect of a chondral-labral defect on glenoid concavity and glenohumeral stability. A cadaveric model." J Bone Joint Surg Am 78(1): 94-102.
Lenters, T. R., A. K. Franta, et al. (2007). "Arthroscopic compared with open repairs for recurrent anterior shoulder instability. A systematic review and meta-analysis of the literature." J Bone Joint Surg Am 89(2): 244-54.
Lippitt, S. and F. Matsen (1993). "Mechanisms of glenohumeral joint stability." Clin Orthop Relat Res(291): 20-8.
Matsen, F. A., 3rd (1991). "Capsulorrhaphy with a staple for recurrent posterior subluxation of the shoulder." J Bone Joint Surg Am 73(6): 950.
Matsen, F. A., 3rd (2002). "The biomechanics of glenohumeral stability." J Bone Joint Surg Am 84-A(3): 495-6.
Matsen, F. A., 3rd, C. Chebli, et al. (2006). "Principles for the evaluation and management of shoulder instability." J Bone Joint Surg Am 88(3): 648-59.
Matsen, F. A., 3rd, C. M. Chebli, et al. (2007). "Principles for the evaluation and management of shoulder instability." Instr Course Lect 56: 23-34.
Matsen, F. A., 3rd, D. T. Harryman, 2nd, et al. (1991). "Mechanics of glenohumeral instability." Clin Sports Med 10(4): 783-8.
Matsen, F. A., 3rd and J. D. Zuckerman (1983). "Anterior glenohumeral instability." Clin Sports Med 2(2): 319-38.
Matsen, L. J., C. Hettrich, et al. (2006). "Direct injection of blood into the labrum enhances the stability provided by the glenoid labral socket." J Shoulder Elbow Surg 15(6): 651-8.
Metcalf, M. H., D. G. Duckworth, et al. (1999). "Posteroinferior glenoplasty can change glenoid shape and increase the mechanical stability of the shoulder." J Shoulder Elbow Surg 8(3): 205-13.
Montgomery, W. H., Jr., M. Wahl, et al. (2005). "Anteroinferior bone-grafting can restore stability in osseous glenoid defects." J Bone Joint Surg Am 87(9): 1972-7.
Schiffern, S. C., R. Rozencwaig, et al. (2002). "Anteroposterior centering of the humeral head on the glenoid in vivo." Am J Sports Med 30(3): 382-7.
Shuman, W. P., R. F. Kilcoyne, et al. (1983). "Double-contrast computed tomography of the glenoid labrum." AJR Am J Roentgenol 141(3): 581-4.
Thomas, S. C. and F. A. Matsen, 3rd (1989). "An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability." J Bone Joint Surg Am 71(4): 506-13.
von Eisenhart-Rothe, R., F. A. Matsen, 3rd, et al. (2005). "Pathomechanics in atraumatic shoulder instability: scapular positioning correlates with humeral head centering." Clin Orthop Relat Res(433): 82-9.
Zuckerman, J. D. and F. A. Matsen, 3rd (1984). "Complications about the glenohumeral joint related to the use of screws and staples." J Bone Joint Surg Am 66(2): 175-80.
Surgery for shoulder dislocations at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington
If you are interested in making an appointment to discuss this procedure in Seattle, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-BONE (2663) to make an appointment. Our clinical center is located in Seattle Washington, USA