Treatment of Recurrent Instability.
Last updated Thursday, February 10, 2005
Open operative management
Surgical stabilization of the glenohumeral joint is considered in
traumatic instability if the condition repeatedly compromises shoulder
comfort or function in spite of a reasonable trial of internal and
external rotator strengthening and coordination exercises.Deciding to treat with surgery In contemplating a surgical approach to anterior traumatic glenohumeral
instability, it is essential to identify preoperatively any factors
that may compromise the surgical results, such as a tendency for
voluntary dislocation, generalized ligamentous laxity, multidirectional
instability, or significant bony defects of the humeral head or
glenoid. When these conditions exist, it is necessary to modify the
management approach. It is noteworthy that these factors can and should
be identified preoperatively.Surgical options In the past, many surgical procedures have been described for the
treatment of recurrent anterior glenohumeral instability. Tightening
and to some degree realigning the subscapularis tendon and partially
eliminating external rotation were the goals of the Magnuson-Stack and
the Putti-Platt procedures. The Putti-Platt operation also tightened
and reinforced the anterior capsule. Reattachment of the capsule and
glenoid labrum to the glenoid lip was the goal of the DuToit staple
capsulorrhaphy, and the Eyre-Brook capsulorrhaphy. (Eyre-Brook, 1943;
Eyre-Brook, 1948) The Bristow procedure transferred the tip of the
coracoid process with its muscle attachments to create a
musculotendinous sling across the anteroinferior glenohumeral joint. An
anterior glenoid bone buttress was the objective of the Oudard and
Trillat procedure. Augmentation of the bony anterior glenoid lip was
the objective of anterior bone block procedures, such as the
Eden-Hybinette. Haaker and Eickhoff (Haaker et al, 1993) used
autogenous bone graft to the glenoid rim for recurrent instability. In
their series recurrent instability in 24 young soldiers, they used
screws to fix an anterior iliac crest graft to the anterior glenoid
rim. At the conclusion of the graft placement, the glenoid labrum is
replaced over the graft.
Large posterolateral humeral head defects have been approached by
limiting external rotation, by filling the defect with the
infraspinatus tendon,or by performing a rotational osteotomy of the
humerus. (Cautilli, Joyce and Mackell, 1978a; Cautilli, Joyce and
Mackell, 1978b; Stufflesser and Dexel, 1977; Weber, 1969)
Evaluation of techniques As we will see below, most of the reported series on the various types
of reconstructions have yielded "excellent" results. However, it is
very difficult to determine how each author graded the results. For
example, if the patient has no recurrences after repair but has loss of
45 degrees of external rotation and cannot throw, is that a fair, good,
or excellent result? The simple fact that the shoulder no longer
dislocates cannot be equated with an excellent result. Although the
older literature suggested that the goal of surgery for anterior
dislocations of the shoulder was to limit external rotation, more
modern literature suggests that a reconstruction can both prevent
recurrent dislocation and allow a nearly normal range of motion and
comfortable function.
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