Treatment of Recurrent Instability.
Last updated Thursday, February 10, 2005
Complications of anterior repairs
Complications of surgical repairs for anterior glenohumeral instability
may be grouped into several categories. (Lazarus and Harryman, 1996)
Postoperative complications The first includes complications that may follow any surgical
procedure. Of primary importance in this category is postoperative
infection. Thorough skin preparation, adhesive plastic drapes, and
prophylactic antibiotics are useful in reducing contamination by
axillary bacterial flora. It also is important to prevent the
accumulation of a significant hematoma by achieving good hemostasis,
obliterating any dead space, and using a suction drain if significant
bleeding persists. Finally, it is important to keep the axilla clean
and dry postoperatively by using a gauze sponge as long as the arm is
held at the side.Postoperative recurrent instability The second category of complications consists of postoperative
recurrent instability. The published incidence of recurrent dislocation
after anterior repairs ranges from zero to 30% per cent. It is
noteworthy that many of the reports included in their tally only
recurrent dislocation, rather than including recurrent subluxation or
recurrent apprehension. A 1975 review of 1634 reconstructions compiled
from the literature revealed that the incidence of redislocation
averaged 3 per cent. (Rockwood, 1984) In a 1983 review of 3076
procedures this incidence was unchanged. (Roca and Ramos-Vertiz, 1962)
This review included 432 Putti-Platt operations, 571 Magnuson-Stack
operations or modifications, 513 Bankart operations or modifications,
45 Saha operations, 203 Bankart--Putti-Platt combinations, 639 Bristow
operations, 115 Badgley combined procedures, 254 Eden-Hybbinette
operations, 277 Gallie operations or modifications, and 27 Weber
operations.
The incidence of recurrence is underestimated by studies with only
two years followup. Morrey and Jones, (Morrey and Janes, 1976) in a
long-term follow-up study of 176 patients that averaged 10.2 years,
found a redislocation rate of 11 per cent. The operative
reconstructions were of the Bankart and Putti-Platt types. In 7 of the
20 patients, redislocation occurred two years or more after surgery.
The need for long-term follow-up was further emphasized in a recent
study by O'Driscoll and Evans, (O'Driscoll and Evans, 1988) who
followed 269 consecutive staple capsulorrhaphies for a minimum of 8.8
years. Twenty-one per cent of 204 shoulders demonstrated redislocation;
this incidence increased progressively with the length of follow-up.
Rowe and colleagues (Rowe et al, 1984) reported on the management of
39 patients with recurrence of instability after various surgical
repairs. Of 32 who were reoperated, 84 per cent had not had effective
repair of the Bankart lesion at the initial surgery. When the
previously unrepaired Bankart lesion was repaired at revision surgery,
almost all (22 of 24) the shoulders became stable and remained so for
at least 2 years. Excessive laxity was thought to be the primary cause
of instability in only four shoulders. Ungersbock et al (Ungersbock,
Michel and Hertel, 1995) also found that rounded or deficient glenoid
rims and large unhealed Bankart lesions were associated with failure of
surgical repairs for anterior instability. Zabinski et al reported
similar findings: over half of their failed instability repairs were
associated with unhealed Bankart lesions; most regained stability after
revision repair. (Zabinski et al, 1995) By contrast only nine of the
twenty-one shoulders with recurrent multidirectional instability
obtained a good/excellent result from revision surgeries.
Refractory instability can be a major problem, whether due to bone
deficiency, poor quality soft tissues, musculotendinous failure, or
decompensation of neuromuscular control (Fig. 14-157). Richards et al
(Richards et al, 1993) have described the challenges associated with
trying to manage such cases of refractory or "terminal" instability
using glenohumeral arthrodesis. Failure of diagnosis The third major category of complications arises from failure of
diagnosis. It is essential to differentiate traumatic unidirectional
instability (TUBS syndrome) from atraumatic multidirectional
instability (AMBRII syndrome) before carrying out any surgical repair.
The consequences of mistaking multidirectional instability for pure
anterior instability are substantial. In this situation, if only the
anterior structures are tightened, limited external rotation along with
the resulting obligate posterior subluxation may lead to the rapid loss
of glenohumeral articular cartilage and capsulorrhaphyarthropathy.
(Hawkins and Angelo, 1990b; Kronberg and Brostrom, 1990; Lusardi,
Wirth, Wurtz et al, 1993) This complication can be prevented only by
accurate preoperative diagnosis and by appropriate surgery which avoids
unnecessary capsular tightening.
The importance of an accurate diagnosis and subsequent treatment
cannot be overemphasized: 20 shoulders (53%) in the study of Cooper and
Brems (Cooper and Brems, 1992) and 22 shoulders (15%) in the report of
Wirth and Rockwood (Wirth, Lyons and Rockwood, 1993) had been
previously operated on for mistaken diagnosis. In the latter report,
diagnostic errors included (in order of decreasing frequency) rotator
cuff disease, biceps tendinitis, thoracic outlet syndrome, and cervical
disk herniation. Neurovascular injuries The fourth category of operative complications consists of
neurovascular injuries. The musculocutaneous nerve runs as a single or
multipartite structure obliquely through the coracobrachialis, a
variable distance distal to the coracoid process. In this location it
may be injured by (1) dissection to free up the coracoid process, (2)
retraction, or (3) inclusion in suture. (Shively and Johnson, 1984)
Helfet (Helfet, 1958) described one case in which the nerve had a high
penetration into the coracobrachialis and became injured where the
conjoined tendon entered the slit made in the subscapularis tendon for
a Bristow procedure. The axillary nerve may be injured in dissection
and suture of the inferior capsule and subscapularis. (Loomer and
Graham, 1989) Richards and associates (Richards et al, 1987) presented
nine patients sustaining nerve injuries during anterior shoulder repair
(three Bristows and six Putti-Platts). Seven involved the
musculocutaneous nerve and two the axillary nerve. Two of the nerves
were lacerated, five injured by suture, and two injured by traction.
These nerve injuries are relatively more common during reoperation
after a previous repair; in this situation the nerves are tethered by
scar tissue and thus are more difficult to mobilize out of harm's way.
Neurovascular complications can best be avoided by good knowledge of
local anatomy (including the possible normal variations), good surgical
technique, and a healthy respect for the change in position and
mobility of the neurovascular structures after a previous surgical
procedure in the area. The authors recommend that the axillary nerve be
routinely palpated and protected during all anterior reconstructions.
(Matsen, Lippitt, Sidles et al, 1994; Rockwood, 1984)Hardware complications The fifth category of complications includes those related to
hardware inserted about the glenohumeral joint. (Cayford and Tees,
1931; Hawkins et al, 1982) The screw used to fix the coracoid fragment
in Bristow procedures has a particular potential for being problematic.
(Nielsen and Nielsen, 1982; Quigley and Freedman, 1974) Loosening of
the screw may result from rotation of the coracoid fragment as the arm
is raised and lowered; this rotation may contribute to screw loosening.
Artz and Huffer (Artz and Huffer, 1972) and Fee et al (Fee et al, 1978)
have reported a devastating complication in which the screw became
loose and caused a false aneurysm of the axillary artery with a
subsequent compression of the brachial plexus and paralysis of the
upper extremity. Similar complications have been reported as late as
three years after surgery. (Fee, McAvoy and Dainko, 1978) In other
instances the Bristow screw has damaged the articular surface of the
glenoid and humeral head when placed too close to the glenoid lip,
irritated the infraspinatus or its nerve when too long, or affected the
brachial plexus when it became loose.
Staples used to attach the capsule to the glenoid may miss their
target, damaging the humeral or glenoid articular cartilage. Staples
also may become loose from repeated pull of the muscles and capsule
during shoulder usage, particularly if they were not well seated in the
first place. O'Driscoll and Evans (O'Driscoll and Evans, 1988) reported
an 11 per cent incidence of staple complications after the DuToit
procedure. If screws and staples migrate into the intra-articular
region, significant damage to the joint surfaces may result. Metal
fixation may injure the biceps tendon in a Magnuson-Stack procedure.
Zuckerman and Matsen (Zuckerman and Matsen, 1984) reported a series
of patients with problems related to the use of screws and staples
about the glenohumeral joint; 21 had problems related to the Bristow
procedure and 14 to the use of staples (either for capsulorrhaphy or
subscapularis advancement). The time between placement and symptom
onset ranged from 4 weeks to 10 years. Screws and staples had been
incorrectly placed in 10 patients, had migrated or loosened in 24, and
had fractured in 3. Almost all patients required reoperation, at which
time 41 per cent had a significant injury to one or both of the joint
surfaces.
Recent attempts to soften the potential complications
of hardware with bioabsorbable implants have been reported. However,
Edwards and colleagues (Edwards et al, 1994) reported the adverse
effects of a polyglyconate polymer in six shoulders after repair of the
glenoid labrum. All patients reported increasing pain and loss of
motion requiring arthroscopic debridement. Dual-contrast
arthrotomography revealed bony cystic changes around the implant, and
histologic evaluation was consistent with a granulomatous reaction.
Taken together, these data suggest that primary repairs using
hardware are more risky yet no more effective than anatomic soft tissue
repairs: the recurrence rates of techniques using screws and staples
are no better than with hardware-free repairs. Risks are incurred with
hardware that simply do not exist with other repair techniques. The
depth and variable orientation of the glenoid at surgery provides
substantial opportunity for hardware misplacement (into the joint,
under the articular cartilage, subperiosteally, out the back, too high,
too low, too medial, too prominent anteriorly, and too insecurely). The
large range of motion of the shoulder with frequent vigorous challenges
to its stability creates an opportunity for hardware loosening and for
irreversible surface and neurovascular damage. Limited range of motion The sixth category of complications is limited motion. Limited range
of motion, especially external rotation, has been reported after the
Magnuson-Stack and the Putti-Platt procedures. It has also been noted
after the Bristow procedure, which was supposed to be free of this
problem. (Bardenheuer, 1886; Braly and Tullos, 1985; Hill and
McLaughlin, 1963) Hovelius and colleagues (Hovelius, Thorling and
Fredin, 1979) reported an average loss of external rotation of 21
degrees with the arm in abduction. In their series of 46 patients with
continuing problems after shoulder reconstruction, Hawkins and Hawkins
(Hawkins and Hawkins, 1985) found that 10 had stiffness related to
limited external rotation.
MacDonald and colleagues (MacDonald et al, 1992) described release
of the subscapularis muscle in 10 patients who had an internal rotation
contracture after shoulder reconstruction for recurrent instability. At
an average follow-up of 3 years, all patients reported less pain and
demonstrated an average increase of 27° of external rotation.
Lazarus and Harryman (Lazarus and Harryman, 1996) pointed out that
each centimeter of surgical lengthening of excessively tightened
capsule regains approximately 20° of rotation.
Rockwood et al reported on 19 patients (20 shoulders) who had been
treated for severe loss of external rotation of the glenohumeral joint
after a previous anterior capsulorrhaphy for recurrent instability.
(Lusardi, Wirth, Wurtz et al, 1993) All 20 shoulders were managed by
release of the anterior soft tissue. The average increase in external
rotation was 45°(range, 25° to 65°). Secondary degenerative joint disease The seventh complication is that of capsulorrhaphy arthropathy, or
secondary degenerative joint disease resulting from surgery for
recurrent instability. (Angelo and Hawkins, 1988; Kronberg and
Brostrom, 1990; Lazarus and Harryman, 1996; Lusardi, Wirth, Wurtz et
al, 1993; Matsen, Lippitt, Sidles et al, 1994) This condition most
commonly arises from excessive surgical tightening of the anterior
capsule causing obligate posterior translation with secondary
degenerative joint disease (see Fig. 14-48, Fig. 14-50). This condition
can be prevented by assuring that the shoulder has a functional range
of motion following repair for instability and by performing a surgical
release of shoulders with major limitations of external rotation.
Severe capsulorrhaphy may require shoulder arthroplasty with
normalization of the posteriorly inclined glenoid version. (Kronberg
and Brostrom, 1990; Lazarus and Harryman, 1996; Lusardi, Wirth, Wurtz
et al, 1993; Matsen, Lippitt, Sidles et al, 1994)
Angelo and Hawkins (Angelo and Hawkins, 1988) reported eight
patients with disabling degenerative arthritis presenting an average of
15.1 years after a Putti-Platt procedure. None of the patients had ever
gained external rotation beyond zero degrees after their repair.
Lusardi et al (Lusardi, Wirth, Wurtz et al, 1993) described 20
shoulders with severe loss of external rotation after anterior
capsulorrhaphy and spoke to the risk of posterior subluxation and
secondary degenerative joint disease under this circumstance.
Rockwood et al (Lusardi, Wirth, Wurtz et al, 1993) reported on 7
shoulders in which the humeral head had been subluxated or dislocated
posteriorly and 16 shoulders had been affected by mild to severe
degenerative joint disease after surgical repair for recurrent anterior
dislocation. Nine required shoulder arthroplasty because of severe
joint surface destruction. At a mean follow-up of 48 months, all
shoulders had an improvement in the ratings for pain and range of
motion. Failure of the subscapularis The eighth complication following surgical repair is failure of the
subscapularis. As pointed out by Lazarus and Harryman (Lazarus and
Harryman, 1996) the clinical manifestations of subscapularis failure
may include pain, weakness of abdominal press and lumbar push off,
apprehension or frank instability. A failed subscapularis can sometimes
be repaired directly and on other occasions may require a hamstring
autograft or allograft.
Rockwood and Wirth (Wirth et al, 1995) reported a series of failed
repairs in which the subscapularis was completely disrupted and
contracted medially into a dense connective tissue scar that precluded
mobilization. Most of the shoulders had undergone multiple previous
procedures. The subscapularis deficiency was reconstructed by transfer
of either the upper portion of the pectoralis major or the pectoralis
minor in five shoulders.
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