Treatment of Recurrent Instability.
Last updated Thursday, February 10, 2005
Figure 1 - Internal rotation Figure 2 - External rotation Figure 4 - Shoulder shrug Figure 5 - Taping the shoulder Figure 6 - Reattachment of the glenohumeral ligaments, capsule, and labrum to the rim of the glenoid Figure 7 - Axillary incision Figure 8 - Exposing the subjacent subscapularis tendon and lesser tuberosity Figure 9 - A blunt elevator is inserted through the interval into the joint Figure 10 - Posterolateral humeral head defect Figure 11 - Bankart lesion Figure 12 - The anterior, non-articular aspect of the glenoid lip is roughened with a curette or a motorized burr. Figure 13 - Glenoid roughening Figure 14 - A 1.8-mm drill is used to make holes on the articular aspect of the glenoid Figure 15 - Continuity is established between the corresponding slots and holes Figure 16 - Sutures are passed through the glenoid lip Figure 17 - Securing the capsule to the glenoid lip Figure 18 - Securing the glenoid lip Figure 19 - Tying the sutures Figure 20 - The labrum and medial edge of the capsule are brought up on the glenoid lip Figure 22 - X-Ray of bone block Figure 23 - X-Ray of bone block Nonoperative management
Coordinated, strong muscle contraction is a key element of
stabilization of the humeral head in the glenoid. Optimal neuromuscular
control is required of the rotator cuff muscles, deltoid and pectoralis
major and the scapular musculature.Stabilizing with muscle strength These dynamic stabilizing mechanisms require muscle strength,
coordination and training. Such a program is likely to be of particular
benefit in patients with atraumatic (AMBRII) instability (Hurley,
Anderson, Dear et al, 1992; Neer, 1970), because loss of neuromuscular
control is one of the major features of this condition. Nonoperative
management is also a particularly attractive option for children, for
patients with voluntary instability (Neer, 1970), for those with
posterior glenohumeral instability, and for those requiring a
supranormal range of motion (such as baseball pitchers and gymnasts) in
whom surgical management often does not permit return to a competitive
level of function. (Hawkins, Koppert and Johnston, 1984; Huber and
Gerber, 1994; Rowe, Pierce and Clark, 1973; Saha, 1971)Strengthening exercises Strengthening of the rotator cuff, deltoid and scapular motors can
be accomplished with a simple series of exercises. During the early
phases of the program, the patient is taught to use the shoulder only
in the most stable positions, that is those in which the humerus is
elevated in the plane of the scapula (avoiding, for example, elevation
in the sagittal plane with the arm in internal rotation if there is a
tendency to posterior instability). As coordination and confidence
improve, progressively less intrinsically stable positions are
attempted. Taping may provide a useful reminder to avoid unstable
positions. The shoulder is then progressed to smooth repetitive
activities, such as swimming or rowing, which can play an essential
role in retraining the neuromuscular patterns required for stability.
Finally, it is important to avoid all activities and habits that
promote glenohumeral subluxation or dislocation; patients are taught
that each time their shoulder goes out it gets easier for it to go out
the next time.
Rockwood and colleagues (Rockwood et al, 1986) and Burkhead and
Rockwood (Burkhead and Rockwood, 1992) found that 16 per cent of
patients with traumatic subluxation, 80 per cent of those with anterior
atraumatic subluxation, and 90 per cent of those with posterior
instability responded to a rehabilitation program. Brostrom et al
(Brostrom et al, 1992) found that exercises improved all but five of 33
unstable shoulders, including traumatic and atraumatic types. Anderson
et al have demonstrated the effectiveness of an exercise program using
rubber bands in improving internal rotator strength. (Anderson et al,
1992) Rockwood et al have demonstrated that nonoperative management can
be successful even when there is a congenital factor in instability.
They reported 16 patients with hypoplasia of the glenoid. (Wirth, Lyons
and Rockwood, 1993) A subset of this group consisted of five patients
with bilateral glenoid hypoplasia and multidirectional instability as
indicated by symptomatic increased translation of the humeral head
during anterior, inferior, and posterior drawer testing. In addition,
generalized ligamentous laxity of the metacarpophalangeal joints,
elbows, or knees was noted in all five patients. Four of the patients
had been involved in occupational or recreational activities, or both,
that had placed heavy demands on the shoulders. Four of these patients
had considerable improvement in the ratings for pain and the ability to
carry out work and sports activities at an average of 3 months after
they had begun a strengthening program designed by Rockwood. None of
the patients needed vocational rehabilitation, despite the heavy
demands on their shoulders associated with their occupational or
recreational activities.
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.
The objective of anatomic repair for traumatic instability is the
reconstruction of the avulsed capsule and labrum at the glenoid lip,
often referred to as a Bankart repair.
History of the procedure he objective of anatomic repair for traumatic instability is the
reconstruction of the avulsed capsule and labrum at the glenoid lip,
often referred to as a Bankart repair. This type of repair was
apparently first performed by Perthes (Perthes, 1906) in 1906, who
recommended the repair of the anterior capsule to the anterior glenoid
rim. He was not in doubt about the pathology of traumatic instability:
"In every case the anterior margin of the glenoid cavity will be found
to be smooth, rounded, and free of any attachments, and a blunt
instrument can be passed freely inwards over the bare bone on the front
of the neck of the scapula." He reattached the capsule to the glenoid
rim by placing drill holes through the bone. Credit for this type of
repair should go to Perthes, but the popularity of the technique is due
to the work of Bankart, (Bankart, 1923; Bankart, 1939) who first
performed the operation in 1923 on one of his former house surgeons.
The procedure commonly used today is based on Bankart's 1939 article in
which he discusses the repair of the capsule to the bone of the
anterior glenoid through the use of drill holes and suture. The
subscapularis muscle, which is carefully divided to expose the capsule,
is reapproximated without any overlap or shortening. Bankart reported
27 consecutive cases with "full movements of the joint and in no case
has there been any recurrence of the dislocation." (Blazina and
Satzman, 1969; Rokous, Feagin and Abbott, 1972; Rowe, 1978; Rowe and
Zarins, 1981)
It is important to emphasize several important differences between
Bankart's original method and the capsulolabral reconstruction
currently recommended. Today we do not osteotomize the coracoid, we do
not shave off bone from the anterior glenoid, and finally, we strive to
reattach the capsule and any residual labrum up on the surface of the
glenoid lip, rather than on the anterior aspect of the glenoid as shown
by Bankart. Efficacy of the procedure Hovelius and coworkers (Hovelius et al, 1979) found a 2 per cent
redislocation rate after the Bankart procedure compared with a 19 per
cent redislocation after the Putti-Platt. Over one-third of patients
under 25 years of age were dissatisfied with the results of the
Putti-Platt. Rowe and Zarins (Rowe and Zarins, 1981) reported a series
of 50 subluxating shoulders with good or excellent results in 94 per
cent after a Bankart repair. A Bankart lesion was found in 64% of these
shoulders. Rowe and coworkers (Rowe, Patel and Southmayd, 1977)
reported on 51 shoulders with a fracture of the anterior rim of the
glenoid. Eighteen shoulders had a fracture involving one-sixth or less
of the glenoid, 26 involved one-fourth of the glenoid, and 7 had
one-third of the anterior glenoid fractured off. In this group of
patients who were treated with a Bankart repair without particular
attention being given to the fracture, the overall incidence of failure
was 2 per cent. Prozorovskii et al (Prozorovskii et al, 1991) reported
no recurrences in the long term followup of 41 Bankart repairs. Martin
and Javelot(Martin et al, 1991) reported excellent results and minimal
degenerative change in a 10 year followup of 53 patients managed with
Bankart repair.Variations on the procedure While many variations on the method of attaching the capsule to the
glenoid have been described, no method has been demonstrated to be
safer or more secure than suture passed through drill holes in the lip
of the glenoid. (Levine et al, 1994; McEleney et al, 1995; Richmond et
al, 1991) Modifications of the technique do not seem to constitute
substantial improvements in the efficacy, cost or safety of the
procedure; for example, suture anchors do not have strength equal to
sutures passed through holes in the glenoid lip. (Gohlke et al, 1993;
Harner and Fu, 1995; Hecker et al, 1993) Furthermore, when suture
anchors are placed in the ideal location for capsulolabral
reattachment, there is a substantial risk of their rubbing on the
articular surface of the humerus. It is difficult to restore the
effective glenoid depth using suture anchors.
Although some have advocated the addition of a capsular shift or
capsulorrhaphy to the Bankart repair (Altchek, Warren, Skyharet al,
1991; Speer et al., 1994), this does not seem necessary or advisable in
the usual case of traumatic instability. In fact, one of the
outstanding features of Bankart's results were that "All these cases
recovered full movement of the joint, and in no case has there been any
recurrence of dislocation." Excessive tightening of the anterior
capsule and subscapularis can lead to limited comfort and function as
well as to the form of secondary degenerative joint disease known as
capsulorrhaphy arthropathy. (Bigliani et al, 1995; Hawkins and Angelo,
1990b; Kronberg and Brostrom, 1990; Lusardi et al, 1993) Rosenberg et
al (Rosenberg et al, 1995) found that 18 of 52 patients had at least
minimal degenerative changes at an average of 15 year followup; as a
cautionary note against unnecessary capsular tightening, these authors
found a correlation between loss of external rotation and the incidence
of degenerative changes. To help guard against post operative loss of
motion, Rowe and associates (Rowe, Patel and Southmayd, 1978) limit
immobilization to just two to three days, after which the patient is
instructed to gradually increase the motion and function of the
extremity.
Recent advances and refinements Thomas and Matsen described a simplified method of anatomically
repairing avulsions of the glenohumeral ligaments directly to the
glenoid lip without coracoid osteotomy, without splitting the capsule
and the subscapularis, without metallic or other anchors, and without
tightening the capsule. (Matsen, Lippitt, Sidles et al, 1994; Thomas
and Matsen, 1989) This method (described in detail in the "Authors
Preferred Method" section) offers excellent range of motion and
stability. Subsequently Berg and Ellison (Berg and Ellison, 1990) have
again emphasized this simplified approach to capsulolabral repair.
When pathologically increased anterior laxity is combined with a
Bankart lesion, the addition of a capsular plication to the
reattachment of the capsulolabral avulsion has been recommended. Jobe
and colleagues (Jobe et al, 1991) and Montgomery and Jobe(Montgomery
and Jobe, 1994) have found good or excellent results in athletes with
shoulder pain secondary to anterior glenohumeral subluxation or
dislocation. Two years after surgery over 80% had returned to their
preinjury sport and level of competition.
Rockwood et al have reported their results in 108 patients (142
shoulders) with recurrent anterior shoulder instability. (Wirth et al,
1996) All patients were managed by repair of capsulolabral injury, when
present, and reinforcement of the anteroinferior capsular ligaments by
an imbrication technique that decreases the overall capsular volume.
According to the grading system of Rowe and associates, 93% of the
results were rated as good or excellent at an average follow-up of 5
years (range, 2 to 12 years). The incidence of recurrent instability
was approximately 1%.
Many other anterior repairs have been described. Most are of historical
interest only. The reader is also referred to an review of the
glenohumeral capsulorrhaphy by Friedman. (Friedman, 1993)Staple capsulorrhaphy In the DuToit staple capsulorrhaphy, the detached capsule is secured
back to the glenoid using staples. (DuToit and Roux, 1956; Sisk and
Boyd, 1974) Actually, the staple repair had been described 50 years
earlier by Perthes. Rao and associates (Rao et al, 1986) reported
follow-up on 65 patients having a DuToit staple repair of the avulsion
of the capsule from the glenoid rim. Two patients showed radiographic
evidence of loose staples. Ward et al (Ward et al, 1990) reviewed 33
staple capsulorrhaphies at an average of 50 months post op. Fifty per
cent continued to have apprehension and 12 had staple malposition.
O'Driscoll and Evans (O'Driscoll and Evans, 1988; O'Driscoll and Evans,
1993) reviewed 269 consecutive DuToit capsulorrhaphies in 257 patients
for a median follow-up of 8.8 years. Fifty-three per cent of the
patients had postoperative pain. Internal and external rotation were
limited. Recurrence was reported in 28 per cent if stapling alone was
done and in 8 per cent if a Putti-Platt procedure was added; 11 per
cent had staple loosening, migration, or penetration of cartilage.
Staple complications contributed to pain, physical restrictions, and
osteoarthritis. Zuckerman and Matsen have pointed out that the use of
staples for surgical repairs may be associated with major
complications. (Zuckerman and Matsen, 1984)
Subscapularis muscle procedures Putti-Platt Procedure
In 1948 Osmond-Clark (Osmond-Clarke, 1948) described this procedure,
which was used by Sir Harry Platt of England and Vittorio Putti of
Italy. Platt first used this technique in November 1925. Some years
later Osmond-Clarke saw Putti perform essentially the same operation
that had been his standard practice since 1923. Scaglietta, one of
Putti's pupils, revealed that the operation may well have been
performed first by Codivilla, Putti's teacher and predecessor. Neither
Putti nor Platt ever described the technique in the literature.
In the Putti-Platt procedure, the subscapularis tendon is divided
2.5 cm from its insertion. The lateral stump of the tendon is attached
to the "most convenient soft-tissue structure along the anterior rim of
the glenoid cavity." If the capsule and labrum have been stripped from
the anterior glenoid and the neck of the scapula, the tendon is sutured
to the deep surface of the capsule, and "it is advisable to raw the
anterior surface of the neck of the scapula, so that the sutured
tendo-capsule will adhere to it." After the lateral tendon stump is
secured, the medial muscle stump is lapped over the lateral stump,
producing a substantial shortening of the capsule and subscapularis
muscle. The exact placement of the lateral stump into the anterior soft
tissues and of the medial stump into the greater tuberosity is
determined so that, after conclusion of the procedure, the arm should
externally rotate to the neutral position. Variations on the
Putti-Platt procedure have been described by Blazina and Satzman
(Blazina and Satzman, 1969), Watson-Jones (Watson-Jones, 1948), Muller
(Muller, 1929) and Symeonides. (Symeonides, 1972)
Quigley and Freedman (Quigley and Freedman, 1974) reported the
results of 92 Putti-Platt operations; of these patients, 11 had more
than a 30 per cent loss of motion. Seven had recurrent instability
after their surgery. Leach and coworkers (Leach et al, 1982) in 1981
reported a series of 78 patients who had been treated with a modified
Putti-Platt procedure. Loss of external rotation averaged between 12
and 19 degrees. Collins and associates (Collins et al, 1986) reviewed a
series of 58 Putti-Platt procedures and 48 Putti-Platt--Bankart
procedures. The redislocation rate was 11 per cent (some because of
significant trauma), 20 per cent had residual pain, and the average
restriction of external rotation was 20 degrees. Hovelius and
colleagues, (Hovelius, Thorling and Fredin, 1979) in a follow-up of 114
patients who underwent either a Bankart or Putti-Platt reconstruction,
found a recurrence rate of 2 per cent in 46 patients treated with the
Bankart procedure and of 19 per cent in 68 patients treated with a
Putti-Platt procedure. The follow-up was between 1.5 and 10 years.
Fredriksson and Tegner (Fredriksson and Tegner, 1991) reviewed 101
patients who had had a Putti-Platt procedure with a mean follow-up of
approximately 8 years (range, 5 to 14 years). Recurrent instability
occurred in 20% of cases and all patients demonstrated a decrease in
the range of all measured movements, especially external rotation.
Additionally, a significant decrease in strength and power was noted by
Cybex dynamometer assessment. The authors noted that the restricted
motion following this procedure did not improve with time as previous
reports had suggested and concluded that this method of reconstruction
should not be recommended for young active patients.
It is important to recognize that if this operation is carried out
as described, a 2.5-cm lateral stump of subscapularis tendon is
attached to the anterior glenoid. Since the radius of the humerus is
approximately 2.5 cm, a 2.5-cm stump of subscapularis fused to the
anterior glenoid would limit the total humeral rotation to one radian,
or 57 degrees. Angelo and Hawkins (Angelo and Hawkins, 1988; Hawkins
and Angelo, 1990a) presented a series of patients who developed
osteoarthritis an average of 15 years after a Putti-Platt repair. It is
now recognized that limitation of external rotation in repairs for
anterior instability is a predisposing factor to capsulorrhaphy
arthropathy. (Kronberg and Brostrom, 1990; Lusardi, Wirth, Wurtz et al,
1993)
Magnuson-Stack Procedure
Transfer of the subscapularis tendon from the lesser tuberosity
across the bicipital groove to the greater tuberosity was originally
described by Paul Magnuson and James Stack in 1940. (Karadimas et al,
1980; Magnuson, 1945; Magnuson and Stack, 1940; Magnuson and Stack,
1943; Miller et al, 1984; Rao, Francis, Hurley et al, 1986) In 1955,
Magnuson (Rao, Francis, Hurley et al, 1986) recommended that in some
cases the tendon should be transferred not only across the bicipital
groove but also distally into an area between the greater tuberosity
and the upper shaft. DePalma (DePalma, 1973) recommended that the
tendon be transferred to the upper shaft below the greater tuberosity.
Karadimas, (Karadimas, Rentis and Varouchas, 1980) in the largest
single series of Magnuson-Stack procedures (154 patients), reported a 2
per cent recurrence rate. Badgley and O'Connor (Badgley and O'Connor,
1965) and Bailey (Bailey, 1962-1969) have reported on a combination of
the Putti-Platt and the Magnuson-Stack operations; they used the upper
half of the subscapularis muscle to perform the Putti-Platt procedure
and the lower half of the muscle to perform the Magnuson-Stack
procedure.
The complications of the Magnuson-Stack procedure include excessive
anterior tightening with posterior subluxation or dislocation, damage
to the biceps, and recurrent instability. Bone block Eden-Hybbinette Procedure
The Eden-Hybbinette procedure was performed independently by Eden
(Eden, 1918) in 1918 and by Hybbinette (Hybbinette, 1932) in 1932. Eden
first used tibial grafts, but both authors finally recommended the use
of iliac grafts. This procedure is supposed to extend the anterior
glenoid. It has been used by Palmer and Widen, (Palmer and Widen, 1948)
Lavik, (Lavik, 1961) and Hovelius (Hovelius, Akermark and Albrektsson,
1983) in treating shoulder subluxation and dislocation. Lavik modified
the procedure by inserting the graft into the substance of the anterior
glenoid rim. Lange (Lange, 1944) inserted the bone graft into an
osteotomy on the anterior glenoid. Hehne and Hubner (Hehne and Hubner,
1980) reported a comparison of the Eden-Hybbinette--Lange and the
Putti-Platt procedures in 170 patients; their results seemed to favor
the latter. Paavolainen and coworkers (Paavolainen et al, 1984)
reported on 41 cases of Eden-Hybbinette procedures; 3 had recurrent
instability, and external rotation was diminished an average of 10 per
cent. They found the results similar to their series of Putti-Platt
operations. Ten per cent in each group developed degenerative joint
disease!
Niskanen and coworkers (Niskanen et al, 1991) reported a series of
52 shoulders with a mean follow-up of 6 years that had been treated
with a modification of the Eden-Hybbinette procedure. The operation
involved the creation of a trough through the capsule and into the
anteroinferior aspects of the scapula neck. A tricortical iliac crest
bone graft was then wedged into the trough without fixation. A 21%
recurrence rate was attributed to one spontaneous dislocation and 10
traumatic redislocations. Postoperative arthrosis was noted in nine
shoulders and early degenerative changes in an additional 18 shoulders.
Oudard Procedure
In 1924 Oudard (Oudard, 1924) described a method in which the
coracoid process was prolonged with a bone graft from the tibia. The
graft (4 3 1 cm) was inserted between the sawed-off tip and
the remainder of the coracoid and was directed laterally and
inferiorly. The graft acted as an anterior buttress that served to
prevent recurrent dislocations. Oudard also shortened the subscapular
tendon. Later he published another method of obtaining the elongation
of the coracoid by performing an oblique osteotomy of the coracoid and
displacing the posterolateral portion to serve as a bone block.
Bone blocks are not the procedure of choice for the routine case of
recurrent anterior glenohumeral instability. One must be concerned
about procedures that may bring the humeral head into contact with bone
that is not covered by articular cartilage because of the high risk of
degenerative joint disease. Soft tissue repairs and reconstructions are
safer and more effective for dealing with the usual case of recurrent
traumatic instability. However, when a major anterior glenoid
deficiency reduces the anterior or anteroinferior balance stability
angle to unacceptably small value, reconstruction of the anterior
glenoid lip may be necessary. Matsen(Matsen and Thomas, 1990) has
described a technique for using a contoured bone graft to replace the
missing glenoid bone covered with joint capsule or other soft tissue in
order to offer a smooth surface to articulate with the humeral head. Coracoid transfer In the transfer of the coracoid process to the anterior glenoid, an
attempt is made to create an anteroinferior musculotendinous sling.
Some authors also refer to a bone block effect and an intentional
tethering of the subscapularis in front of the glenohumeral joint. Thus
it is apparent that these procedures do not address the usual pathology
of traumatic instability. The redislocation rates after coracoid
transfer for the usual case of traumatic instability are no lower than
for soft tissue reconstructions, but the rate of serious complications
is substantially higher. Furthermore in contrast to soft tissue
procedures, coracoid transfer procedures are extremely difficult and
hazardous to revise: the subscapularis, musculocutaneous and axillary
nerves are scarred in abnormal positions; the subscapularis muscle is
scarred and tethered; and the axillary artery may be displaced in scar
tissue.
Trillat Procedure
Trillat and Leclerc-Chalvet (Bodey and Denham, 1983; Noesberger and
Mader, 1976; Trillat, 1954; Trillat and Leclerc-Chalvet, 1973)
performed an osteotomy at the base of the coracoid process and then
displaced the coracoid downward and laterally. The displaced coracoid
is held in position by a special nail-pin or screw. The pin is passed
into the scapula above the inferiorly displaced subscapularis muscle,
which effectively shortens the muscle.
Bristow-Helfet Procedure
This procedure was developed, used, and reported by Arthur Helfet
(Helfet, 1958) in 1958 and was named the Bristow operation after his
former chief at St. Thomas Hospital, W. Rowley Bristow of South Africa.
Helfet originally described detaching the tip of the coracoid process
from the scapula just distal to the insertion of the pectoralis minor
muscle, leaving the conjoined tendons (i.e., the short head of the
biceps and the coracobrachialis) attached. Through a vertical slit in
the subscapularis tendon, the joint is exposed and the anterior surface
of the neck of the scapula is "rawed up." The coracoid process with its
attached tendons is then passed through the slit in the subscapularis
and kept in contact with the raw area on the scapula by suturing the
conjoined tendon to the cut edges of the subscapularis tendon.
Effectively, a subscapularis tenodesis is performed.
In 1958, T. B. McMurray (son of T. P. McMurray of hip osteotomy
fame) visited Dr. Newton Mead (Mead and Sweeney, 1964) of Chicago and
described modifications of the Bristow operation that were being used
in Capetown, Johannesburg, and Pretoria. Mead and Sweeney (Mead and
Sweeney, 1964) reported the modifications in over 100 cases. The
modifications consist of splitting the subscapularis muscle and tendon
unit in line with its fibers to open the joint and firmly securing the
coracoid process to the anterior glenoid rim with a screw. May (May,
1970) has modified the Bristow procedure further by vertically dividing
the entire subscapularis tendon from the lesser tuberosity; after
exploring the joint, he attaches the tip of the coracoid process with
the conjoined tendon to the anterior glenoid with a screw. The
subscapularis tendon is then split horizontally and reattached--half of
the tendon above and half below the transferred conjoined tendon--to
the site of its original insertion. Again, the net effect is a
tenodesis of the subscapularis.
Helfet (Helfet, 1958) reported that the procedure not only
"reinforced" the defective part of the joint but also had a "bone
block" effect. Mead, (Mead and Sweeney, 1964) however, does not regard
the bone block as being a very important part of the procedure and
believes that the transfer adds a muscle reinforcement at the lower
anterior aspect of the shoulder joint that prevents the lower portion
of the subscapularis muscle from displacing upward as the humerus is
abducted. Bonnin (Bonnin, 1969; Bonnin, 1973) has modified the Bristow
procedure in the following way: he does not shorten or split the
subscapularis muscle tendon unit but for exposure he divides the
subscapularis muscle at its muscle-tendon junction and, following the
attachment of the coracoid process to the glenoid with a screw, he
reattaches the subscapularis on top of the conjoined tendon. Results
with this modification in 81 patients have been reported by Hummel and
associates. (Hummel et al, 1982)
Torg and coworkers (Torg et al, 1987) reported their experience with
212 cases of the Bristow procedure. In their modification the coracoid
was passed over the superior border rather than through the
subscapularis. Their postoperative instability rate was 8.5 per cent
(3.8 per cent redislocation and 4.7 per cent subluxation). Ten patients
required reoperation for screw-related problems; 34 per cent had
residual shoulder pain and 8 per cent were unable to do overhead work.
Only 16 per cent of athletes were able to return to their preinjury
level of throwing. Carol and associates (Carol et al, 1985) reported on
the results of the Bristow procedure performed for 32 recurrent
dislocating shoulders and 15 "spontaneous" shoulder instabilities. At
an average follow-up of 3.7 years, only one patient had recurrent
instability and the average limitation of external rotation was 12
degrees. Banas et al (Banas et al, 1993) reported 4% recurrence with a
8.6 year followup; however, additional surgery was required in 14%.
Wredmark et al (Wredmark et al, 1992) found only 2 out of 44 recurrent
dislocations at an average followup of 6 years, but 28% percent of
patients complained of pain. Hovelius and coworkers (Hovelius, Akermark
and Albrektsson, 1983) reported follow-up on 111 shoulders treated with
the Bristow procedure. At 2.5 years their postoperative instability
rate was 13 per cent (6 per cent dislocation and 7 per cent
subluxation). External rotation was limited an average of 20 degrees,
and 6 per cent required reoperation because of screw-related
complications. Muscle strength was 10 per cent less in the operated
shoulder. Chen and colleagues (Chen et al, 1984) found that after the
Bristow procedure, the reduced strength of the short head of the biceps
was compensated for by increased activity in the long head.Other series
of Bristow procedures have been reported, each of which emphasizes the
potential risks. (Weaver and Derkash, 1994)
Lamm and coworkers (Lamm et al, 1982) and Lemmens and de Waal
Malefijt (Lemmens and de Waal Malefitj, 1984) have described four
special x-ray projections to evaluate the position of the transplanted
coracoid process: anteroposterior, lateral, oblique lateral, and
modified axial. Lower and coworkers (Lower et al, 1985) used CT to
demonstrate the impingement of a Bristow screw on the head of the
humerus. Collins and Wilde (Collins and Wilde, 1973) and Nielsen and
associates (Nielsen and Nielsen, 1982) reported that while they had
minimal problems with recurrence of dislocation, they did encounter
problems with screw breakage, migration, and nonunion of coracoid to
scapula. Hovelius and colleagues (Hovelius, 1982; Hovelius et al, 1983)
reported only a 50 per cent union rate of the coracoid to the scapula.
Norris and associates (Norris et al, 1987) evaluated 24 patients
with failed Bristow repairs; only two had union of the transferred
coracoid. Causes of failure included (1) residual subluxation and (2)
osteoarthritis from screw or bone impingement or overtight repair. They
pointed to the difficulty of reconstructing a shoulder after a failed
Bristow procedure. Singer et al (Singer et al, 1995) conducted a
20-year follow-up study of the Bristow-Latarjet procedure; in spite of
an average Constant-Murley score of 80 points there was radiographic
evidence of degenerative joint disease in 71%.
Ferlic and DiGiovine (Ferlic and DeGiovine, 1988) reported on 51
patients treated with the Bristow procedure. They had a 10% incidence
of redislocation or subluxation and a 14% incidence of complications
related to the screw. An additional surgical procedure was required in
14% of the patients. In a long-term follow up study of 79 shoulders,
Banas and colleagues (Banas, Dalldorf, Sebastianelli et al, 1993) also
reported complications necessitating reoperation in 14% of patients.
Seventy-three percent of reoperations were for hardware removal
secondary to persistent shoulder pain.
There also appears to be a significant problem with recurrent
subluxation after the Bristow procedure. (Ferlic and DeGiovine, 1988;
Hovelius, Eriksson, Fredin et al, 1983; Mackenzie, 1984; McFie, 1976;
Norris, Bigliani and Harris, 1987) Hill and coworkers (Hill et al,
1981) and MacKenzie (Mackenzie, 1980) noted failures to manage
subluxation with this procedure. Schauder and Tullos (Schauder and
Tullow, 1992) reported 85% good or excellent results with a modified
Bristow procedure in 20 shoulders with a minimum 3-year follow-up.
Interestingly, the authors attributed the success to healing of the
Bankart lesion, since there were many instances in which the position
of the transferred coracoid precluded it from containing the humeral
head. The authors suggested that the 15% fair or poor results were
secondary to persistent or recurrent subluxation.
In 1989, Rockwood and Young (Rockwood and Young, 1989; Young and
Rockwood, 1991), reported on 40 patients who had previously been
treated with the Bristow procedure. They commented on the danger and
the technical difficulty of these repairs. Thirty-one underwent
subsequent reconstructive procedures: 10 had a capsular shift
reconstruction, four required capsular release, four had total shoulder
arthroplasty, one had an arthrodesis, and six had various combined
procedures. The authors concluded the Bristow procedure was
nonphysiologic and was associated with too many serious complications
and recommended that it not be performed for routine anterior
reconstruction of the shoulder.
Latarjet Procedure
The Latarjet procedure, (Latarjet, 1958; Latarjet, 1968; Pascoet et
al, 1975) described in 1954, involves the transfer of a larger portion
of the coracoid process than used with the Bristow procedure with the
biceps and coracobrachialis tendons to the anteroinferior aspect of the
neck of the scapula. Instead of the raw cut surface of the tip of the
coracoid process being attached to the scapula as is done in the
Bristow-Helfet procedure, the coracoid is laid flat on the neck of the
scapula and held in place with one or two screws. Tagliabue and
Esposito (Tagliabue and Esposito, 1980) have reported on the Latarjet
procedure in 94 athletes.
Wredmark and colleagues (Wredmark, Tornkvist, Johansson et al, 1992)
analyzed 44 patients at an average follow-up of 6 years after a
Bristow-Latarjet procedure for recurrent shoulder dislocation.
Seventy-two percent of patients had no discomfort, but the remaining
28% complained of moderate exertional pain. Vittori has modified the
procedure by turning downward the subscapularis tendon and holding it
displaced downward with the transferred coracoid. Pascoet and
associates reported on the Vittori modification in 36 patients with one
recurrence.
Other open repairs Gallie procedure
Gallie and LeMesurier (Gallie and LeMesurier, 1927; Gallie and
LeMesurier, 1948) originally described the use of autogenous fascia
lata to create new ligaments between the anteroinferior aspect of the
capsule and the anterior neck of the humerus in 1927. Bateman (Bateman,
1963) of Toronto has also used this procedure. While fascia lata may
not be the ideal graft material, the use of exogenous autograft or
allograft to reconstruct deficient capsulolabral structures may be
necessary in the management of failed previous surgical repairs.
Nicola Procedure
Toufick Nicola's name is usually associated with this operation, but
the procedure was first described by Rupp (Rupp, 1926) in 1926 and
Heymanowitsch (Heymanowitsch, 1927) in 1927. In 1929, Nicola (Nicola,
Ellman, Eckardt et al, 1981) published his first article in which he
described the use of the long head of the biceps tendon as a checkrein
ligament. The procedure has been modified several times. (Nicola,
Ellman, Eckardt et al, 1981; Nicola, 1929b; Nicola, 1942; Nicola, 1949)
Recurrence rates have been reported to be between 30 and 50 per cent.
(Carpenter and Millard, 1982; Jones, 1940; Weber, 1969)
Saha Procedure
K. Saha (Saha, 1961; Saha, 1967; Saha, 1971; Saha, 1973; Saha et
al, 1956) has reported on the transfer of the latissimus dorsi
posteriorly into the site of the infraspinatus insertion on the greater
tuberosity. He reports that, during abduction, the transferred
latissimus reinforces the subscapularis muscle and the short posterior
steering and depressor muscles by pulling the humeral head backward. He
has used the procedure for traumatic and atraumatic dislocations, and
in 1969 he reported 45 cases with no recurrence.
Boytchev Procedure
Boytchev first reported this procedure in 1951 in the Italian
literature, (Boytchev, 1951; Boytchev et al, 1962) and later
modifications were developed by Conforty. (Conforty, 1980) The muscles
that attach to the coracoid process along with the tip of the coracoid
are rerouted deep to the subscapularis muscle between it and the
capsule. The tip of the coracoid with its muscles is then reattached to
its base in the anatomical position. Conforty (Conforty, 1980) reported
on 17 patients, none of whom had a recurrence of dislocation. Ha'eri
and associates( Ha'eri and Maitland, 1981) reported 26 cases with a
minimum of two years' follow-up.
Osteotomy of the Proximal Humerus
Debevoise and associates (Debevoise et al, 1971; Kronberg and
Brostrom, 1990) stated that humeral torsion is abnormal in the
repeatedly dislocating shoulder. B. G. Weber (Kavanaugh, 1978; Miller,
Donahue, Good et al, 1984; Rao, Francis, Hurley et al, 1986; Weber,
1969; Weber et al, 1984) of Switzerland reported a rotational osteotomy
whereby he increased the retroversion of the humeral head and
simultaneously performed an anterior capsulorrhaphy. The indications
were a moderate to severe posterior lateral humeral head defect, which
he found in 65 per cent of his patients with recurrent anterior
instability. By increasing the retroversion, the posterolateral defect
is delivered more posteriorly and the anterior undisturbed portion of
the articular surface of the humeral head then articulates against the
glenoid. It is recognized that the effective articular surface of the
humerus is reduced by the posterior lateral head defect, and that the
osteotomy repositions the remaining articular surface in a position
more compatible with activities of daily living. Weber and colleagues
(Weber, Simpson and Hardegger, 1984) reported a redislocation rate of
5.7 per cent with good to excellent results in 90 per cent. Most
patients required reoperation for plate removal.
Osteotomy of the Neck of the Glenoid
In 1933, Meyer-Burgdorff reported on decreasing the anterior tilt of
the glenoid by a posterior wedge closing osteotomy. (Saha, 1961) Saha
has written (Saha, 1961) about an anterior opening wedge osteotomy with
bone graft into the neck of the glenoid to decrease the tilt.
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.
The patient with traumatic anterior glenohumeral instability usually
has symptoms primarily when the arm is elevated near the coronal plane,
extended, and externally rotated. Characteristically the shoulder is
relatively asymptomatic in other extreme positions or in midrange
positions. Thus, for some patients appropriate management may consist
solely of education about the nature of the lesion and identification
of the positions and activities that need to be avoided.Exercise program Strengthening the shoulder musculature may help prevent the shoulder
being forced into positions of instability. The exercise program
previously described for atraumatic instability may be considered as an
option for traumatic instability as well.Prescribing surgery The option of surgical repair is discussed when careful clinical
evaluation has documented the diagnosis of refractory anterior
instability resulting from an initial episode which was sufficiently
traumatic to tear the anterior inferior glenohumeral ligament and which
produces significant functional deficits (recurrentapprehension,
subluxation, or dislocation) when the arm is in abduction, external
rotation, and extension.
The patient desiring surgical stabilization is presented with a
frank discussion of the alternatives and the risks of infection,
neurovascular injury, stiffness, recurrent instability, pain and the
need for revision surgery.
Preparation for surgery Preoperative radiographs are obtained, including an AP in the plane of
the scapula, an apical oblique (Garth view) and an axillary view. A
preoperative rotator cuff ultrasound is obtained if there is suspicion
of cuff disease, for example in an individual over the age of 40 with
pain between episodes of dislocation and/or weakness of internal
rotation, external rotation, or elevation. An electromyogram is
obtained if clinical evaluation suggests the possibility of nerve
injury.Goal of surgery The goal of surgical management of traumatic anterior inferior
glenohumeral instability is the safe, secure and anatomic repair of the
traumatic lesion, restoring the attachment of the glenohumeral
ligaments, capsule, and labrum to the rim of the glenoid from which
they were avulsed. By assuring that reattachment occurs to the rim, the
effective depth of the glenoid is restored. This anatomic reattachment
should reestablish not only the capsuloligamentous check rein but also
the fossa-deepening effect of the glenoid labrum. Unnecessary steps are
avoided, such as coracoid osteotomy and splitting the subscapularis
from the capsule. No attempt is made to modify the normal laxity of the
anterior capsule in the usual case of traumatic instability. The repair
must be secure from the time of surgery so that it will allow the
patient to resume activities of daily living while the repair is
healing. Such a secure repair allows controlled mobilization, thereby
minimizing the possibility of unwanted stiffness. The tools needed for
this repair are simple and commonly available.
Anesthesia The procedure is performed under a brachial plexus block or a general
anesthetic. The glenohumeral joint is examined under anesthesia.
Although this examination rarely changes the procedure performed, it
provides helpful confirmation of the diagnosis.Positioning the patient The patient is positioned in a slight head-up position
(approximately 20 degrees) with the shoulder off the edge of the
operating table. This position provides a full range of humeral and
scapular mobility, and, if necessary, access to the posterior aspect of
the shoulder. The neck, chest, axilla, and entire arm are prepared with
iodine solution.
The procedure The shoulder is approached through the dominant anterior axillary
crease which is marked prior to the application of an adherent,
transparent plastic drape to facilitate a cosmetically acceptable scar.
(Harryman, 1992)
The skin is incised and the subcutaneous tissue are undermined up to
the level of the coracoid process, which is then used as a guide to the
cephalic vein and the deltopectoral groove. The groove is opened by
spreading with the two index fingers medial to the cephalic vein. A
neurovascular bundle (a branch of the thoracoacromial artery and the
lateral pectoral nerve) is commonly identified in the upper third of
the groove;(Grant, 1972) this bundle is cauterized and transected. It
is not necessary to release the upper pectoralis major, unless a
prominent falciform border extends up to the superior extent of the
bicipital groove.
The clavipectoral fascia is incised just lateral to the short head
of the biceps, up to but not through the coracoacromial ligament,
entering the humeroscapular motion interface and exposing the subjacent
subscapularis tendon and lesser tuberosity. The axillary nerve is
routinely palpated as it crosses the anteroinferior border of the
subscapularis. At this point it is useful to insert a self-retaining
retractor, with one blade on the deltoid muscle and the other on the
coracoid muscles. Care must be taken to assure the medial limb of this
retractor does not compress the brachial plexus. Rotating the arm from
internal to external rotation reveals, in succession, the greater
tuberosity, the bicipital groove, the lesser tuberosity, and the
subscapularis. The anterior humeral circumflex vessels can usually be
protected by bluntly dissecting them off of the subscapularis muscle at
its inferior border. The interval between the supraspinatus and
subscapularis tendons is identified by palpation, and a blunt elevator
is inserted through this interval into the joint. This elevator brings
the upper subscapularis into the incision. With care to protect the
tendon of the biceps, the subscapularis tendon and subjacent capsule
are then incised together approximately 1 cm medial to the lesser
tuberosity, beginning at the superior rounded edge of the tendon. A tag
suture is placed in the upper rolled border of the subscapularis to
mark it for subsequent repair. The incision is then extended inferiorly
to the level of the anterior circumflex humeral vessels. It is
important that the incision through the subscapularis tendon leaves
strong tendinous material on both sides of the incision to facilitate a
secure repair at the conclusion of the procedure.
Without separating them, the subscapularis tendon and anterior
shoulder capsule are retracted medially, providing an excellent view of
the joint. If necessary for greater exposure, the joint capsule may be
further divided parallel to the upper rolled border of the
subscapularis. The biceps tendon is inspected and note taken of the
integrity of the transverse humeral ligament. Particularly in patients
over 40 years of age the shoulder is inspected for evidence of rotator
cuff tears. In traumatic anterior instability, a posterolateral humeral
head defect is usually palpable by passing an index finger over the top
of the humeral head. If the humeral head defect is so large that it
contributes to instability in functional positions, anterior capsular
tightening may be necessary to keep the defect from entering the joint
on external rotation.
The capsule and subscapularis are retracted together medially and a
humeral head retractor is placed so that it leans on the posterior
glenoid lip and pushes the humeral head posterolaterally. This reveals
the anterior inferior glenoid lip from which the labrum and capsule are
avulsed in the great majority of patients with anterior traumatic
instability. The labrum usually remains attached to the capsular
ligaments but may remain on the glenoid side of the rupture, may be a
separate ("bucket handle") fragment, or may be absent. Occasionally
flimsy attempts to heal the lesion will temporarily obliterate the
defect. However, in these cases a blunt elevator will easily separate
the capsule from the glenoid lip, revealing the typical lesion in the
anterior-inferior quadrant of the glenoid. A spiked retractor is then
placed through the capsular avulsion to expose the glenoid lip. The
glenohumeral joint is inspected thoroughly for loose bodies, defects of
the bony glenoid, and loss of cartilage from the remaining anterior
glenoid.
The reconstruction of the capsulolabral detachment from the glenoid
is necessary and sufficient for the surgical management of most cases
of traumatic instability. This repair is carried out from inside the
joint, without needing to separate the capsule from the subscapularis
muscle and tendon. The glenoid is well exposed by a humeral head
retractor laterally and a sharp-tipped levering retractor inserted
through the capsular defect onto the neck of the glenoid. Bucket handle
or flap tears of the glenoid labrum. (Adams, 1891; Barrett, 1971) are
preserved for incorporation into the reconstruction of the glenoid lip.
The anterior, non-articular aspect of the glenoid lip is roughened
with a curette or a motorized burr, taking care not to compromise the
bony strength of the glenoid lip. A 1.8-mm drill is used to make holes
on the articular aspect of the glenoid 3 to 4 mm back from the edge of
the lip to ensure a sufficiently strong bony bridge. We place these
holes 5 to 6 mm apart; thus the size of the defect dictates the number
of holes used for the reconstruction. Corresponding slots are placed on
the anterior non-articular aspect of the glenoid.Using a 000 angled
curette, continuity is established between the corresponding slots and
holes.
A strong #2 absorbable braided suture is passed through the holes in
the glenoid lip using a trocar needle and an angled needle holder.
After each suture is placed through the glenoid lip, the integrity of
the bony bridge is checked by a firm pull on the suture.
When sufficient sutures have been placed to span the capsular
defect, the sharp-tipped levering retractor is removed and replaced by
a right-angled retractor positioned to reveal the trailing medial edge
of the avulsed capsule. This edge is most easily identified by tracing
the intact labrum around the glenoid to its point of detachment at the
Bankart defect. Next, using the trocar needle, the anterior end of the
suture (the limb exiting the anterior non-articular aspect of the
glenoid lip) is passed through the trailing medial edge of the capsule,
taking care to incorporate the glenoid labrum, if present, and the
strong medial edge of the capsule. No more capsule is taken than
necessary to obtain a firm purchase. This prevents unwanted tightening
of the anteroinferior capsule. In larger glenohumeral ligament
avulsions, the detached medial edge of the capsule tends to sag
inferiorly; in this situation an effort is made to pass each suture
through the capsule slightly inferior to the corresponding bony hole in
the glenoid lip. Thus, when the sutures are tied, the inferiorly
sagging medial capsule is repositioned anatomically.
Once the sutures have been passed through the capsule, they are tied
so that the labrum and medial edge of the capsule are brought up on the
glenoid lip to restore the fossa-deepening effect of the labrum.
(Lazarus, Sidles, Harryman et al, 1996) The knots are tied so that they
come to rest over the capsule, rather than on the articular surface of
the glenoid. Because they lie over soft tissue, these sutures do not
present a mechanical problem, even though they lie within the joint.
Once these sutures are tied, the smooth continuity between the
articular surface of the glenoid fossa and the capsule should be
reestablished along with a reconstructed labrum-like structure. No
stepoff or discontinuity in the capsule should be present. If a
substantial anterior capsular defect exists anywhere but at the normal
subcoracoid recess, it is closed.
Approximately 10 per cent of TUBS patients have fractures or
deficiencies of the anterior bony lip of the glenoid. At the initial
surgery, it usually seems reasonable to attempt reconstruction by
attaching the avulsed anterior capsule to the lip of the remaining
glenoid articular surface. Anterior glenoid deficiencies greater than
33 per cent or those associated with previous surgical failure may
require that the repair of the capsule to the edge of the remaining
articular cartilage be backed up by the reconstruction of the lip of
the glenoid using an iliac bone block. The iliac bone block is
contoured flush with the normal glenoid curvature and held to the
anterior glenoid with two screws placed securely and well away from the
humeral joint surface. By placing the graft outside the repaired
capsule, it becomes covered with periosteum or joint capsule preventing
direct contact with the humeral head.
At the conclusion of the surgical repair the capsule and
subscapularis tendon are repaired anatomically to their mates at the
lesser tuberosity, using the upper rolled border of the subscapularis
as a reference. At least six sutures of number two braided
non-absorbable suture are used in this repair, assuring good bites in
both the medial and lateral aspects of the repair. If the tissue on the
lateral side is insufficient, the tendon and capsule are repaired to
drill holes at the base of the lesser tuberosity. A strong
subscapularis and capsular repair is essential to early rehabilitation.
The shoulder should have at least 30 degrees of external rotation at
the side after the subscapularis/capsular repair. Once this repair has
been completed, the shoulder stability is examined. If excessive
anterior laxity remains, for example external rotation in excess of
45° (which is rarely the case), the lateral capsular and
subscapularis reattachment may be advanced laterally or superolaterally
as desired.
In the highly unusual situation in which a shoulder with the TUBS
syndrome is found not to have capsular detachment, the shoulder should
be inspected carefully for mid substance capsular defects. If none is
found, the anterior instability may be treated by reefing the anterior
capsule and the subscapularis tendon. Shortening these structures by 1
cm limits external rotation of the humerus by approximately 20 degrees.
Generally, restricting external rotation to 30 degrees at the operating
table will permit a very functional shoulder after rehabilitation is
complete. If the patient has marked anterior ligamentous laxity,
proportionately greater anterior tightening may be necessary, although
the surgeon must be certain that the patient does not have
multidirectional laxity before a unidirectional tightening is carried
out.
A standard wound closure is carried out, using a subcuticular suture, which is removed at three days.
Recovery After surgery, most patients are started on a self-conducted '90-0"
rehabilitation program with instructions from a physical therapist or a
physician. We move the shoulder soon after surgical repair because 1)
it has proven safe for the reliable patient, and 2) there is evidence
that early motion can increase the ultimate strength of a ligament
repair. (Frank, 1996)Patient post-op limitations On the day after surgery, five times daily exercises are started,
including assisted flexion to 90° and external rotation to 0°.
The contralateral arm is used as the assistant until the
operated arm can conduct the exercises alone. The patient is allowed to
perform many activities of daily living as comfort permits within the
90°/0° range without lifting anything heavier than a glass of
water.
Allowed activities include eating and personal hygiene, as well as
certain vocational activities, such as writing and keyboarding.
Gripping, isometric external rotation, and isometric abduction
exercises are started immediately after surgery to minimize effects of
disuse. If a patient does not appear able to comply with this
restricted use program, the arm is kept in a sling for three weeks,
otherwise a sling is used only for comfort between exercise sessions
and to protect the arm when the patient is out in public and at night
while sleeping. Driving is allowed as early as two weeks after surgery,
if the arm can be used actively and comfortably, particularly if the
patient's car has automatic transmission and if the operated arm is not
used to set the emergency brake.
This rapid return to functional activities is made possible because
of the strength of the repair and is encouraged to maintain the
shoulder's strength and neuromuscular control. It minimizes the
immediate postoperative disability and discomfort without jeopardizing
the healing process. Re-evaluation and rehabilitation At three weeks the patient should return for an examination and
should have at least 90 degrees of elevation and external rotation to
zero degrees. From three weeks to six weeks postoperatively, the
patient is instructed to increase the range of motion to 140 degrees of
elevation and 40 degrees of external rotation. At six weeks after
surgery, if there is good evidence of active control of the shoulder,
controlled repetitive activities such as swimming and using a rowing
machine are instituted to help rebuild coordination, strength, and
endurance of the shoulder. More vigorous activities such as basketball,
volleyball, throwing, and serving in tennis should not be started until
three months and only then if there is excellent strength, endurance,
range of motion, and coordination of the shoulder.
Vigilance must be exercised for patients over 35 years of age to be
sure that they do not develop unwanted postoperative stiffness. Thus,
particularly for these patients, the three week and six week checks are
very important to make sure that the ranges of elevation and external
rotation are respectively 90 and 0 degrees at three weeks, and 140 and
40 degrees at six weeks. Efficacy of this program In a 5.5-year follow-up of the first group of these repairs, we found
97 per cent good to excellent results based on Rowe's(Rowe, 1978)
grading system. One of 39 shoulders had a single redislocation four
years after repair while the patient was practicing karate. He became
asymptomatic after completing a strengthening program and is back to
full activities including karate. The average range of motion at
follow-up was 171 degrees of elevation, 68 degrees of external rotation
with the arm at the side, and 85 degrees of external rotation at 90
degrees of abduction. Ninety-five per cent of these patients reported
that their shoulder felt stable with all activities; 80 per cent had no
shoulder pain while 20 per cent had occasional pain with activity. None
had complications of posterior subluxation due to excessive anterior
tightness. None had complications related to hardware!
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