Treatment of Recurrent Instability.
Last updated Thursday, February 10, 2005
Capsulolabral reconstruction
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%.
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