Treatment of Recurrent Instability.
Last updated Thursday, February 10, 2005
Other anterior repairs
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.
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