Aims

The prevalence of osteoarthritis (OA) associated with instability of the shoulder ranges between 4% and 60%. Articular cartilage is, however, routinely assessed in these patients using radiographs or scans (2D or 3D), with little opportunity to record early signs of cartilage damage. The aim of this study was to assess the prevalence and localization of chondral lesions and synovial damage in patients undergoing arthroscopic surgery for instablility of the shoulder, in order to classify them and to identify risk factors for the development of glenohumeral OA.

Aims. The risk factors for recurrent instability (RI) following a primary traumatic anterior shoulder dislocation (PTASD) remain unclear. In this study, we aimed to determine the rate of RI in a large cohort of patients managed nonoperatively after PTASD and to develop a clinical prediction model. Methods. A total of 1,293 patients with PTASD managed nonoperatively were identified from a trauma database (mean age 23.3 years (15 to 35); 14.3% female). We assessed the prevalence of RI, and used multivariate regression modelling to evaluate which demographic- and injury-related factors were independently predictive for its occurrence. Results. The overall rate of RI at a mean follow-up of 34.4 months (SD 47.0) was 62.8% (n = 812), with 81.0% (n = 658) experiencing their first recurrence within two years of PTASD. The median time for recurrence was 9.8 months (IQR 3.9 to 19.4). Independent predictors increasing risk of RI included male sex (p < 0.001), younger age at PTASD (p < 0.001), participation in contact sport (p < 0.001), and the presence of a bony Bankart (BB) lesion (p = 0.028). Greater tuberosity fracture (GTF) was protective (p < 0.001). However, the discriminative ability of the resulting predictive model for two-year risk of RI was poor (area under the curve (AUC) 0.672). A subset analysis excluding identifiable radiological predictors of BB and GTF worsened the predictive ability (AUC 0.646). Conclusion. This study clarifies the prevalence and risk factors for RI following PTASD in a large, unselected patient cohort. Although these data permitted the development of a predictive tool for RI, its discriminative ability was poor. Predicting RI remains challenging, and as-yet-undetermined risk factors may be important in determining the risk. Cite this article: Bone Joint J 2024;106-B(10):1111–1117

Concepts in glenoid tracking and treatment strategies of glenoid bone loss are well established. Initial observations in our practice in Singapore showed few patients with major bone loss requiring glenoid reconstructions. This led us to investigate the incidence of and the extent of bone loss in our patients with shoulder instability. Our study revealed bony Bankart lesions were seen in 46% of our patients but glenoid bone loss measured only 6–10% of the glenoid surface. In the same study we found that arthroscopic labral repair with capsular plication and Mason-Ellen suturing (Hybrid technique) was sufficient to stabilise patients with bipolar bone defects and minor glenoid bone loss. This led us to develop the concept of minor bone loss and a new algorithm. Our algorithm and strategies to deal with major bone loss will also be discussed, and techniques & outcomes of Arthroscopic Bony Bankart repair, Arthroscopic Glenoid Reconstruction and Arthroscopic Remplissage procedures will be shown

The natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients remains unclear and there is no consensus for management of these patients.

The objectives of this study were to report the natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients and to identify the risk factors for recurrent dislocation.

We reviewed prospectively-collected clinical and radiological data on 133 adolescent patients diagnosed with a primary anterior dislocation of the glenohumeral joint who had been managed non-operatively at our hospital between 1996 and 2008. There were 115 male (86.5%) and 18 female patients (13.5%) with a mean age of 16.3 years (13 to 18) and a mean follow-up of 95.2 months (1 to 215).

During follow-up, 102 (absolute incidence of 76.7%) patients had a recurrent dislocation. The median interval between primary and recurrent dislocation was ten months (95% CI 7.4 to 12.6). Applying survival analysis the likelihood of having a stable shoulder one year after the initial injury was 59% (95% CI 51.2 to 66.8), 38% (95% CI 30.2 to 45.8%) after two years, 21% (95% CI 13.2 to 28.8) after five years, and 7% (95% CI 1.1 to 12.9) after ten years. Neither age nor gender significantly predicted recurrent dislocation during follow-up.

We conclude that adolescent patients with a primary anterior dislocation of the glenohumeral joint have a high rate of recurrent dislocation, which usually occurs within two years of their initial injury: these patients should be considered for early operative stabilisation.

Cite this article: Bone Joint J 2015;97-B:520–6.

The June 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: suprascapular nerve and rotator cuff pathology; anchors in Bankart repair: it’s not what you’ve got, but how you use it; not all shoulder PROMs are equal; reverse shoulder arthroplasty OK in trauma; not all in the mind: frozen shoulder personality debunked; open and arthroscopic repair equivalent in shoulder instability; natural history of olecranon fractures not so bleak?; and resurfacing of the shoulder: a Danish perspective.

The ideal treatment for traumatic anterior dislocation of the shoulder in the skeletally immature patient is controversial. The aim of this study is to evaluate the outcomes after either conservative and/or surgical treatment using the Latarjet technique. A retrospective series of 49 out of 80 patients were reviewed. We found no significant differences between either treatment method regarding functional scores and pain levels. Although not statistically significant, post-surgical patients showed better signs of shoulder stability than others who have a higher rate of recurrence. Further, 92% of the post-surgical group had returned to the same level of activity versus 52% in the non-surgically treated group. We found no contraindications to operate on a skeletally immature patient.

Cite this article: Bone Joint J 2014;96-B:354–9.

Hypothesis. Recurrent shoulder dislocation is associated with bony defect of the glenoid rim, commonly seen along with bankart tear - a soft tissue injury of glenoid labrum. This cadaveric study compares the bone block effect of coracoid transfer using using two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet. We hypothesized that the force needed to dislocate the shoulder would be greater in Congruent Arc technique than the Classical Latarjet, because of increased contact surface area as a result of greater linear dimensions. Material and methods. We dissected 14 cadaveric shoulders. A bony Bankart lesion was created in form of an inverted pear glenoid. The humeral head was attached to a pulley system that was sequentially loaded until the shoulder dislocated anteriorly. The force needed to dislocate was noted. This was repeated after coracoid transfer with two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet. Results. The mean force required to dislocate shoulder post-Classical Latarjet technique was 325.71N, compared to 123.57 N in uncorrected shoulder. Similarly, the mean force required to dislocate shoulder post Congruent-Arc Latarjet technique was 327.14 N compared to 123.57 N in uncorrected shoulder. The two-tailed P value in either case was less than 0.0001, thus statistically significant. Unpaired t-test was done to compare the force required to dislocate the shoulder post procedure. Mean force required to dislocate shoulder post-Classical Latarjet, was 325.7N compared to 327N in post-Congruent Arc. The two-tailed P value equals 0.9020 and the 95% confidence interval was from −25.05 to 22.19, thus the difference was not statistically significant. Conclusion. The results confirm that both (Classical and Congruent-Arc Latarjet) techniques are good for addressing the shoulder instability, however bone block effect provided by one is not superior to other

Dislocation of the shoulder may occur during seizures in epileptics and other patients who have convulsions. Following the initial injury, recurrent instability is common owing to a tendency to develop large bony abnormalities of the humeral head and glenoid and a susceptibility to further seizures. Assessment is difficult and diagnosis may be missed, resulting in chronic locked dislocations with protracted morbidity. Many patients have medical comorbidities, and successful treatment requires a multidisciplinary approach addressing the underlying seizure disorder in addition to the shoulder pathology. The use of bony augmentation procedures may have improved the outcomes after surgical intervention, but currently there is no evidence-based consensus to guide treatment. This review outlines the epidemiology and pathoanatomy of seizure-related instability, summarising the currently-favoured options for treatment, and their results.

Primary traumatic anterior dislocations of the shoulder are common injuries which are complicated by persistent instability in a high proportion of patients. Surgery is successful and has been well described in the literature. Current controversies centre on the role of open and arthroscopic techniques. We describe the outcomes of a new mini-incision surgical (MIS) technique which was developed within our institution. 27 patients with traumatic shoulder instability (2 bilateral) were prospectively entered into a database between June 1998 and March 2008. The mean age was 31 years and the mean follow up period was 53 months. 29 shoulders underwent diagnostic shoulder arthroscopy and mini-incision surgery using a delto-pectoral approach and 3 bio-absorbable anchors. Patients reported no re-dislocation in 24 shoulders (83%). 5 shoulders, including one with a bony Bankart lesion, re-dislocated with additional trauma. One shoulder required revision to a Bristow-Latarjet. Satisfaction was very good in 16 and good in 9 shoulders (83%). 19 patients had minimal or no pain. 8 patients experienced moderate shoulder pain with the other two complaining of severe pain. QuickDASH scores were encouraging. Our technique combines the ability to appreciate all shoulder pathology arthroscopically with the visualisation gained in open Bankart surgery. Functionally, patients do well. The higher than expected re-dislocation rate is concerning. We advise that long term outcomes are needed

Shoulder Instability impacts on the ability of military personnel to fulfil their operational role and maintain sporting competence. Magnetic Resonance Imaging (MRI) and Arthrogram (MRA) are increasingly available as diagnostic adjuncts. We analysed MR reports from personnel undergoing stabilisation, correlating clinical diagnosis with operative findings and reviewed the literature in order to recommend improvements. We report a retrospective, consecutive case note analysis of 106 personnel undergoing open anterior capsulolabral reconstruction (ACLR) by a single surgeon. Seventy patients had MR (48 MRA, 22 MRI). Commonly reported pathology included Hill Sachs Lesions (41%), Soft tissue (59%) and bony Bankart lesions (16%), capsular laxity (20 %), supraspinatus lesion (20%), ACJ disease (13%) and SLAP tear (12%). The sensitivity of MR for identification of labral lesions was 82% with a specificity of 86%. For bony glenoid lesions, sensitivity was 63% and specificity 94%. Disparity between report and operative findings occurred mainly in standard MRI. Patients with lesions unrelated to instability achieved a pain free functioning shoulder following stabilisation. 100% of patients referred for ACLR with clinical evidence of instability without MR had positive pre-operative and operative correlation with instability. In 5 cases, the original equivocal MRI was repeated by MRA due to clinical suspicion of instability. In all cases the repeat MRA correlated with pre-operative and operative findings of instability. In 5 cases with equivocal clinical findings, MRA provided confirmation of instability. Delay in referral due to scanning and follow up ranged from 0 – 15 weeks. The diagnosis of those instigating referral is accurate. Reporting of MR is open to variation and has cost implications. MRA performed by a radiologist with a musculoskeletal specialist interest is recommended on an individual basis only and routine use of non-arthrographic studies should be discontinued. This will improve the efficiency of the fast track pathway

Shoulder Instability impacts on the ability of military personnel to fulfil their operational role and maintain sporting competence. Magnetic Resonance Imaging (MRI) and Arthrogram (MRA) are increasingly available as diagnostic adjuncts. We analysed MR reports from personnel undergoing stabilisation, correlating clinical diagnosis with operative findings and reviewed the literature in order to recommend improvements. This was a retrospective, consecutive case note analysis of 106 personnel undergoing open anterior capsulolabral reconstruction (ACLR) by a single surgeon. 70 patients had MR (48 MRA, 22 MRI). Commonly reported pathology included Hill Sachs Lesions (41%), Soft tissue (59%) and bony Bankart lesions (16%), capsular laxity (20 %), supraspinatus lesion (20%), ACJ disease (13%) and SLAP tear (12%). The sensitivity of MR for identification of labral lesions was 82% with a specificity of 86%. For bony glenoid lesions, sensitivity was 63% and specificity 94%. Disparity between report and operative findings occurred mainly in standard MRI. Patients with lesions unrelated to instability achieved a pain free functioning shoulder following stabilisation. 100% of patients referred for ACLR with clinical evidence of instability without MR had positive pre-operative and operative correlation with instability. In 5 cases, the original equivocal MRI was repeated by MRA due to clinical suspicion of instability. In all cases the repeat MRA correlated with pre-operative and operative findings of instability. In 5 cases with equivocal clinical findings, MRA provided confirmation of instability. Delay in referral due to scanning and follow up ranged from 0–15 weeks. The diagnosis of those instigating referral is accurate. Reporting of MR is open to variation and has cost implications. MRA performed by a radiologist with a musculoskeletal specialist interest is recommended on an individual basis only and routine use of non-arthrographic studies should be discontinued. This will improve the efficiency of the fast track pathway

We document intra-articular pathology in collision athletes with shoulder instability and describe the ‘collision shoulder’ – a direct impact without dislocation, with unusual labral injury, significant intra-articular pathology and neurology. 183 collision athletes were treated for labral injuries in 3 centres. Details of injury mechanism and intra-articular pathology at surgery were recorded. Premier league and International (Elite) comprised 72 players. A tackle was implicated in 52% of injuries and 65% had a dislocation. The mechanism of injury was ABduction External Rotation (ABER) in 45%, direct impact 36%, abduction only 8% and axial load 6%. Dislocation occurred in 51% of shoulders with ABER mechanism. A Bankart lesion was found in 79% of these shoulders; Hill-Sachs in 58% and Bony Bankart in 26%. Inferoposterior labral tears were present in only 11%, Superior Labral Antero-Posterior (SLAP) lesions in 32% and partial injury to the rotator cuff in 32%. In those sustaining a direct impact to the shoulder, 61% did not document dislocation, had a high incidence of inferoposterior labral involvement (50%), neurological symptoms (32%), but a low incidence of Bankart (33%), Hill-Sachs (22%) and Bony Bankart (11%) lesions. The mechanism did not affect incidence of superior labral/SLAP tears (18%), or capsular tears (including Humeral Avulsion of Glenohumeral Ligaments – HAGL) – 15%. Elite athletes had less dislocations (43% vs 74%) irrespective of mechanism, but were 40% more likely to have neurology, posteroinferior labral, cartilaginous or capsular injuries. They had twice the incidence of Bony Bankart and rotator cuff lesions and 5 times more SLAP/superior labral tears. Collision athletes with shoulder instability have a wide spectrum of pathoanatomy of the labrum and frequent associated intra-articular lesions. Significant injury often occurs in the Elite athlete and those sustaining a direct hit without dislocation (the ‘Collision Shoulder’)

The management of bony lesions associated with glenohumeral instability has been open to debate. Invariably a significant period of time elapses between injury and surgery during which the bony fragment may atrophy and reduce both in size and in quality. Histomorphometric bone analyses were prospectively performed on the glenoid bone fragments harvested during the modified Latarjet operation. The main purpose of the study was to assess the viability of the bone. Biopsies were obtained from 21 patients that had given informed consent. Median age was 21 years (range 16–50). All were male patients. The most important sports identified were rugby (64%) and water sports (surfing, water polo, water skiing, surfing (21%)). Mean glenoid bone loss on CT scan was 17% (range 10–50%). Thirty-three percent had bone loss greater than 20%. Gross morphology of glenolabral fragments identified a single large fragment (11/21); dominant large fragment plus smaller fragments (7/21); multiple fragments (4/21). Single large fragments comprised 52% of the study. Mean volume and mass of bony fragments were 2.18 ml (range 1–3 ml) and 1.64 gms (range 0.43–2.8 g), respectively. Histology of the specimens revealed no bone in three of the 21 specimens. Bony necrosis was present in 8/18 (44%) of the specimens. From a histopathological point of view, reattachment of these devitalized bone fragments by screws or anchors may result in predictable operative failure and recurrent instability. We can therefore not support the practice of “repair” of bony Bankart lesions based on the above findings

We identified ten patients who underwent arthroscopic revision of anterior shoulder stabilisation between 1999 and 2005. Their results were compared with 15 patients, matched for age and gender, who had a primary arthroscopic stabilisation during the same period.

At a mean follow-up of 37 and 36 months, respectively, the scores for pain and shoulder function improved significantly between the pre-operative and follow-up visits in both groups (p = 0.002), with no significant difference between them (p = 0.4). The UCLA and Rowe shoulder scores improved significantly (p = 0.004 and p = 0.002, respectively), with no statistically significant differences between groups (p = 0.6). Kaplan-Meier analysis for time to recurrent instability showed no differences between the groups (p = 0.2).

These results suggest that arthroscopic revision anterior shoulder stabilisation is as reliable as primary arthroscopic stabilisation for patients who have had previous open surgery for recurrent anterior instability.

We reviewed the outcome of arthroscopic stabilisation of anterior glenohumeral instability in young adults using the transglenoid suture technique. A questionnaire was sent to 455 consecutive patients who had undergone this procedure between 1992 and 2000. Of these, 312 patients (68.5%) with 313 affected shoulders and a mean age of 20 years (18 to 28) responded.

Outcome was determined by the number of re-dislocations or, in patients who had not re-dislocated, by the disease-specific quality of life as measured by the Western Ontario Shoulder Instability index. During a mean follow-up of 6.4 years (1 to 14), 177 patients (56%) sustained a re-dislocation, including 70 who required a further operation. In 136 patients (44%) who reported neither re-dislocation nor re-operation, the index scores were good (median 90.4%; 28.9% to 100%). No significant peri- or pre-operative predictors of re-dislocation or re-operation were found.

We found a high rate of re-dislocation after transglenoid suture repair in young, physically active patients.

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury).

Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries.

A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated.

We prospectively evaluated 61 patients treated arthroscopically for anterior instability of the shoulder at a mean follow-up of 44.5 months (24 to 100) using the Rowe scale. Those with post-operative dislocation or subluxation were considered to be failures. Logistic regression analysis was used to identify patients at increased risk of recurrence in order to develop a suitable selection system.

The mean Rowe score improved from 45 pre-operatively to 86 at follow-up (p < 0.001). At least one episode of post-operative instability occurred in 11 patients (18%), although their stability improved (p = 0.018), and only three required revision. Subjectively, eight patients were dissatisfied. Age younger than 28 years, ligamentous laxity, the presence of a fracture of the glenoid rim involving more than 15% of the articular surface, and post-operative participation in contact or overhead sports were associated with a higher risk of recurrence, and scored 1, 1, 5 and 1 point, respectively. Those patients with a total score of two or more points had a relative risk of recurrence of 43% and should be treated by open surgery.