We have investigated the outcome of arthroscopic revision surgery for recurrent instability of the shoulder after failed primary anterior stabilisation. We identified 40 patients with failed primary open or arthroscopic anterior stabilisation of the shoulder who had been treated by revision arthroscopic capsulolabral reconstruction and followed up for a mean of 36 months (12 to 87). There were 34 men and six women with a mean age of 33.1 years (15 to 48). Details of the patients, the technique of the primary procedure, the operative findings at revision and the clinical outcome were evaluated by reviewing the medical records, physical examination and the use of the Western Ontario shoulder instability index score, the American Shoulder and Elbow Surgeons score and the health status questionnaire 12. Recurrent instability persisted in four patients after the revision arthroscopic procedure. At the final follow-up, the mean American Shoulder and Elbow Surgeons score was 81.1 (17.5 to 99.5) and the mean Western Ontario shoulder instability index score was 68.2 (20 to 98.2). Quality-of-life scoring showed good to excellent results in most patients. Arthroscopic revision capsulolabral reconstruction can provide a satisfactory outcome in selected patients for recurrent instability of the shoulder provided that no large Hill-Sachs lesion is present

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. Methods. A total of 140 shoulders in 140 patients with a mean age of 28.5 years (15 to 55), who underwent arthroscopic treatment for recurrent glenohumeral instability, were included. The prevalence and distribution of chondral lesions and synovial damage were analyzed and graded into stages according to the division of the humeral head and glenoid into quadrants. The following factors that might affect the prevalence and severity of chondral damage were recorded: sex, dominance, age, age at the time of the first dislocation, number of dislocations, time between the first dislocation and surgery, preoperative sporting activity, Beighton score, type of instability, and joint laxity. Results. A total of 133 patients (95%) had synovial or chondral lesions. At the time of surgery, shoulders were graded as having mild, moderate, and severe OA in 55 (39.2%), 72 (51.4%), and six (4.2%) patients, respectively. A Hill-Sachs lesion and fibrillation affecting the anteroinferior glenoid cartilage were the most common findings. There was a significant positive correlation between the the severity of the development of glenohumeral OA and the patient’s age, their age at the time of the first dislocation, and the number of dislocations (p = 0.004, p = 0.011, and p = 0.031, respectively). Conclusion. Synovial inflammation and chondral damage associated with instability of the shoulder are more prevalent than previously reported. The classification using quadrants gives surgeons more information about the chondral damage, and could explain the pattern of development of glenohumeral OA after stabilization of the shoulder. As the number of dislocations showed a positive correlation with the development of OA, this might be an argument for early stabilization. Cite this article: Bone Joint J 2024;106-B(10):1125–1132

We diagnosed 50 patients (58 shoulders) with a mean age at presentation of 17.3 years, as having involuntary positional instability of the shoulder. They were managed by a programme consisting of a careful explanation, analysis of abnormal muscle couples and then muscle retraining carried out by a specialist physiotherapist. The mean follow-up was two years. Six shoulders had a poor result, but 52 were graded as good to excellent. Nine patients (12 shoulders) relapsed and required further episodes of retraining. In our experience, involuntary positional instability of the shoulder causes symptoms which interfere with normal activities; these can be controlled by a treatment plan of retraining of the muscle pattern with functional benefit. Only 19 of the patients were referred with a diagnosis of positional instability. There should be more awareness of this rather uncommon condition. Surgery is not indicated in these patients

11 patients (7 girls and 4 boys) with multidirectional instability of the shoulder were treated between 1999 and 2000. The average age was 15 years 8 months (range, 14–17), with a follow-up of 1 year 6 months. In the examination under general anesthesia it was confirmed that the luxation had more than one direction. The surgery was performed with general anesthesia using a standard arthroscope with video camera and classic approach for the shoulder. In order to decrease the capsular volume, capsular plicature and retraction by heat were used The plicatures were anterior, inferior and posterior. Patients were immobilized postoperatively in plaster splints or casts during 3 weeks and then they were placed in a rehabilitation program. The patients were followed up postoperatively, the UCLA Score was used during this period. Results were excellent and good in 90% of the patients, who were pain free and had full external rotation. Only one patients (10%) presented recurrence of the instability. Patients showed the same pre surgical sport performance. Only one case presented capsule laxity and an open surgery was performed. This patient was reexamined and was labeled as a psychiatric case wrongly selected. Only 2 patients presented capsule inflammation with limited external rotation. They were treated with intensive rehabilitation. The arthroscopic method allows for capsular volume reduction. Results were similar to the ones described with the open technique. The reduction of the capsular volume is done mixing capsular plicature and retraction by heat. This arthroscopic techniques, previously described for adult patients with multidirectional instability, proved to be useful in adolescents

Purpose: The objective of the study was to perform a prospective evaluation of thermal capsulorraphy for the treatment of multidirectional instability of the shoulder. Summary of Methods: Over a period of two years, 19 patients with multidirectional instability were treated with thermal shrinkage. Fifteen patients had involuntary dislocation and four voluntary. The predominant direction of instability was anterior/inferior in 10, posterior in 5 and multiple directions in 4. Patients were followed for a minimum of two years or until surgical failure and recurrence of symptomatology. Postoperatively patients were immobilised in a sling for a period of 3 weeks and were reviewed at 6 weeks and 3, 6, 9 and 12 months and then at six monthly intervals. The Western Ontario shoulder Instability Index was used as a clinical outcome measure as well as subjective and objective evaluation of patient’s function, range of motion, pain and instability. Results: Nine patients had recurrence of their instability occurring at an average of nine months following their surgical procedure (range 7–14 months). One patient had axillary nerve dysfunction postoperatively with difficulty in abducting the shoulder. Three patients had sensory dysaesthesia related to the axillary nerve territory. All neurological subjective evaluations recovered within 9 months. Four of five patients with a predominantly posterior direction to their instability failed this surgical procedure. Only 2 of 10 (20%) with predominantly anterior instability failed. Conclusion: Analysis of patients with multidirectional laxity determined that thermal capsulorraphy had a high failure rate (9/19, 47%) with associated significant postoperative complications including axillary nerve dysaesthesias and stiffness

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.

Purpose

The presence of a Hill-Sachs lesion is a major contributor to failure of surgical intervention following anterior shoulder dislocation. The relationship between lesion size, measured on pre-operative MRI, and risk of recurrent instability after surgery has not previously been defined.

Hypothesis: We hypothesized that the size of Hill-Sachs lesions on pre-op MRI would be greater among patients who failed soft tissue stabilization when compared to patients who did not fail. We also hypothesized that the existence of a glenoid lesion would lead to failure with smaller Hill-Sachs lesions.

We reviewed 26 patients with 34 shoulders treated by the inferior capsular shift operation for inferior and multidirectional instability. The mean follow-up was 8.3 years. In total, 12 shoulders showed voluntary subluxation. Eight operations used an anterior and posterior approach, 11 were by the posterior route, and 15 shoulders had an anterior approach. In 30 shoulders (85%) the outcome was satisfactory and 20 (59%) scored good or excellent results on the Rowe system. Instability had recurred in nine shoulders (26%) from three months to three years after the operation. Six of the 12 shoulders with voluntary subluxation (50%) had recurrence, as against three of the other 22 (14%), a statistically significant difference. The operation is therefore not indicated for voluntary subluxation.

The 19 shoulders which had been assessed in 1987 at a mean of 3.5 years after surgery, were also reviewed in 1995 and found to have no significant changes in instability or Rowe score. This shows that the capsular shift appeared to have maintained its tension over an eight-year period. After the use of a posterior approach, 64% of the shoulders showed a posterolateral defect on radiographs of the humerus.

Thermal capsular shrinkage presents the prospect of reducing redundant capsule, and therefore may be a suitable method of treating capsular-type instability. A prospective study of fifty-four consecutive patients (58 shoulders) treated exclusively with radiofrequency capsular shrinkage for atraumatic instability. The mean Rowe score improved from 33.1 to 74.1 points at followup of up to 48 months. Twenty of the fifty-eight shoulders had recurrence instability. Recurrent instability was related to the type of instability: 76.9% for voluntary instability, 30.3% for involuntary instability and none of 12 shoulders for instability/impingement pain. Recurrence was related as well to previous instability surgery (70%). The outcome was not related to the direction of instability, type of radiofrequency probe used, age of patient or ligamentous laxity. Twenty-two (57.9%) of thirty-eight patients returned to their pre-instability level of sporting activity. By using repeated RF treatments for the failed thermal shrinkage cases the failure rate was reduced from (20/58) 34.5% to (13/58) 22.4% and cumulative changes were seen on electron microscopy. These results are comparable to some of the results for open inferior capsular shift for patients with multidirectional instability with substantial less morbidity. The application of the minimal effective energy is controlled according to the tissue response without any charring or burning effect to the tissue. No scar was seen in repeated arthroscopies, or in electron microscopy studies. Thermal shrinkage does not negatively affect a later open stabilisation, but rather may provide better conditions for secure open surgery. We have found significant improvement in proprioception following thermal shrinkage treatment. We believe that by re-tensioning the proprioceptors they begin to fire off at lesser degrees of movement, and that there is a greater dynamic muscular contribution to shoulder stability. When using the correct technique for the right indications, Radiofrequency thermal shrinkage is a viable alternative to open inferior capsular shift in patients with capsular type of instability

We compared the long-term function of subscapularis after the Latarjet procedure using two surgical approaches. We treated 102 patients (106 shoulders) with a mean age of 26.8 years (15 to 51) with involuntary unidirectional recurrent instability. The operation was carried out through an L-shaped incision with trans-section of the upper two-thirds of the muscle in 69 cases and with a subscapularis split in 37. All clinical results were assessed by the Rowe and the Duplay scores and the function of subscapularis by evaluating the distance and strength at the lift-off position. Bilateral CT was performed in 77 patients for assessment of fatty degeneration. The mean follow-up was 7.5 years (2 to 15) and 18% of cases were lost to follow-up. The mean Duplay score was 82 of 100 for the L-shaped incision group and 90 of 100 for those with a subscapularis split (p = 0.02). The mean fatty degeneration score was 1.18 after an L-shaped incision compared with 0.12 after subscapularis split (p = 0.001). The subscapularis split approach is therefore recommended.

Anterior and posterior drawer tests of the shoulder are described. Their purpose is to detect anterior and posterior shoulder instability and thereby to eliminate some of the failures of operative treatment. Their value in assessing unidirectional and multidirectional instability both before and after operation is discussed.

Purpose: We hypothesized that lateralization of the RSA, with a glenoid bone graft taken from the osteotomised humeral head, would prevent those problems without increasing torque on the glenoid component by keeping the center of rotation within the glenoid. The objectives of this study were to describe the results of the first 12 patients that underwent a bony increased-offset RSA (BIO RSA).

Method: Thirty-six shoulders in 34 consecutive patients with cuff tear arthritis (mean age 72 years, range 52–86 years) received a BIO RSA, consisted of a RSA incorporating an autogenous humeral head bone graft placed beneath the glenoid baseplate. A baseplate with a lengthened central peg (+25 mm) was inserted in the glenoid vault, securing the bone graft beneath the baseplate and screws. All patients underwent clinical and radiographic (computed tomography) review at a minimum 1-year follow-up.

Results: All patients were satisfied or very satisfied and all had no or slight pain. Mean active elevation increased from 72° to 142° (p< 0.05), external rotation from 10° to 18° (p< 0.05) and internal rotation from L4 to L3 (p> 0.05). Constant Score improved from 27 to 63 points (p< 0.05). The Subjective Shoulder Value (SSV) increased from 27% to 73% (p< 0.05). Radiographically, the graft healed to the native glenoid in all cases and no graft resorption under the baseplate was observed. Complications included one patient with scapular notching (stage 1) and one patient with previous radiotherapy had a deep infection. No postoperative instability, and no glenoid loosening were observed.

Conclusion: The use of an autologous bone graft harvested from the humeral head can lateralize the center of rotation of a RSA while keeping the center of rotation at the glenoid bone-prosthesis interface. The clinical advantages of a BIO RSA are a decrease in scapular notching, enhanced stability and mobility, and improved shoulder contour while keeping the center of rotation at the glenoid bone-prosthesis interface. This bony lateralization allows maintenance of the principles of Grammont and seems to be more appropriate than prosthetic lateralization. These promising early results of this novel procedure warrant further investigation.

Purpose: The purpose of our work was to report causes and results of treatment of anterior shoulder instability after implantation of a shoulder prosthesis. Material and methods: This retrospective multicentric study included 51 patients with prosthetic anterior instability: 42 patients after first-intention shoulder prosthesis and nine after prosthesis revision. There were 39 women (79%) and 12 men, mean age 67 years, who underwent total shoulder arthroplasty (n=29, 57%) or hemiarthro-plasty (n=22, 43%). Thirty-eight patients (75%) had prosthetic dislocation and 13 (25%) subluxation associated with pain an loss of anterior elevation. The initial prosthesis was implanted for degenerative disease (n=29), rheumatoid arthritis (n=7), or fracture (n=15). Anterior prosthetic instability occurred early in 23 shoulders (first six weeks) and lat in 28 shoulders (7 after trauma, 21 without trauma). Conservative treatment by reduction-immobilisation was performed in 16 cases and prosthetic revision in 35. The patients were reviewed radiographically at mean 41 months follow-up (range 24–62). Results: Subscapular tear or incompetence was the main cause of prosthetic anterior instability, observed in 87% of the cases. Technical errors concerning the prosthesis were also observed: oversized head, malrotation of the prosthesis. Associated complications were frequent: glenoid loosening (24%), polyethylene dissociation from the metal glenoid implant (10%), infection (10%), humeral fracture (4%). The final Constant score was 54 points and 55% of the patients were disappointed or dissatisfied. None of the shoulders were stable after consevative treatment. The prosthetic revision provided disappointing results with 51% recurrent anterior instability. Discussion: Anterior instability of shoulder prostheses is a serious complication which responds poorly to treatment. Loosening of the subscapular suture is the main cause

Expert North American shoulder surgeons were poled on the diagnosis and treatment of five shoulder conditions. To quantify inter-observer agreement in the diagnosis and treatment of shoulder instabilities, they chose one of five diagnostic conditions and one or more of seven treatment options. The greatest diagnostic and treatment differences were noted for a painful shoulder in a throwing athlete with subtle anterior instability and a patient with voluntary posterior instability with an asymptomatic sulcus sign. An arthroscopic approach was consistently preferred to open surgery. These inconsistencies highlight the need for standardized diagnostic criteria and more universal treatment plans.

To quantify inter-observer agreement in the diagnosis and treatment of shoulder instabilities among expert North American shoulder surgeons.

These inconsistencies, particularly in diagnosis, highlight the need for standardization of diagnostic criteria and guidelines working towards more universal treatments and evaluations of outcomes.

The greatest diagnostic differences were noted for a painful shoulder in a throwing athlete with subtle anterior instability(Ksc0.46, 55% agreement) and a patient with voluntary posterior instability with an asymptomatic sulcus sign(Ksc0.41, 50% agreement). The presence of an asymptomatic sulcus sign alone may have been mistakenly interpreted as inferior instability rather than inferior laxity. There was a high level of agreement in diagnosing anterior and bi-directional instability. An arthroscopic approach to treatment was consistently preferred to open surgery. The greatest differences in treatment choice were for the throwing athlete(Ksc0.38, 47% agreement on arthroscopic repair), a patient with voluntary posterior instability(Ksc0.34, 43% agreement on arthroscopic capsular repair) and a patient with bi-directional instability(Ksc0.23, 34% agreement on arthroscopic anterior Bankart repair).

Active members of the American Shoulder and Elbow Surgeons and JOINTS Canada (Orthopaedic Initiatives for National Trials of the Shoulder) were poled on the diagnosis and treatment of five shoulder conditions. They were to choose one of five conditions and one or more of seven treatment options. A Kappa coefficient of agreement was used to assess inter-observer reliability; a Ksc of 1 denotes perfect agreement on a category and a Ksc of −1 denotes perfect agreement on not endorsing a category.

Aims. The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR). Methods. This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport. Results. At a mean follow-up of four years (1.0 to 8.25), ten patients (7.5%) had recurrent instability. Patients in group B had a significantly higher recurrence rate than those in group A (p = 0.001). Using a multivariate logistic regression, the presence of glenoid erosion of > 10% (odds ratio (OR) = 35.13 (95% confidence interval (CI) 8 to 149); p = 0.001) and age < 23 years (OR = 0.89 (0.79 to 0.99); p = 0.038) were associated with a higher risk of recurrent instability. A total of 80 patients (78%) could return to sport, but only 11 athletes (65%) who practiced high-risk (collision or contact-overhead) sports. All seven shoulders which were revised using a Latarjet procedure were stable at a mean final follow-up of 36 months (11 to 57) and returned to sports at the same level. Conclusion. Patients with subcritical glenoid bone loss (> 10%) and younger age (≤ 23 years) are at risk of failure and reoperation after ABR-HSR. Furthermore, following this procedure, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder. Cite this article: Bone Joint J 2021;103-B(4):718–724

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use. Cite this article: Bone Joint J 2024;106-B(9):970–977

Purpose: There are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the shoulder. The purpose of this study was to evaluate the results of arthroscopic methods in the treatment of athletes with symptomatic multidirectional instability of the shoulder. Method: Forty patients (43 shoulders) with multidi-rectional instability of the shoulder were treated via arthrscopic means and were evaluated at a mean of 33.5 months post-operatively. The mean patient age was 19.1 years (range 14 to 39). There were 24 male patients and 16 female patients. Patients were evaluated with the ASES and WOSI scoring systems. Stability, strength, and range of motion were evaluated with patient-reported scales. Results: The mean ASES score postoperatively was 91.4 out of 100. The mean WOSI post-operative percentage score was 91.1 out of 100. Ninety-one percent of patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% of patients were able to return to their sport with little or no limitation. Conclusion: Arthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic population

Aims. The factors that predispose to recurrent instability and revision stabilization procedures after arthroscopic Bankart repair for anterior glenohumeral instability remain unclear. We sought to determine the rate and risk factors associated with ongoing instability in patients undergoing arthroscopic Bankart repair for instability of the shoulder. Materials and Methods. We used the Statewide Planning and Research Cooperative System (SPARCS) database to identify patients with a diagnosis of anterior instability of the shoulder undergoing arthroscopic Bankart repair between 2003 and 2011. Patients were followed for a minimum of three years. Baseline demographics and subsequent further surgery to the ipsilateral shoulder were analyzed. Multivariate analysis was used to identify independent risk factors for recurrent instability. Results. A total of 5719 patients were analyzed. Their mean age was 24.9 years (. sd.  9.3); 4013 (70.2%) were male. A total of 461 (8.1%) underwent a further procedure involving the ipsilateral shoulder at a mean of 31.5 months (. sd.  23.8) postoperatively; 117 (2.1%) had a closed reduction and 344 (6.0%) had further surgery. Revision arthroscopic Bankart repair was the most common subsequent surgical procedure (223; 65.4%). Independent risk factors for recurrent instability were: age < 19 years (odds ratio 1.86), Caucasian ethnicity (hazard ratio 1.42), bilateral instability of the shoulder (hazard ratio 2.17), and a history of closed reduction(s) prior to the initial repair (hazard ratio 2.45). Revision arthroscopic Bankart repair was associated with significantly higher rates of ongoing persistent instability than revision open stabilization (12.4% vs 5.1%, p = 0.041). Conclusion. The incidence of a further procedure being required in patients undergoing arthroscopic Bankart repair for anterior glenohumeral instability was 8.1%. Younger age, Caucasian race, bilateral instability, and closed reduction prior to the initial repair were independent risk factors for recurrent instability, while subsequent revision arthroscopic Bankart repair had significantly higher rates of persistent instability than subsequent open revision procedures. Cite this article: Bone Joint J 2018;100-B:324–30

The purpose of this study was to evaluate the expression of acid-sensing ion channels (ASICs) in the capsule and synovial fluid of patients with frozen shoulder. Capsular tissue and synovial fluid were obtained from 18 patients with idiopathic frozen shoulder (FS group) and 18 patients with instability of the shoulder (control group). The expressions of ASIC1, ASIC2, and ASIC3 in the capsule were determined using the reverse transcriptase-polymerase chain reaction, immunoblot analysis, and immunohistochemistry (IHC). The concentrations in synovial fluid were evaluated using an enzyme-linked immunosorbent assay. . The mRNA expression of ASIC1, ASIC2 and ASIC3 in the capsule were significantly increased in the FS group compared with the control group. The protein levels of these three ASICs were also increased. The increased expressions were confirmed by IHC. Of the ASICs, ASIC3 showed the greatest increase in both mRNA and levels of expression compared with the control group. The levels of ASIC1 and ASIC3 in synovial fluid were significantly increased in the FS group. . This study suggests that ASICs may play a role as mediators of inflammatory pain and be involved in the pathogenesis of frozen shoulder. Cite this article: Bone Joint J 2015;97-B:824–9