Purpose: Our goal was to analyze the results of 194 consecutive arthroscopic Bankart repairs (performed by 2 surgeons with an identical suture anchor technique) in order to identify specific factors related to recurrence of instability. Type of Study: Case series. Materials and Methods: We analyzed 194 consecutive arthroscopic Bankart repairs by suture anchor technique performed for traumatic anterior-inferior instability. The average follow-up was 27 months (range, 14 to 79 months). There were 101 contact athletes (96 South African rugby players and 5 American football players). We identified significant bone defects on either the humerus or the glenoid as (1) “inverted-pear” glenoid, in which the normally pear-shaped glenoid had lost enough anterior-inferior bone to assume the shape of an inverted pear; or (2) “engaging” Hill-Sachs lesion of the humerus, in which the orientation of the Hill-Sachs lesion was such that it engaged the anterior glenoid with the shoulder in abduction and external rotation. Results: There were 21 recurrent dislocations and subluxations (14 dislocations, 7 subluxations). Of those 21 shoulders with recurrent instability, 14 had significant bone defects (3 engaging Hill-Sachs and 11 inverted-pear Bankart lesions). For the group of patients without significant bone defects (173 shoulders), there were 7 recurrences (4% recurrence rate). For the group with significant bone defects (21 patients), there were 14 recurrences (67% recurrence rate). For contact athletes without significant bone defects, there was a 6.5% recurrence rate, whereas for contact athletes with significant bone defects, there was an 89% recurrence rate. Conclusions: (1) Arthroscopic Bankart repairs give results equal to open Bankart repairs if there are no significant structural bone deficits (engaging Hill-Sachs or inverted-pear Bankart lesions). (2) Patients with significant bone deficits as defined in this study are not candidates for arthroscopic Bankart repair. (3) Contact athletes without structural bone deficits may be treated by arthroscopic Bankart repair. However, contact athletes with bone deficiency require open surgery aimed at their specific anatomic deficiencies. (4) For patients with significant glenoid bone loss, the surgeon should consider reconstruction by means of the Latarjet procedure, using a large coracoid bone graft. Key Words: Instability—Arthroscopic instability repair—Shoulder instability—Bone defect—Bone graft—Latarjet reconstruction.

/pdf/traumatic-glenohumeral-bone-defects-and-their-relationship-3ikzfqcdq4.pdf

Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.

Background and Purpose. Treatment of patients with impingement symptoms commonly includes exercises intended to restore “normal” movement patterns. Evidence that indicates the existence of abnormal patterns in people with shoulder pain is limited. The purpose of this investigation was to analyze glenohumeral and scapulothoracic kinematics and associated scapulothoracic muscle activity in a group of subjects with symptoms of shoulder impingement relative to a group of subjects without symptoms of shoulder impingement matched for occupational exposure to overhead work. Subjects. Fifty-two subjects were recruited from a population of construction workers with routine exposure to overhead work. Methods. Surface electromyographic data were collected from the upper and lower parts of the trapezius muscle and from the serratus anterior muscle. Electromagnetic sensors simultaneously tracked 3-dimensional motion of the trunk, scapula, and humerus during humeral elevation in the scapular plane in 3 hand-held load conditions: (1) no load, (2) 2.3-kg load, and (3) 4.6-kg load. An analysis of variance model was used to test for group and load effects for 3 phases of motion (31°–60°, 61°–90°, and 91°–120°). Results. Relative to the group without impingement, the group with impingement showed decreased scapular upward rotation at the end of the first of the 3 phases of interest, increased anterior tipping at the end of the third phase of interest, and increased scapular medial rotation under the load conditions. At the same time, upper and lower trapezius muscle electromyographic activity increased in the group with impingement as compared with the group without impingement in the final 2 phases, although the upper trapezius muscle changes were apparent only during the 4.6-kg load condition. The serratus anterior muscle demonstrated decreased activity in the group with impingement across all loads and phases. Conclusion and Discussion. Scapular tipping (rotation about a medial to lateral axis) and serratus anterior muscle function are important to consider in the rehabilitation of patients with symptoms of shoulder impingement related to occupational exposure to overhead work.

https://ir.uiowa.edu/cgi/viewcontent.cgi?article=1000&context=oeh_pubs

Alterations in Shoulder Kinematics and Associated Muscle Activity in People With Symptoms of Shoulder Impingement

A standardized method for the assessment of shoulder function

J Bone Joint Surg [Br] 2010;92-B:651-5. Received 30 September 2009; Accepted after revision 26 January 2010 We present the long-term outcome, at a median of 18 years (12.8 to 23.5) of open posterior bone block stabilisation for recurrent posterior instability of the shoulder in a heterogenous group of 11 patients previously reported on in 2001 at a median follow-up of six years. We found that five (45%) would not have chosen the operation again, and that four (36%) had further posterior dislocation. Clinical outcome was significantly worse after 18 years than after six years of follow-up (median Rowe score of 60 versus 90 (p = 0.027)). The median Western Ontario Shoulder Index was 60% (37% to 100%) at 18 years’ follow-up, which is a moderate score. At the time of surgery four (36%) had glenohumeral radiological osteoarthritis, which was present in all after 18 years. This study showed poor long-term results of the posterior bone block procedure for posterior instability and a high rate of glenohumeral osteoarthritis although three patients with post-traumatic instability were pleased with the result of their operations.

:A long term follow-up study

We evaluated the results of 105 operative repairs of tears of the rotator cuff of the shoulder in eighty-nine patients at an average of five years postoperatively. We correlated the functional result with the integrity of the cuff, as determined by ultrasonography. Eighty per cent of the repairs of a tear involving only the supraspinatus tendon were intact at the time of the most recent follow-up, while more than 50 per cent of the repairs of a tear involving more than the supraspinatus tendon had a recurrent defect. Older patients and patients in whom a larger tear had been repaired had a greater prevalence of recurrent defects. At the time of the most recent follow-up, most of the patients were more comfortable and were satisfied with the result of the repair, even when they had sonographic evidence of a recurrent defect. The shoulders in which the repaired cuff was intact at the time of follow-up had better function during activities of daily living and a better range of active flexion (129 +/- 20 degrees compared with 71 +/- 41 degrees) compared with the shoulders that had a large recurrent defect. Similar correlations were noted for the range of active external and internal rotation and for strength of flexion, abduction, and internal rotation. In the shoulders in which the cuff was not intact, the degree of functional loss was related to the size of the recurrent defect.(ABSTRACT TRUNCATED AT 250 WORDS)

Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff.

Impingement on the tendinous portion of the rotator cuff by the coraco-acromial ligament and the anterior third of the acromion is responsible for a characteristic syndrome of disability of the shoulder A characteristic proliferative spur and ridge has been noted on the anterior lip and undersurfac

Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report.

On the basis of roentgenographic appearance and anatomical lesions in 300 displaced fractures and fracture-dislocations of the proximal end of the humerus, a new classification was made of these injuries. Existing classifications were found to be inadequate to describe the lesion encountered. The ne

Displaced proximal humeral fractures. I. Classification and evaluation.

A study of 117 three-part and four-part displaced proximal humeral fractures, followed for from one to sixteen years, is presented. The ages of the patients averaged 55.3 years. Treatment began with closed reduction in seventy-seven patients, the result of which were accepted in thirty-one. Open reduction was done in forty-three patients, and prosthetic replacement in forty-three patients. Their results were rated by a numerical system. Closed reduction was found inadequate for active, healthy patients in either group. This was because of uncontrollable rotatory displacement in three-part fractures and avascular necrosis of the detached head in four-part fractures. Most of the poor results of open reduction in three-part displacements were due to errors in reduction or fixation while those in four-part displacements were due to avascular necrosis of the head. It. was concluded that the preferable method for three-part fractures was open reduction and that for four-part fractures was prosthetic replacement. Using these indications, the typical result was satisfactory but imperfect and many months were required for maximum recovery. Surgical errors and technique are discussed.

Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement.

In thirty-six patients (forty shoulders) with involuntary inferior and multidirectional subluxation and dislocation, there had been failure of standard operations or uncertainty regarding diagnosis or treatment. Clinical evaluation of these patients stressed meticulous psychiatric appraisal, conservative treatment, and repeated examination of the shoulder. All patients were treated by an inferior capsular shift, a procedure in which a flap of the capsule reinforced by overlying tendon is shifted to reduce capsular and ligamentous redundancy on all three sides. This technique offers the advantage of correcting multidirectional instability through one incision without damage to the articular surface. One shoulder began subluxating again within seven months after operation, but there have been no other unsatisfactory results to date. Seventeen shoulders were followed for more than two years.

Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report.

Forty-eight shoulders with glenohumeral osteoarthritis were treated by hemireplacement arthroplasty with a Vitallium humeral-head prosthesis in forty-seven patients, twenty-nine of whom were women. The results in an average follow-up of six years (range, one to twenty years) showed relief of pain and restoration of good function in nearly all patients. Recovery of adequate strength was slow, and continued fatigability was noted by some. Total shoulder-joint surface replacement was performed in one patient in this series with good early results.

Charles S. Neer

Papers

Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report.

Displaced proximal humeral fractures. I. Classification and evaluation.

Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement.

Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report.

Replacement arthroplasty for glenohumeral osteoarthritis.