Upper extremity Failed shoulder stabilization surgery: what to do?

Transcription

1 S P E C I A L F O C U S Upper extremity Failed shoulder stabilization surgery: what to do? Neil Ghodadra a, Robert Grumet a, Lance LeClere b and LCDR Matthew T. Provencher, MD MC USN b ABSTRACT Despite advances in arthroscopic techniques and implants for shoulder instability repair, the failure rate is still between 5 30%, resulting in a loss of functional performance of athletic and other shoulder activities. In general, failure of shoulder instability can be divided into failures from recurrence of instability, failure from postoperative stiffness, and failure from persistent pain. Each of these may occur individually or be part of a spectrum of issues surrounding the failed instability repair. Each cause should be carefully screened to elucidate the contributing factors. The treatment of a failed instability procedure is predicated upon a sound history and physical examination, with appropriate radiographic workup to exclude causes of failure such as rotator cuff tear, SLAP injury, and glenoid and humeral head bone loss. With careful attention to the factors associated with failed instability repair, a viable revision surgery plan can be devised to achieve optimal results. Keywords Bankart, capsule, failed instability repair, failure, labrum, shoulder instability a Rush University, Department of Orthopaedic Surgery b Naval Medical Center San Diego, Division of Shoulder, Knee and Sports Surgery, Department of Orthopaedic Surgery Correspondence to Matthew T. Provencher, MD, Department of Orthopaedic Surgery, Bob Wilson Dr., Ste 112, San Diego, CA , USA Tel: ; fax: ; matthew.provencher@med.navy.mil ß 2009 Wolters Kluwer Health Lippincott Williams & Wilkins INTRODUCTION The pathology, treatment, and results of shoulder instability have been well documented in the literature. 1,2,3 Despite a more evolved understanding of anterior shoulder instability, failure rates after primary open and arthroscopic surgery are noted to be between 5 30%. 3,4,5 In general, a shoulder instability procedure can fail for one of three reasons: recurrence of instability, residual pain and postoperative stiffness. These can each present individually or in concert and diminish overall satisfaction and preclude return to activities. It is critical to try and identify the reasons for failure because optimal treatment for revision surgery success is predicated upon a keen preoperative revision surgery plan. Patients who present with failed shoulder instability surgery typically complain of feelings of recurrent instability, unremitting pain and shoulder stiffness. Persistent or recurrent glenohumeral instability after a previous surgical stabilization has been reported to be caused by initial misdiagnosis of concomitant pathology in up to 84% of revision cases. 1,2,5 This further emphasizes the importance of proper assessment of a patient with shoulder instability, especially the failure to diagnose potential underlying pathology (Table 1). The diagnosis of failed shoulder instability procedure begins with appropriate diagnosis and determination of mode of failure. Thus, a thorough history and complete physical examination are essential to plan for potential future surgical intervention. Several key issues in the patient history are important, including a potential mechanism of re-injury, previous surgical treatment of the shoulder, and whether the previous shoulder stabilization ever relieved the patient s symptoms. Specific questions to be asked include whether or not the re-injury was traumatic, if there is apprehension or instability in midranges of motion, and if there is associated pain and stiffness. While these questions seem standard for any patient interview for recurrent shoulder instability, the answers to these questions may help the surgeon direct physical examination and radiographs to determine the source of instability surgery failure. In conjunction with the history, physical examination is essential to define the direction and magnitude of instability, assess range of motion and pain, as well as co-existing, previously untreated pathology. The structure, function, neurological status and strength of the injured shoulder should be compared with the contralateral shoulder. Pain or grinding with motion or loss of motion should alert the surgeon to additional pathology or additional missed diagnoses such as anchor malposition. Shoulder stability testing should also be further evaluated. Special attention should be Volume 20 Number 4 July/August 2009 Current Orthopaedic Practice 1

2 2 Volume 20 Number 4 July/August 2009 TABLE 1. Diagnosis issues encountered in the preoperative workup Complication Misdiagnosis Inadequate imaging Inadequate history Inadequate physical examination Asymmetrical loss of ER at side Asymmetrical loss of ER at abduction Weakness in the scapular plane Pearls: how to avoid Thorough history and full shoulder exam West Point axillary view (glenoid bone loss) Stryker Notch view (Hill Sachs lesion) 3-D CT Scan (bone loss) MRI/MRA (concomitant pathology) Determine cause (voluntary, traumatic, recurrent?) Determine if patient had previous surgery MDI vs. anterior instability vs. posterior instability Possible overconstraint of subscapularis or rotator interval Possible overconstraint of IGHL Alert to concomitant pathology including RC tear and suprascapular nerve palsy CT, computed tomography; ER, external rotation; IGHL, inferior glenohumeral ligament; MDI, multi-directional instability; MRA, magnetic resonance arthrography; MRI, magnetic resonance image; RC, rotator cuff; ROM, range of motion. given to the various glenohumeral ligaments, as the type of laxity might change the surgical plan. Specifically, asymmetrical loss of external rotation at the side (ERS) may be indicative of over-constraint of the subscapularis, the rotator interval, or the superior capsule (superior and middle glenohumeral ligaments) and may herald a potential technical issue in that the primary instability pathology (inferior glenohumeral ligament) was not treated. Asymmetrical loss of external rotation in abduction (ABER) may identify nonanatomic over-constraint of the inferior ligaments. Ligamentous hyperlaxity is critical to determine preoperatively because external rotation more than 908 with the arm at the side is an indication of anterior hyperlaxity and a risk factor for failed instability surgery. 6 In addition, a stretched inferior glenohumeral ligament has been noted to be a risk factor for failed surgical stabilization and can be ascertained preoperatively with an asymmetrical hyperabduction test of more than 208 TABLE 2. Common causes of failure of instability repair Age Activity Level Capsular Integrity Voluntary component Failure to recognize pathological lesion Technical inadequacies Poor tissue quality Bony loss Glenoid Humeral head Inappropriate rehabilitation compared to the contralateral side. 6 It also is vital to recognize any capsular pathology because failure to do so has been shown to be the most common cause of a failed arthroscopic stabilization. 1,7 11,12,13,14 According to clinical studies and experimental studies, the capsule is always overstretched in shoulder instability, and capsular redundancy must be treated at the time of surgery. 15,16 In his classic article on anterior instability, Rowe et al. 16 noted that failed open stabilizations could be attributed to both persistent capsular laxity and a recurrent Bankart lesion suggesting, as many other biomechanical studies have, that successful stabilization must treat both lesions. Next, strength in all planes should be evaluated. Weakness in one or more planes should alert the surgeon to the presence of concomitant pathology, such as rotator cuff tear or suprascapular nerve palsy. Specific attention to subscapularis function using the belly press test and lift-off maneuver should always be performed. In patients who have undergone previous open surgery, failure of subscapularis repair or subscapularis dysfunction may be present and should be noted and documented preoperatively. In a 2005 study performed by Sachs et al., 17 23% of the 30 patients studied had an incompetent subscapularis at an average of 4 years after open Bankart repair. Of these patients, only 57% stated that they would have the surgery again, while 100% of the patients with an intact subscapularis claimed that they would have the surgery again. Furthermore, studies have shown decreased subscapularis volume and diameter and clinical subscapularis dysfunction in 70% of patients after open Bankart repair. 18 Appropriate imaging can serve as an adjunct to successful evaluation and diagnosis of bone loss and concomitant pathology in patients with recurrent instability in both a TABLE 3. Technical errors during instability repair Complication Misdiagnosis Failure to diagnose concomitant pathology Inadequate capsulorrhaphy tension Inadequate restoration of glenoid concavity HAGL Hardware failure HAGL, Humeral avulsion glenohumeral ligament; ROM, range of motion. Pearls: how to avoid Full shoulder examination under anesthesia Place patient in lateral decubitus position for optimal visualization and access to glenoid labrum Complete diagnostic arthroscopy prior to instability repair Examine shoulder ROM after repair Incorporate bony Bankart into repair If >25%, consider bone augmentation with Latarjet vs. Iliac Crest Graft Avoid excessive anterior-inferior capsular tightening in overhead throwers Proper mobilization and repair onto humerus Do not use bioabsorbable tacks Place anchors below articular margin with firm purchase in subchondral bone Place 3 anchors below 3:00 Use >3 anchors with 1st anchor at 6:00 position and 458 to articular surface

3 Current Orthopaedic Practice 3 TABLE 4. Common pathologic findings with anterior instability repair Complication Pearls: how to treat Rotator cuff tear Identify partial tears and look for common tear patterns: Crescent U-shaped L-shaped Note! intact cuff confers stability AC Joint Pain Distal clavicle excision vs. preoperative AC joint injection Extensive Labral Tear Visualize entire glenoid labrum SLAP Address at time of surgery Look for concomitant biceps pathology ALPSA lesion Tear of anterior band of IGHL Labrum and scapula periosteal sleeve detached medially and inferiorly on glenoid neck HAGL lesion Visualize from posterior portal with 308 scope in axillary pouch in ER and IR Repair both in inferior! superior and medial! lateral directions Bankart lesion Dissect labrum medially until muscle fibers of subscapularis are visible: <15% bone loss! labral and capsular repair 15 25% bone loss! incorporate bony fragment into repair >25% bone loss! glenoid bone reconstruction Hill Sachs lesion If engaging, consider remplissage or bone augmentation AC, Acromioclavicular; ALPSA, Anterior Labrum Periosteal Sleeve Avulsion; ER, External Rotation; HAGL, Humeral Avulsion of Anterior Glenohumeral Ligament; IGHL, Inferior Glenohumeral Ligament; IR, Internal Rotation; SLAP, Superior Labrum Anterior to Posterior. primary and revision settings (Tables 2 4). Bone loss of the glenoid and humeral head has been shown to be an important predictor of clinical failure after anterior shoulder stabilization surgery. 1,2,3,7 10,19 Preoperative radiographs include the anteroposterior (AP), scapular-y, and axillary views. Additionally, a Stryker notch view is helpful for evaluating Hill-Sachs lesions, while the West Point view may be used to determine glenoid bone loss (Figure 1). CT is an extremely useful way to determine the extent of any bone loss in the humeral head or glenoid component, especially with advanced software that allows for threedimensional imaging of surface lesions (Figure 1). Several published clinical studies have shown increased recurrence rates of glenohumeral instability after surgical repair when preoperative glenoid bone loss ranged from 20 to 30%, 2,20 and in 2000, Burkhart et al. 3 reported a 67% recurrence rate when a patient has significant bone loss. In patients with a large amount of glenoid bone loss (generally greater than 25%), an open, bony augmentation procedure provides predictable restoration of stability. In addition, plain radiographs and CT imaging can be used to determine potential technical errors in shoulder instability repair such as inadequate anchor number and placement and anchor chondrolysis. Thus, CT (especially three-dimensional reconstruction) is extremely helpful in identifying patients with incorrect anchor placement and those who require bony reconstruction in lieu of arthroscopic soft-tissue repair (Figure 2). MRI is the modality of choice to evaluate the soft-tissue structures surrounding the shoulder including the glenoid labrum and glenohumeral ligament complex. MR arthrography has been shown to be helpful in improved exposure of glenohumeral pathology (Table 4). Failure to identify and treat concomitant pathology such as superior glenoid labrum anterior to posterior (SLAP) tears, rotator cuff tears, patulous capsular stretching, and humeral avulsion of the glenohumeral ligament (HAGL lesion) may lead to an increased rate of recurrence. 2,6,11,13,21,22,23,24,25 Preoperative identification of concomitant shoulder pathology with appropriate imaging allows for successful surgical planning in revision instability cases. TREATMENT The basis for treatment of failed shoulder stabilization is a thorough preoperative history, examination and imaging modalities in an effort to delineate the aforementioned FIGURE 1. Anteroposterior (A) and lateral (B) radiographs of a patient who presented with a failed instability procedure. The surgical repair demonstrates metal anchors that are in a superior position, less than optimal for repair of the anteroinferior capsulolabral structures.

4 4 Volume 20 Number 4 July/August 2009 FIGURE 2. An example of humeral avulsion of the glenohumeral ligament (HAGL) of the shoulder capsule. reasons for failure. The surgical intervention necessary is then guided by the underlying pathology, patient demographics, activity level and expectations. Glenoid bone loss Unrecognized glenoid bone loss is the most common reason for failure of shoulder instability surgery. 2,3,16,23,26,27 Glenoid bone loss can be initially evaluated pre-operatively by obtaining plain radiographs (axillary, West Point, apical oblique, Didiee). However, more advanced imaging, including CT reconstruction usually is necessary to further identify and quantify the severity of bone loss. Finally, a definitive determination of the bony deficiency can be made at the time of arthroscopy. In general, the bare area of the glenoid marks the center of the inferior two-thirds of the glenoid. 28 The amount of bone loss can be calculated using a calibrated probe and is defined as: %Glenoid Bone Loss ¼ ðbare Spot to Posterior Rim Bare spot to remaining anterior glenoid rimþ 2ðBare Spot to Posterior Rim 100Þ The quantity of bony deficiency will help guide the decision making in terms of arthroscopic versus open repair as well as the need for bony reconstruction of the glenoid rim. Patients with less than 15% bone loss of the anterior glenoid can be treated with revision repair of the capsulolabral restraint. Both open and arthroscopic techniques have shown good success in this population of patients with low recurrence rates. 28,29,30,31,32 An important exception should be made for patients with recurrent instability and a bony Bankart lesion. These patients benefit from either open or arthroscopic repair of the bony Bankart or incorporation of the bony fragment into the labral repair with resultant restoration of the normal anterior glenoid architecture. 24,26,29 Patients with 15 25% glenoid loss are a more controversial category with regard to treatment. Many authors have described successful treatment with arthroscopic capsulolabral repair. These results are likely further improved by incorporating the bony fragment, if present, into the repair. 34,35 Other authors have advocated a bony reconstruction procedure (Latarjet, Bristow) to the anterior glenoid rim in highlevel contact athletes. 10,29 While there are a host of treatment options available for this group of patients with good success, the appropriate treatment for this degree of bony deficiency may be more appropriately guided by patient specific factors (activity level, demand, expectations). Finally, most authors would agree that patients with greater than 25 30% loss of the anterior glenoid would benefit from bony reconstruction to prevent recurrence. There are several reconstructive procedures described in the literature. The Bristow procedure was originally described as a transfer of the tip of the coracoid process with the attached conjoined tendon to the anteroinferior rim of glenoid through a split in the subscapularis tendon. 10 Historically, the procedure has seen several modifications with the underlying concept being the sling effect of the conjoined tendon to resist anterior humeral translation, especially in a position of abduction and external rotation. 10,30 The Latarjet procedure involves the transfer of a larger portion of the coracoid and conjoined tendon to the anterior glenoid, thereby providing a larger surface area to the glenoid in addition to the effect of the conjoined tendon 31,32 (Figure 3). While both procedures have shown a favorable outcome with respect to recurrence rates, there is a significant risk of arthrosis, motion loss and subscapularis dysfunction reported. 9,18 In addition to transfer of the coracoid process, some authors have described the use of iliac crest bone graft to the anterior glenoid with similar good success. 33 Hill-Sachs Lesions In addition to glenoid bony loss, a Hill-Sachs lesion on the humeral head is a significant risk factor for recurrent dislocation and failed instability surgery. Depending on the size, a posterior humeral head defect from a traumatic dislocation may decrease the arc of motion, engage on the anterior rim of the glenoid and effectively lever the humeral head out of the glenohumeral joint causing recurrent instability. 34 The size of the Hill-Sachs lesion often can be appreciated on the Stryker notch view or a three-dimensional CT scan. Typically when the associated injuries (labral tear, HAGL, glenoid bone deficiency) are treated appropriately, the Hill-Sachs lesion can be ignored because the defect no longer has the ability to engage on the anterior rim. A careful dynamic inspection of the bony defect at the time of arthroscopy may guide whether the Hill-Sachs lesion needs to be treated surgically to prevent engagement of the lesion. Surgical options include bone grafting (allograft, autograft) or synthetic plugs to fill the defect, soft-tissue interposition such as transfer of the infraspinatus tendon into the defect, humeroplasty or disimpaction of the defect, or in severe cases, humeral head resurfacing (Figure 4). 34 Rotator Interval The role for closure of the rotator interval in the setting of shoulder instability is controversial. A cadaver study by Provencher et al. 35 compared the effect of arthroscopic

5 Current Orthopaedic Practice 5 FIGURE 3. Patient with large amount of glenoid bone loss demonstrated on the sagittal oblique MR arthrogram (A) of approximately 25 30%. The postoperative axial CT scan is shown (B) that demonstrates excellent bone healing after a Latarjet procedure. and open rotator interval closure. The authors found that the arthroscopic group had reduced anterior translation in the abducted and externally rotated humerus. However, these specimens also exhibited loss of motion with reduced external rotation in the abducted, externally rotated position. In a follow-up study, Mologne et al. 36 evaluated the effect of rotator interval closure after instability repair (anterior and posterior). The authors concluded that rotator interval closure further reduced anterior humeral translation in the anteroinferior instability group; however, there was no change in posterior translation with interval closure. Closure of the rotator interval therefore may play a role in revision anterior instability repair in an effort to further reduce anterior humeral translation; however, additional studies are necessary. Subscapularis Insufficiency Insufficiency or dysfunction of the subscapularis has been reported to occur in 4% to 54% of open instability surgeries. 17,18 This complication must be considered in patients undergoing revision instability repair after a failed open procedure. Pre-operative planning in patients with suspected subscapularis dysfunction includes an MRI to evaluate the integrity and quality of the tendon insertion on the lesser tuberosity. More importantly, however, the MRI sagittal oblique may be used to evaluate the subscapularis muscle belly for atrophy and fatty infiltration. Clinically significant subscapularis dysfunction may occur in as many as 70% of patients after an open instability repair. 18 Surgical management may include subscapularis repair if possible, pectoralis major transfer, or allograft reconstruction. Capsular Injury and Management Insufficient capsule, injury (HAGL), redundancy (multidirectional instability) and tightness are all important preoperative and intra-operative considerations in management of the patient with recurrent instability. Poor capsular quality may require open reconstruction of the deficient capsule with allograft or autograft in an effort to improve the static restraint of the glenohumeral ligaments. Alternatively, a bone augmentation procedure, such as a Latarjet, may be considered to provide an anterior restraint to the humerus with the attached conjoined tendon. A HAGL lesion or capsular redundancy previously untreated may require repair or plication, respectively, to restore shoulder stability. Finally, while seemingly counterintuitive, select cases of recurrent instability may be caused by iatrogenic capsular tightness from previous procedures. The Erlenmeyer flask phenomenon is described in patients who may exhibit excessive anterior tightness with residual inferior laxity allowing them to escape inferiorly (Arciero, The failed instability patient: what went wrong, AAOS ICL, Las Vegas 2009). These patients typically have tightness in external rotation with a residual sulcus sign. Patients may be treated arthroscopically with anterior release and revision plication with incorporation of the inferior capsular redundancy. Open Versus Arthroscopic Revision Instability Repair Recent advances in arthroscopic techniques have shown that the results of arthroscopic repair for primary shoulder instability are comparable to open techniques with fewer complications. 6,21,27,36,37 40 Arthroscopic revision stabilization when indicated has been shown to have reasonably good results. 12,13,23,24,25,41 The principles of revision instability repair are to perform an anatomic repair, restore ligament tension and provide secure fixation. With these fundamentals in mind, arthroscopic revision instability surgery is indicated on a case-by-case basis. For example, a previously missed or inappropriately treated capsular laxity or injury (HAGL) may be easily and reliably repaired arthroscopically. Similarly, an unrecognized labral injury (SLAP, posterior labrum) may be more easily approached arthroscopically with predictable results. In addition, as mentioned previously, patients with anterior glenoid bone loss can

6 6 Volume 20 Number 4 July/August 2009 FIGURE 4. A patient who presented with recurrent instability after anterior repair with a very large Hill-Sachs defect (A). He had no significant glenoid bone loss and was treated with an osteochondral allograft to the humeral head which demonstrated full healing at 1 year postoperatively (B F).

7 Current Orthopaedic Practice 7 be adequately treated with revision stabilization procedures. Open procedures often are indicated for patients with severe glenoid bone loss requiring bony reconstruction as mentioned above, subscapularis deficiency requiring surgical intervention or patients in whom an engaging Hill- Sachs lesion is believed to play a role in the recurrent instability. Regardless of the type of method of revision stabilization,theresultsofrepairarenotasgoodasthe primary intervention. Hardware Complications, Placement, and Treating Pathology The term post-arthroscopic glenohumeral chondrolysis (PAGCL) has been termed to define early chondral damage after instability repair. Although this is a problem with likely multifactorial etiology, there are associations with prominent glenoid anchors causing early chondral wear and osteoarthritis (Figure 5). In addition, there is recent evidence that the use of postoperative glenohumeral pain pumps and FIGURE 5. A patient in whom two open anterior instability repairs failed presented with recurrent instability and subscapularis insufficiency with profound internal rotation weakness. He was treated with a bony augmentation procedure (Latarjet) and split pectoralis major tendon transfer to the lesser tuberosity (A F).

8 8 Volume 20 Number 4 July/August 2009 thermal devices may be associated with early chondrolysis and glenohumeral joint degeneration. CONCLUSION The problem of recurrent instability in a patient with a previously failed shoulder stabilization procedure can be a significant challenge from a technical perspective and patient expectation and outcome after revision repair. It is essential that the surgeon have an understanding of the causes of failure and a systematic approach to managing each one. The ideal management for revision stabilization should be considered on a case-by-case basis with particular emphasis on the patient and anatomy-specific factors mentioned. REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest 1. Pagnani MJ. Open capsular repair without bone block for recurrent anterior shoulder instability in patients with and without bony defects of the glenoid and/or humeral head. Am J Sports Med. 2008; 36: The author recommends open capsular repair as the primary method of treatment given the high complication rate historically associated with bone-block techniques. 2. Boileau P, Villalba M, Hery JY, et al. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg. 2006; 88(A): This new intra- and extra-articular combined technique constitutes an alternative in the treatment of anterior shoulder instability in patients with deficient or stretched anterior capsule. 3. Burkhart SS, De Beer JF. 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. Arthroscopy. 2000; 16: Barnes CJ, Getelman MH, Snyder SJ. Results of arthroscopic revision anterior shoulder reconstruction. Am J Sports Med. 2009; 37: The results of this study suggest arthroscopic revision anterior shoulder reconstruction using suture anchors is a viable treatment alternative for patients with failed anterior shoulder reconstructions. 5. Mazzocca AD, Brown FM Jr, Carreira DS, Hayden J, Romeo AA. Arthroscopic anterior shoulder stabilization of collision and contact athletes. Am J Sports Med. 2005; 33: Levine WN, Arroyo JS, Pollock RG, Flatow EL, Bigliani LU. Open revision stabilization surgery for recurrent anterior glenohumeral instability. Am J Sports Med. 2000; 28: Hill JD, Lovejoy JF Jr, Kelly RA. Combined posterior Bankart lesion and posterior humeral avulsion of the glenohumeral ligaments associated with recurrent posterior shoulder instability. Arthroscopy. 2007; 23:327e1 327e3. Arthroscopic anatomic reconstruction of both lesions resulted in an excellent clinical outcome. 8. Ozbaydar M, Elhassan B, Diller D, et al. Results of arthroscopic capsulolabral repair: Bankart lesion versus anterior labroligamentous periosteal sleeve avulsion lesion. Arthroscopy. 2008; 24: Patients with ALPSA lesions present with a higher number of recurrent dislocations than those with discrete Bankart lesions. 9. Cheung EV, Sperling JW, Hattrup SJ, Cofield RH. Long-term outcome of anterior stabilization of the shoulder. J Shoulder Elbow Surg. 2008; 17: This study reports long-term experience with anterior shoulder capsule stabilization by performing the Bankart repair when labral tearing was present with a laterally based T-capsule repair in both primary and revision surgery. 10. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C. Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: the belt-and-suspenders operative technique and preliminary results. Arthroscopy. 2007; 23: This new intra- and extra-articular combined technique constitutes an alternative in the treatment of anterior shoulder instability in patients with deficient or stretched anterior capsule. 11. Marquardt B, Garmann S, Schulte T, et al. Outcome after failed traumatic anterior shoulder instability repair with and without surgical revision. J Shoulder Elbow Surg. 2007; 16: This paper shows that a satisfying functional outcome can be expected mainly in patients with one revision surgery. 12. Meehan RE, Petersen SA. Results and factors affecting outcome of revision surgery for shoulder instability. J Shoulder Elbow Surg. 2005; 14: Patel RV, Apostle K, Leith JM, Regan WD. Revision arthroscopic capsulolabral reconstruction for recurrent instability of the shoulder. J Bone Joint Surg. 2008; 90(B): 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. 14. Savoie FH 3rd, Holt MS, Field LD, Ramsey JR. Arthroscopic management of posterior instability: evolution of technique and results. Arthroscopy. 2008; 24: This paper shows that careful attention to the rotator interval, the anterior-superior labrum, and its attached superior glenohumeral ligament, the coracohumeral ligament, the inferior glenohumeral ligament complex, and the infraspinatus, in addition to the posterior labrum and capsule, allows excellent outcomes to be achieved with arthroscopic posterior reconstruction techniques. 15. Bigliani LU, Pollock RG, Soslowsky LJ, et al. Tensile properties of the inferior glenohumeral ligament. J Orthop Res. 1992; 10: Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg. 1984; 66(A): Sachs RA, Williams B, Stone ML, Paxton L, Kuney M. Open Bankart repair: correlation of results with postoperative subscapularis function. Am J Sports Med. 2005; 33: Scheibel M, Nikulka C, Dick A, et al. Structural integrity and clinical function of the subscapularis musculotendinous unit after arthroscopic and open shoulder stabilization. Am J Sports Med. 2007; 35: This study confirms previous observations that open shoulder stabilization using a subscapularis tenotomy may lead to atrophy and fatty infiltration of the subscapularis muscle, resulting in postoperative subscapularis dysfunction. 19. Levine WN, Flatow EL. The pathophysiology of shoulder instability. Am J Sports Med. 2000; 28: Kim SH, Ha KI, Cho YB, Ryu BD, Oh I. Arthroscopic anterior stabilization of the shoulder: two to six-year follow-up. J Bone Joint Surg. 2003; 85(A): Kim SH, Ha KI. Bankart repair in traumatic anterior shoulder instability: open versus arthroscopic technique. Arthroscopy. 2002; 18: Yiannakopoulos CK, Mataragas E, Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthroscopy. 2007; 23: This excellent study shows that associated, secondary intra-articular lesions are more frequent in patients with chronic compared with acute shoulder instability. 23. Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid. Am J Sports Med. 2007; 35: This excellent paper shows that arthroscopic stabilization for recurrent instability, even in the presence of a significant bony defect of the glenoid, can yield a stable shoulder.

9 Current Orthopaedic Practice Neri BR, Tuckman DV, Bravman JT, et al. Arthroscopic revision of Bankart repair. J Shoulder Elbow Surg. 2007; 16: This purpose of this study was to report the success rates achieved using arthroscopic techniques to revise failed Bankart repairs. The authors were unable to conclude any pattern of failure or selection criteria for this procedure. 25. Sisto DJ. Revision of failed arthroscopic bankart repairs. Am J Sports Med. 2007; 35: The author reports that patients with failed arthroscopic Bankart repairs can be successfully treated with a revision, open Bankart repair. Inadequate postoperative immobilization, large rotator intervals, and improper anchor placement are possible risk factors that may increase the incidence of failure of an arthroscopic Bankart repair. 26. Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA 3rd. Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elbow Surg. 2009; 18: This study reports that large humeral head defects can be treated by transhumeral bone grafting techniques or osteoarticular allograft reconstruction. 27. Millett PJ, Braun S. The bony Bankart bridge procedure: a new arthroscopic technique for reduction and internal fixation of a bony Bankart lesion. Arthroscopy. 2009; 25: These authors present a new easy and reproducible technique for arthroscopic reduction and suture anchor fixation of bony Bankart fragments. 28. Burkhart SS. The bare spot of the glenoid. Arthroscopy. 2007; 23:449; author reply 450. This reference is an author reply from Dr. Burkhart regarding his technique for measurement of the bare spot of the glenoid. 29. Bushnell BD, Creighton RA, Herring MM. Bony instability of the shoulder. Arthroscopy. 2008; 24: This comprehensive article reviews recent developments in the diagnosis and treatment of bony instability. 30. Schroder DT, Provencher MT, Mologne TS, Muldoon MP, Cox JS. The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. Am J Sports Med. 2006; 34: This study represents the longest follow-up in the literature of the modified Bristow procedure with 70% good and excellent results and recurrent instability comparable with other long-term follow-up studies of open instability procedures. 31. Burkhart SS, De Beer JF, Barth JR, et al. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy. 2007; 23: The results of this study show the efficacy of the modified Latarjet procedure in the extremely challenging category of patients who present with such dramatic bone loss that soft-tissue reconstruction, either open or arthroscopic, is not a reasonable option. 32. Hovelius L, Sandstrom B, Saebo M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study II-the evolution of dislocation arthropathy. J Shoulder Elbow Surg. 2006; 15: When follow-up studies of operated series of shoulder dislocations with the Bristow-Latarjet method are done, it is important to have the same radiologic views to compare the incidence of dislocation arthropathy correctly. 33. Warner JJ, Gill TJ, O Hollerhan JD, Pathare N, Millett PJ. Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft. Am J Sports Med. 2006; 34: This paper demonstrates that anatomical reconstruction of the glenoid with autogenous iliac crest bone graft for recurrent glenohumeral instability in the setting of bone deficiency is an effective form of treatment for this problem. 34. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-sachs remplissage : an arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy. 2008; 24: These authors present an arthroscopic technique used to treat traumatic shoulder instability in patients with glenoid bone loss and a large Hill-Sachs lesion. 35. Provencher MT, Mologne TS, Hongo M, et al. Arthroscopic versus open rotator interval closure: biomechanical evaluation of stability and motion. Arthroscopy. 2007; 23: This study suggests that arthroscopic RI closure adds little to the overall posterior and inferior stability of the shoulder joint, although anterior stability may be improved. 36. Mologne TS, Zhao K, Hongo M, et al. The addition of rotator interval closure after arthroscopic repair of either anterior or posterior shoulder instability: effect on glenohumeral translation and range of motion. Am J Sports Med. 2008; 36: In this paper, the authors suggest that arthroscopic closure may be beneficial in certain cases of anterior shoulder instability; however, posterior instability was not improved. 37. Kropf EJ, Tjoumakaris FP, Sekiya JK. Arthroscopic shoulder stabilization: is there ever a need to open? Arthroscopy. 2007; 23: This study reports that despite potential advantages, arthroscopic stabilization is clearly contraindicated when a significant pathologic lesion contributing to recurrent instability cannot be adequately treated as a result of the limitations of current techniques or instrumentation. 38. Millar NL, Murrell GA. The effectiveness of arthroscopic stabilisation for failed open shoulder instability surgery. J Bone Joint Surg. 2008; 90(B): These results suggest that arthroscopic revision anterior shoulder stabilization is as reliable as primary arthroscopic stabilization for patients who have had previous open surgery for recurrent anterior instability. 39. Franceschi F, Longo UG, Ruzzini L, et al. Arthroscopic salvage of failed arthroscopic Bankart repair: a prospective study with a minimum follow-up of 4 years. Am J Sports Med. 2008; 36: This is an excellent prospective 4-year followup study in which the authors report that arthroscopic Bankart revision surgery is a reliable procedure with respect to recurrence rate, range of motion, and shoulder function in carefully selected patients. 40. Owens BD, Deberardino TM, Nelson BJ, et al. Long-term followup of acute arthroscopic bankart repair for initial anterior shoulder dislocations in young athletes. Am J Sports Med. 2009; 37: This excellent article showed that at long-term follow-up, acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations resulted in excellent subjective function and return to athletics in young, active patients with an acceptable rate of recurrence and reoperation. 41. Creighton RA, Romeo AA, Brown FM Jr, Hayden JK, Verma NN. Revision arthroscopic shoulder instability repair. Arthroscopy. 2007; 23: This study shows that arthroscopic revision instability repair by use of a combination of suture anchors, plication stitches, and rotator interval closure can result in a satisfactory outcome in selected patients.