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.

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).

Objectives. A variety of operative techniques have been described as under the term ‘Bristow-Latarjet’ procedure. This review aims to define the original procedure, and compare the variation in techniques described in the literature, assessing any effect on clinical outcomes. Materials and Methods. A systematic review of 24 studies was performed to compare specific steps of the technique (coracoid osteotomy site, subscapularis approach, orientation and position of coracoid graft fixation and fixation method, additional labral and capsular repair) and detect any effect this variability had on outcomes. Results. Overall recurrence rate was 5.36% (2.94% to 43%). Half of the studies performed the procedure for recurrent shoulder instability, with only five studies documenting glenoid bone loss as an indication: 12 studies used the procedure as the primary surgical intervention for recurrent instability. No change in outcome was noted when examining variation in the coracoid osteotomy site, the fixation site on the scapular neck, the fixation method or whether a capsular repair was also performed. Performing a horizontal split in subscapularis may preserve external rotation compared with performing a tenotomy. Conclusions. This is the first review to examine various operative techniques of the Bristow-Latarjet procedure, and their effect on outcome. We found that other than the approach through subscapularis, outcome was independent of the surgical technique, and depended more on patient selection. We would commend future publications on this procedure to provide a detailed description of the surgical technique, and as a minimum present rates of recurrence as an outcome measure. Cite this article: Bone Joint J 2016;98-B:1208–14

Hill-Sachs and reverse Hill-Sachs lesions come in different shapes and sizes, and their effect on “glenoid track” can vary. Small Hill-Sachs lesions that do not engage can be successfully treated with a Bankart repair alone done arthroscopically or open. Moderate, engaging, Hill-Sachs lesions can be treated either with the addition of remplissage to an arthroscopic Bankart or by adding the triple blocking effect of the Bristow-Latarjet procedure. Surface replacements vary in size from the small hemi-cap type of procedure to an entire humeral head replacement (HHR). These devices can be used as opposed to allograft replacement when the risk of post-reconstruction arthritis is high with the aforementioned more conventional treatment techniques. When 45% or more of the humeral head is involved with the lesion, or Outerbridge stage III and IV changes prevail, a HHR is preferred. An oval shaped HHR is the author's preference, and the long diameter can be used to provide coverage anteriorly or posteriorly and is particularly useful in large Hill-Sachs lesions associated with epilepsy

The October 2012 Shoulder & Elbow Roundup. 360. looks at: fast-absorbing suture anchors for use in shoulder labral tears; double-row rotator cuff repair; degenerate massive rotator cuff tears addressed with partial repair; open and arthroscopic stabilisation of Bankart lesions; predicting the risk of revision humeral head replacement; arthroscopic treatment for frozen shoulder; and long-term follow-up of the Bristow-Latarjet procedure

Recurrent shoulder instability in those with bony defects is a difficult surgical problem to resolve. Burkhart and De Beer described an unacceptably high recurrence rate for arthroscopic Bankart repair in the presence of an inverted-pear glenoid with or without an engaging Hill-Sachs lesion, with suggestions that an open modified Latarjet procedure should be recommended in such patients. The Congruent-Arc Latarjet is a modification of the Latarjet open bony stabilisation for shoulder instability developed by Burkhart and De Beer. It involves rotation of the coracoid so the curved under-surface lies congruent with the glenoid. At the Royal Derby Hospital, UK, this procedure has been adopted by our four shoulder surgeons, two of whom undertook fellowship training with De Beer, we studied the outcomes of the patients who had undergone the modified Congruent-Arc Latarjet procedure in our department. Fifty-two consecutive patients were identified over a five-year period at the Royal Derby Hospital or Derbyshire Royal Infirmary between 2006 and 2010 inclusive. With the approval of the clinical audit department, the data was collected using theatre records and clinical coding information to identify the patient group. A review of the case notes and local PACS system was undertaken to establish pre and post-operative examination findings, radiology findings regarding Hill-Sachs defects and glenoid bone loss, re-dislocation rates and post-operative function with return to normal activity. The endpoints of this study were aimed at finding out whether patients did return to normal function, were able to continue doing activity that would have provoked dislocation prior to surgery, and how many of the cases re-dislocated. No surgeon consultant had a patient who re-dislocated after this procedure. The follow-up period was from 1 year to 6 years post-operatively. The complications of this procedure were found to be the dislodgement of bone anchors in 2 patients, who required further arthroscopy to remove the suture anchor from the gleno-humeral joint. One patient had prolonged functionally limiting loss of external rotation, which resolved after intensive physiotherapy at 7 months follow up. We will provide graphical representation of the pre and post operative functional scores. We have demonstrated that the Congruent-Arc Latarjet is a reproducible procedure in the hands of surgeons other than the original authors, particularly when comparing our current 0% re-dislocation rate with the published literature, which suggests that 3.9% of patients undergoing this procedure with greater than 25% bone loss of the glenoid or an engaging Hill-Sachs will re-dislocate post-operatively, and this is better than the 6% re-dislocation rate of the standard Bristow-Latarjet procedure

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

Purpose of the study: The purpose of this study was to determine the feasibility and reproducibility of a new arthroscopic procedure combining a Bristow-Latarjet lock with Bankart reinsertion of the lambrum. Material and methods: Forty-seven consecutive patients with significant bone defects in the glenoid and a deficient capsule were treated arthroscopically: arthroscopic Bankart had failed in six. The procedure was performed exclusively arthroscopically using a special instrumentation: after its osteotomy and identification of the axiallary nerve, the coracoids was passed through the subcapular muscle with its tendon; the block was fixed on the scapular neck after 90° lateral rotation so as to prolong the natural concavity of the glenoid. Anchors and sutures were then used to refix the capsule and the labrum onto the glenoid border, leaving the block in an extra-articular position. Follow-up included a physical examination and standard x-rays at 45, 90 and 180 days; 31 patients had a postoperative scan. Three independent operators read the images. Results: The procedure was completed arthroscopically in 41 of 47 patients (8%); conversion to a deltopectoral approach was required for six patients (12%). The axillary nerve was successfully identified in all shoulders. The block had a subequatorial position in 98% (46/47 shoulders) and equatorial in one. The block was tangent to the surface of the glenoid in 92% (43/47), lateral in one (2%) and too medial (> 5mm) in three (6%). One patient presented an early fracture of the block and five patients exhibited block migration; there was a partial lysis of the block in two patients. The final rate of nonunion of the block was 13% (6/47). Fractures, migrations and non-unions were related to technical errors: screws too short (unicortical) and/or poorly centred in the block. Conclusion: Our results show that arthroscopic transfer of the coracoids to the scapular neck is a safe and successful operation. The rate of correctly positioned healed blocks was equivalent or superior to conventional techniques. The complications observed show that the arthroscopic block technique is difficult with a long learning curve

Introduction: The incidence of early osteoarthritis after the modified Bristow procedure for recurrent anterior shoulder dislocation has been the subject of several articles during the last decade. Recurrent dislocation, recurrent subluxation after surgery or the procedure itself have been suggested as the main causes of degenerative changes.

Materials and Methods: Thirty-four patients with recurrent anterior dislocation of the shoulder were treated by the same surgeon between May 1989 and April1999. Nineteen patients were allocated for long term follow-up assessment. Patients filled in a questionnaire in which they scored mobility, strength, stability and satisfaction. A Rowe score was established in each patient and radiographs in two directions (AP and axial) were taken.

Results: Twenty shoulders (6 women and 13 men) with an average follow-up of 7.7 years were seen. Seventeen patients had an history of more than 3 dislocations. The mean interval between the first dislocation and surgery was 6.8 years. In all patients a substantial improvement of stability was recorded after surgery. Redislocation occurred in only one patient. The overall satisfaction rate was 6.2. The mean Rowe score at follow-up was 92. There was no limitation in abduction while external rotation was slightly limited in 7 patients. Three patients showed arthritic changes (2 mild, 1 moderate), which, surprisingly, were also seen in the opposite shoulder.

Conclusion: The occurrence of arthropathic changes in a shoulder after surgical stabilisation is based on multiple factors. The recurrent dislocation that has taken place before any surgical procedure plays a predominant role.

Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis.

At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively.

Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of p?ctoralis major, particularly if there is pre-operative anterior subluxation of the humeral head.

There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation. We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour. These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead

We report the outcome of a modified Bankart procedure using suture anchors in 31 patients (31 shoulders) with a mean follow-up of 11 years (10 to 15). The mean age of the patients was 28 years (16 to 39). At follow-up, the mean Rowe score was 90 points (66 to 98) and the Constant score was 96 points (85 to 100). A total of 26 shoulders (84%) had a good or excellent result. The rate of recurrence varied between 6.7% and 9.7% and depended on how recurrence was defined. Two patients had a significant new injury at one and nine years, respectively after operation. The overall rate of instability (including subluxations) varied between 12.9% and 22.6%. All patients returned to work, with 29 (94%) resuming their pre-operative occupation and level of activity. Mild radiological osteoarthritis was seen in nine shoulders (29%) and severe osteoarthritis in one.

We conclude that the open modified Bankart procedure is a reliable surgical technique with good long-term results.

We report the 20-year results of Bonnin's modification of the Bristow-Latarjet procedure in 14 patients operated on by one surgeon. All but one patient had had traumatic dislocations. At review, the Rowe scores were excellent in five, good in eight and fair in one. The functional outcome was satisfactory, with a mean Constant-Murley score of 80 points (68 to 95), but 12 patients had restriction of external rotation (86%). There were radiological degenerative changes in ten shoulders (71%): six in Samilson grade I, one in grade II, and three in grade III. Isometric power was considerably reduced in patients with grade-III degenerative change. This operation provides good long-term shoulder stability, but the high incidence of radiological degenerative change is a cause for concern