|Year : 2002 | Volume
| Issue : 4 | Page : 221-224
|Anterior inferior shoulder instability - Part II: Management of anterior inferior dislocation of shoulder
DV Rajan1, NA Antao2
1 Sports Injury and Arthroscopy Clinic, SARC # 1, Venkatachlam Road, RS Puram, Coimbatore 641 002, India
2 Holy Spirit Hospital, Andheri (E) and Holy Family Hospital, Bandra, and Arthroscopy and Sports medicine Centre, Hillway clinic, Hill Road, Bandra ,Bombay 50., India
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Rajan D V, Antao N A. Anterior inferior shoulder instability - Part II: Management of anterior inferior dislocation of shoulder. Indian J Orthop 2002;36:221-4
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Rajan D V, Antao N A. Anterior inferior shoulder instability - Part II: Management of anterior inferior dislocation of shoulder. Indian J Orthop [serial online] 2002 [cited 2020 Feb 20];36:221-4. Available from: http://www.ijoonline.com/text.asp?2002/36/4/221/48608
The traditional management of acute anterior dislocation of the shoulder [Figure 4] has been closed reduction under general anaesthesia (using the Kocher's maneuvers or other reduction maneuvers); and immobilization for 3 weeks followed by rehabilitation. The recurrence rate has been varied from 25% to 80%. ,,,
According to Wheeler and associates,  the recurrence rate dropped to 15-20% when these athletes were initially treated with arthroscopic stabilization. The arthroscopic surgical technique, helps to visualize the anatomic structures involved in the injury, its potential for healing and the type of repair necessary to give optimum results.
Arciero et al  compared a prospective study of patients treated with closed reduction and arthroscopic stabilization with transglenoid suture as described by Morgan and Bodenstab.  The non-operative group had 80% recurrence and the arthroscopy group 14%.
The general impression today is that a young athlete with an acute anterior glenohumeral dislocation is best suited for arthroscopic stabilization since the capsulolabral tissue is not stretched or deformed.
Recurrent anterior instability
When the dislocation occurs more than once, it is termed as recurrent dislocation. In such patients the frequency of dislocations keeps increasing with time and overhead activity. This is because the capsulolabral injury is not healed. With repeated dislocations the capsule gets deformed, the capacity becomes voluminous and causes enough damage to the posteromedial aspect of the head of humerus resulting in Hill Sach's lesion [Figure 5] or to the anterior inferior part of the glenoid (the glenoid shape changes from pear shaped to inverted pear shaped).
Whenever there is continued functional impairment, pain and instability despite adequate rehabilitation, the shoulder needs to be surgically stabilized. Early surgical intervention is a necessity in high demand athletes, sportspersons with overhead activities, overhead workers, and personnel who need a strong shoulder without instability.
In the past many open surgical procedures have decreased the recurrence rate to nearly 5 to 10%, but the functional losses have been significant in terms of loss of external rotation and even arthritis with the onset of time. Among the many open surgical procedures described, the Bankart's procedure still remains the gold standard.
The debate regarding the open versus arthroscopic stabilization continues as more and more improved fixations in arthroscopic stabilization are developed. Rowe  reported 96.5% success rate for dislocation / subluxation using open capsulorrhaphy. Thomas and Matsen  had 97% success rate in which capsule and subscapularis were taken as one layer and then repaired without reefing the capsule. Altchek  reported 95% results with modified Tplasty modification of capsular shift.
All the surgical procedures performed above do not All the surgical procedures performed above do not restore the anatomy back, and even if it restores the anatomy back, as in Bankart's repair, capsuloplasty need to be added to bring about excellent stability in high demand elite athletes.
Arthroscopy helps to evaluate the extent of labral tear, the state of the capsule, the inferior glenohumeral ligaments, and other associated lesions. During arthroscopy frayed/degenerated tissue from the labrum and also damaged tissue under the rotator cuff may also be debrided.
In anterior stability, the capsule needs to be released from one o'clock position. The neck of the glenoid need to be abraded to bleeding bone and the suture anchors need to be placed at 1, 3 and 5 O'clock position without medialization, at the junction of the articular cartilage and the neck.
Instability without Bankart's lesion
Snyder  described a variety of soft tissue lesions above the equator involving the superior labrum in conjunction with the biceps tendon. He termed them as SLAP lesions (superior labrum anterior posterior), and described 4 types with different characteristics. Type I and Type III simply consists of debridement of the frayed or torn labral tissue. In Types II and IV, the pathological labrum is fixed to the glenoid. If a SLAP lesion is found, it is imperative to critically evaluate the remainder of the labrum and the capsule to find out the cause of the instability. Injuries to the anterior labrum and middle glenohumeral ligaments have been seen in up to 75% of SLAP lesions. Suspected Type II and Type IV need to be differentiated from the anatomical variations and normal recesses. A superior pouch will have articular cartilage extending over the top of the glenoid to the insertion of the labrum and biceps. A SLAP lesion will have an area of exposed bone beneath the labrum not covered by articular cartilage. After debridement of the bone the suture anchor is placed at 12:30 to 1 O' clock position for right shoulder. The suture grasper is directed through the biceps anchor and the superior labrum and the labrum is secured to the glenoid through an arthroscopic knot. In type IV there may be associated biceps tendon lesions that need to be repaired, released or tenodesis need to be done.
Anterior superior instability
The superior labrum anterior cuff lesion (SLAC) is different from the SLAP lesion. It is an injury to the anterior superior glenoid labrum that involves the insertion of the superior glenohumeral ligament and anterior portion of the biceps tendon. The lesion allows the undersurface of the supraspinatus tendon to contact the anterior superior labrum and glenoid. If severe enough contact occurs, a partial thickness supraspinatus tear at the anterior edge can occur with the labral injury. The undersurface of the pathological cuff and greater tuberosity is debrided if less than 5 mm, but more than 5 mm tear it needs to be sutured. The bed is prepared to along the edge of the anterior glenoid and suture anchor is placed at 1 o' clock position to suture the torn tissue of superior glenohumeral ligaments through the biceps tendon.
Straight anterior instability
It is caused because of sudden hyperextension movement at the shoulder resulting in isolated injury to middle glenohumeral ligaments. This can give symptoms of painful subluxation with popping, tearing or pain with overhead use of arm. The anterior labrum is debrided and the glenoid abraded and anchor placed at 3 o' clock position, and the labrum and middle glenohumeral ligament (MGHL) is sutured with an arthroscopic knot.
In recurrent dislocations besides soft tissue mentioned earlier, bony injuries such as bony Bankart, compression of the anterior glenoid or Hill Sach's lesion of the humerus. These are vital to be identified arthroscopically and addressed and can present a challenge to the orthopaedic surgeon in his effort to bring about successful result.
The normal shape of the glenoid is pear shaped with lower half being significantly larger and wider than the upper half. In normal glenoid the bare spot is equidistant between the anterior and posterior rims. A significant impression caused as a result of the fracture of the anterior glenoid rim or compression of the anterior rim changes the configuration to "inverted pear". In fresh cases, a large fracture fragment can be fixed with cancellous screw arthroscopically. In chronic situations the fragment should be removed and the bony buttress can be achieved by either transfer of coracoid process  , allograft bone grafting to the glenoid and Laterjet procedure  .
Humeral head deficiency
Around 80% of anterior dislocations are associated with Hill Sach's lesion. The success of the repair procedure depends upon whether the lesion is engaged or not. The lesion is said to be "engaged", when the humeral defect with its long axis is parallel to the anterior rim at some point within the range of movement of the shoulder for that particular activity (900 of abduction and external rotation 0 to 135 0 ). A "non-engaging lesion" is one when the lesion is not parallel to the rim and directed obliquely vertical and the entrapment occurs in a non-functional position of the shoulder of extension or slight degree of abduction. The treatment options include
- Open capsular shift
- Building up the osteoarticular defect with bone graft from the iliac crest
- Internal rotation osteotomy of the humeral head.
The last option is to lengthen the glenoid articular arc in a similar manner to convert an engaging humerus to a non-engaging one. According to Bukhart and DeBeer  , the recurrence rate with "inverted pear" glenoid is 61% and 100% with engaging Hill Sach's lesion. According to them, when there is no significant bony defect either in the humerus or glenoid, the success rate of either arthroscopic or open Bankart repairs is equally good.
However, at this juncture it would be interesting, how the pioneers in the shoulder started and developed the arthroscopic procedures to replicate the open procedures.
Evolution of arthroscopic stabilization procedures in recurrent anterior dislocation
Lanny Johnson  is credited to do the first arthroscopic stabilization to replicate the open DU Toit staple procedure. The recurrence rate has been varied (15 % to 25%) as per the observation of many authors ,, . There have been failure rates due to loosening of staples, metal breakage, impingement improper placement and osteoarthritis. The results are unpredictable and hence most surgeons have abandoned the procedure.
It was described by Caspari and Savoie  in the late 80's. The technique involves decortication of the anterior neck of the glenoid, mobilization of the labrocapsular complex, and reattaching it to the raw glenoid area by means of monofilament sutures. These sutures are taken through the capsulolabral complex and tied to the back of glenoid by drill holes, or the infraspinatus fascia. To improve fixation, Yoneda et al  introduced a biodegradable button on the fascia. The shoulder is immobilized for 3 to 4 weeks followed by gradual rehabilitation and sports resumption by 6 months. The recurrence rate varies for this procedure, as per various authors from 8% to 60%. The failure is because of nonanatomical placement of the capsulolabral complex and loosening and stretching with time. There have also been reports of pain over the suture and suprascapular nerve palsy in considerable number of patients.
To avoid the above complications, suture anchors like Mitek (non absorbable) and absorbable like fastek, biotack were developed.
This tack was developed by Warner and Warren.  It has an enlarged head with spikes on its undersurface which helps to compress the tissue against the glenoid. The implant is made of polyglyconate, with pullout strength of approximately 100N.  Pagnani  has shown that the degradation occurs by hydrolysis and animal studies have shown that near complete loss of fixation strength by 4-6 weeks.
The reported failure rate in unidirectional traumatic instability with Bankart lesion and robust inferior glenohumeral ligament is reported as 1% in a study of 19 patients.  Resch and associates  have modified the surgical technique using a transcapularis portal. They believe that more caudal placement of the anterior inferior portal allows increased shifting and retensioning of the inferior capsule.
The suture anchor was developed by Wolf et al.  The placement of this punch determines the amount of capsular shift distanced with this technique. Piercing the tissue that is more inferior to the anchor down to 6 o'clock position will result in superior shifting of the capsule and recreation of the proper tension within the capsuloligamentous complex. It is critical that the drill hole is placed on the articular surface slightly to avoid medialisation of the capsulolabral complex [Figure 6]. The anchor is placed at 5.30 o'clock and the shuttle relay suture, developed by Snyder et al  is used to pass the permanent suture. An arthroscopic knot is tied.
Recurrence rate with this technique have been variable for 2% to 8%.  This technique was compared to open stabilization by Weber and he reported 8% recurrence with arthroscopic stabilization and 2% with open stabilization.
Arthroscopic suture anchor stabilization is technically demanding and requires advanced arthroscopic skills. There is an extensive learning curve and in the mastery of the technique. The techniques are still evolving. There are many factors that will be considered for arthroscopic stabilization of the shoulder in recurrent anterior instability. The ideal candidate must have clear traumatic episode, a clear Bankart lesion with robust capsulolabral tissue with moderate capsular redundancy. Those patients with no Bankart and excessive capsular laxity, with the Sulcus sign and bilateral atraumatic shoulder instability must be treated with open method. Patients who desire to return to contact sports must be treated with open technique.
The arthroscopic procedure must be a mirror to the open technique. It is vital to mobilize the labrum and to decorticate the anterior neck of glenoid, to bleeding bed to allow soft tissue healing. The securing of the labrum on the articular margin in an effort to deepen the glenoid, and retensioning of the inferior glenohumeral ligament on the capsulolabral complex, remains "in verbum de facto" of this technique.
A pathological rotator cuff interval and the lax capsule if extensive needs to be closed using a suture punch hook by plication.  A technique that can accomplish all of these criteria should be successful regardless of the procedure being performed open or arthroscopically. An arthroscopy suture technique in properly selected patients has the best potential to provide results comparable to open stabilization. Arthroscopy is less morbid and assures full external rotation especially in athletes involved in overhead throwing sports.
Multidirectional instability (MDI)
The entity of multidirectional stability was first given attention by Neer and Foster.  All these patients were athletes, with various degree of trauma to shoulder, who demonstrated not only anterior instability but also inferior and posterior instability. Rockwood and Burkhead  reported excellent results with an exercise programme. McIntyre  has classified MDI into 3 subgroups. The first group consisted of male athletes who were involved in contact sports and demonstrated both anterior and posterior Bankart lesions. The second group was also generally athletes who had increased inferior laxity in addition to a Bankart's lesion. The 1 st and 2 nd groups had significant history of trauma. The final group consists of athletic men and women who had global capsular laxity and no labral lesion. They had repetitive microtrauma. The role of arthroscopy is different for each of these subgroups.
Altchek et al  reported 95% excellent results in 42 patients using a 'T' plasty capsular shift. The technique involves shifting the capsule on the glenoid side. Bigliani et al  reported a 1.5% recurrence rate with open technique using inferior capsular shift. The inferior capsular shift performed either on the humeral or glenoid side represents the standard procedure for the surgical management of MDI.
Duncan and Savoie  in 1993 described arthroscopic management. Since there were no Bankart lesions, the author divide the anterior and inferior capsule beginning at 1 o'clock. The sutures are brought out posteriorly in a tranglenoid manner and tied over the infraspinatus. McIntyre and associates  involved a technique dividing both the anterior and posterior capsule. The sutures in the anterior capsule are brought out posteriorly and tied over the infraspinatus. Sutures placed on the posterior capsule are brought up through a supraglenoid post through a drill hole in the capsular and tied down. They reported good to excellent results in (95%) in 19 patients.
Role of thermal capsuloraphy
The thermal treatment of the capsule brings about shrinkage of the capsule and decrease in the shoulder volume. The thermal energy is delivered either through a laser or radio frequency probe. The capsule of the shoulder joint is type I collagen in a highly ordered triple helix configuration in crystalline state by inter and intra molecular bonds. These bonds are disrupted by thermal energy and the collagen contracts to random coil.  Temperature above 61 0 C results in significant shrinkage of cadaveric glenohumeral capsule. It is shown that thermal shrinkage results in hyalinization of the collagen, followed by fibroblast infiltration, in animals. Shaefer et al  have shown that thermal shrinkage of rabbit tendon result in significant shrinkage followed by tendon length increasing beyond its original length. This study has raised concerns about long terms status of the thermally modified collagen and whether the initial shrinkage remains the same throught the healing response. Hardy et al  have reported 18 patients treated with suture and capsular shrinkage with no recurrence for 1 year. Gartsman et al  reported 8% recurrence rate with arthroscopic technique combined with thermal capsular shrinkage. Thermal shrinkage has an interesting potential for arthroscopic management, but the long term histological, and biomechanical effects of thermal capsular shrinkage are not known. More information is required before this technology is recommended.
| Conclusion|| |
The results of arthroscopic and open surgical procedures match the success rate when the labrum is properly fixed to the rim with sulture anchors, without medialization, the capsule properly retensioned and associated soft tissue pathology addressed. It is very important to have an ideal patient to get ideal results with strict selection criteria. The criteria include traumatic anterior dislocation with Bankart lesion without associated glenoid or humeral deficiency. Patients with multiple recurrences, anterior instability with no Bankart, contact athletes, pathological lax tissue and bony deficiencies should be well dealt with open procedures.
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D V Rajan
Sports Injury and Arthroscopy Clinic, SARC # 1, Venkatachlam Road, RS Puram, Coimbatore 641 002
Source of Support: None, Conflict of Interest: None
[Figure 4], [Figure 5], [Figure 6]
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