The therapeutic option of conservative treatment in cases of anterior instability should be considered, especially in younger patients. This approach initially consists of a period of shoulder immobilization. Physiotherapy then restores the range of motion and reinforces the rotator cuff may follow.
The first thought in the conservative treatment is the age of the patient. Rowe et al. found significantly higher recurrence rates in young patients. The recurrence rate in patients up to 10 years old was 100%, which decreased to 94% in persons aged 10 to 20 years, to 79% in persons 20 to 30 years and to 50% in persons 30 to 40 years.
With regard to physiotherapy, one should focus on isotonic reinforcement before isokinetic reinforcement. The first muscles to be considered are those of the scapula and the deltoid, while later on, the reinforcement should be focused on the rotator cuff.
Shoulder Instability – Anterior Shoulder Instability Treatment – SURGICAL TREATMENT
The indication for surgical treatment of anterior instability is not clear and obvious. The patient, in cooperation with the surgeon, must examine the level of activity and physical progression of the condition, in order to weigh and evaluate the potential benefits of the surgical procedure.
If a patient has experienced anterior shoulder dislocation less than three times, it is reasonable to undergo arthroscopic restoration, as arthroscopic restoration is associated with lower rates of postoperative shoulder stiffness but has higher recurrence rates.
In the case of many recurrent shoulder replacements, the patient may opt for the open Bankart restoration, which on one hand is associated with some degree of stiffness, but on the other hand provides lower recurrence rates.
There are many surgical options to repair anterior shoulder instability and arthroscopic repair is the least invasive. Bankart open surgery and Latarjet surgery are two widely used surgical methods.
Arthroscopic restoration has some advantages, including smaller incision, reduced postoperative pain, reduced surgical time, reduced blood loss and maintenance of the outward turn, related to the subscapularis.
Shoulder Instability – Anterior Shoulder Instability Treatment – ARTHROSCOPIC REHABILITATION
Proper selection of patients has led to good results of the arthroscopic method of rehabilitation. Good candidates for arthroscopy are those who suffer from a distinct Bankart lesion, with the inferior glenohumeral ligament (IGHL) intact and without significant articular loosening. In addition, it is advisable not to have shoulder injuries or multidirectional instability.
There are several factors to consider for a successful Bankart arthroscopic restoration:
- Appropriate selection of patients
- Proper mobilization of articular elements
- Suturing and restoration at the tip of the articular surface and not at the neck of the glenoid cavity.
- Identification and treatment of other articular and cartilage injuries.
Finally, a pre-operative X-ray will rule out the possibility of bone fracture (bony Bankart).
Arthroscopic treatment of a Bankart injury begins with a recent shoulder examination under anesthesia. The patient is placed either in a beach chair position or in a lateral position. Access to the joint is achieved through the posterolateral portal for the joint overview. A thorough examination before the anterior portal follows.
The tip of the articular cartilage is being sharpened. The cartilage that is detached from the anterior rim of the glenoid cavity with the articular elements is identified and advanced above the sharpened area. The cartilage is then stabilized by the use of anchors and sutures (usually on the “3rd, 4th and 5th hour” if we think of the glenoid cavity as a clock, followed by the folding of the loose anterior pocket. The lower suture is usually placed first to allow the remaining sutures to tighten the articular-ligament elements. The knots are made with the shoulder in turned inwards, followed by an intraoperative assessment of movements.
OPEN REHABILITATION INTERVENTION
Although the operation has evolved over the years, Bankart’s open surgery restoration has remained essentially unchanged since Rowe’s original description in 1978.
Initially, the patient’s shoulder is examined under anesthesia to ensure that the patient really experiences anterior shoulder instability, so as to benefit from the procedure.
The incision is performed starting from the coracoid process to the axillary area. The incision continues between the deltoid and the pectoralis major with special attention to the branchiocephalic vein. This is followed by an osteotomy of the coracoid process, to elevate the biceps’ short head and the coracobrachial for better access.
The outward turn of the arm exposes the subscapularis and the vessels are ligated to the lower limit of the muscle. The subscapularis is then separated from the articular capsule. With the arm fully turned outwards, a vertical incision is made on the subscapularis. This provides a large piece for stapling.
With the humeral head in inferior position, the rim of the glenoid cavity is sharpened and rejuvenated with a small osteotomy. Then three holes on the “1st, 3rd and 5th hour” for the right upper extremity and the “11th, 9th and 7th hour” for the left upper extremity are created (if we consider the glenoid cavity a clock).
A double suture passes through each hole, which then passes through the cartilage and part of the articular capsule and is stabilized. Next, the outward turn is assessed, which should reach 25-30° beyond the neutral position.
Finally, suturing in layers is performed for the subscapularis without shortening and re-fixating the coracoid process.
LATARJET SURGERY
The Latarjet open surgery is increasingly used as a treatment option in anterior instability due to a significant bone deficiency of the glenoid cavity (>21%).
An incision is performed between the pectoralis major and deltoid muscles to reveal and prepare the coracoid process. The coracoacromial ligament and the minor thoracic muscle are separated in their insertion, while the coracohumeral muscle and the biceps brachii remain intact. An osteotomy is performed at the distal part of the coracoid process, approximately 1.5 cm in length, so as not to injure the musculocutaneous nerve. With the upper extremity turned outwards, the subscapularis muscle is separated longitudinally or detached from the minor femoral tubercle. The bone graft is prepared and shaped, so that it can be placed in the anterior and lower part of the glenoid cavity and secured in place with screws. With the coracobrachial and biceps muscles still adhering to the coracoid process, they now serve as a limiting factor for the joint. Finally, the subscapularis muscle is again sutured.
Latarjet surgery has been reported to prevent recurrent instability in up to 99% of properly selected patients. However, there are several disadvantages that can lead to complications, such as stiffness.
POSTOPERATIVE PROGRESS
Postoperatively, the shoulder is kept in a suspension folder for 3-4 weeks. The shoulder can move inwards and with a slight abduction for hygiene reasons, but external rotation is prohibited.
After 4 weeks, the patient is encouraged to perform active movements of full recession, while at 6 weeks, inward and outward movements begin with the use of extra weight. Full and unrestricted weight lifting is permitted at three months, and athletes return to sports activities after 6 months. At 3 months the patient regains 70% of the outward turn and shoulder lift. At 6 months, 75-100% of normal shoulder movement is restored.
WHY AND WHEN AN ARTHROSCOPIC METHOD IS PREFERRED OVER LATARJET SURGERY?
It is more suitable for patients with Bankart injury (rim cartilage) without bone deficits. Less invasive method. Smaller number of complications than Latarjet surgery.
WHY AND WHEN A LATARJET SURGERY IS PREFERRED OVER ARTHROSCOPIC RECOVERY?
It has a lower recurrence rate than arthroscopic repair. Faster post-operative rehabilitation and return to sports activities.
WHAT ARE THE ALTERNATIVES OF ARTHROSCOPIC METHOD AND LATARJET SURGERY?
REMPLISSAGE METHOD
The word is derived from French and means “filling”. It refers to fixation of the Infraspinatus muscle, which is sutured within the Hill-Sachs lesion, that is, the compressive fracture of the head of the humerus. It is a concomitant injury following anterior shoulder dislocation. The method of Remplissage is used in the aftermath of the Bankart injury repair, which in the majority of cases coexists. It is performed arthroscopically and is believed to reduce the risk of instability in the case of a bone defect in the anterior rim of the glenoid cavity.
EVIDENCE: E.M. Wolf & A. Arianjam: Hill-Sachs Remission An arthroscopic solution for engaging Hill-Sachs lesions: 2 – 10 years follow-up and incidence of recurrence. J Shoulder and Elbow Surgery 2014: 814-20.
- 4% relapse rate
- No re-interventions or complications (although stiffness may be observed to a small percentage of cases)
ARTHROSCOPIC LATARJET SURGERY
Latarjet arthroscopy is a new technique with the same philosophy, but is completely arthroscopic. It presents a higher degree of difficulty and therefore the rate of complications depends on the “curve” of the surgeon’s learning and experience.
RECONSTRUCTION OF THE GLENOID CAVITY WITH A BONE AUTOGRAFT
In cases of severe bone deficits of the glenoid cavity, as a result of traumatic injury or unsuccessful surgery, the reconstruction of the glenoid cavity is performed using a bone graft (usually iliac graft). This is the most appropriate procedure when the deficit is so large that it cannot be restored with Latarjet surgery.