First-Time Traumatic Anterior Shoulder Instability: Management in the Young and Active Patient.
Anatomy and Pathophysiology
The shoulder has the highest degree of motion of any joint in the human body. (2) Shoulder stability relies upon both static and dynamic stabilizers working in concert to simultaneously maximize range of motion while minimizing instability. (1) Static stabilizers include the capsule, labrum, articular cartilage, and negative intra-articular pressure; of particular importance is the anterior band of the inferior glenohumeral ligament and the anterio-inferior portion of the capsule, which provide restraint in the abducted and externally rotated position of apprehension. Dynamic stabilizers include the rotator cuff, the long head of the biceps tendon, and the deltoid musculature. Contraction of these muscles compresses the humeral head against the glenoid and serves to stabilize this articulation. The glenoid is naturally "pear-shaped," and is widest inferiorly. The concavity of the glenoid is only approximately 4 mm deep, and 25% to 30% of the humeral head is in contact with the glenoid at any time. (3) Due to this relatively small degree of bony articulation, the competence of the surrounding soft tissue stabilizers is of great importance to shoulder function. An anterior instability event often results in damage to both the anterior glenoid rim and the posterior-superior aspect of the humeral head. This pathology is respectively termed a Bankart lesion and a Hill-Sachs lesion and occurs when the humeral head impacts on the dense bone of the anterior glenoid rim. (4) Additionally, periosteal avulsions and capsular attenuation, stretching, and tearing may be present. (2) Combined, these lesions reduce the concavity of the glenohumeral joint and lessen the joint's compression effect, increasing stress on the surrounding stabilizers, compromising the joint's ability to resist translational force, and increasing the risk for subsequent recurrent instability. (5)
The glenohumeral joint is the most commonly dislocated large-joint. (2) Hovelius estimated the incidence in the general population to be approximately 1.7%, (6) while more recent studies have reported a range of between 8 and 25 per 100,000 person years. (7,8) Among young and active patients, incidence rates as high as 3% have been reported, (9) and up to 80% of all glenohumeral instability episodes occur in young patients. (10) Males are particularly at risk, with dislocation rates estimated to be 2.5 to 3 times higher than females. (6,8) Dislocation risk is higher in athletes, and Owens et al. (11) estimated that glenohumeral instability events occur at a rate of 0.12 episodes per 1,000 sporting exposures. In this study, contact sports such as rugby, American football, and hockey were identified as the highest risk sports. When corrected for the specific sport played, dislocation rates among male and female athletes were not significantly different. (11)
Initial presentations of shoulder instability may involve either a reduced or an acutely dislocated joint. In the setting of an acute dislocation, management should consist of appropriate reduction of the glenohumeral joint accompanied by a detailed pre- and post-reduction neurovascular assessment of the affected extremity. The patient should be assessed for concomitant injuries such as rotator cuff tears and nerve palsies.
Obtaining a detailed history and performing an appropriate, focused physical examination are critical components to the diagnosis and workup of first-time shoulder instability. While the specific pathology of an injury greatly influence treatment, ideal management is also dictated by the characteristics of each individual patient. Discussion with the patient should be aimed at clarifying both the nature of the injury--the mechanism and the need for formal reduction --as well as risk factors for recurrent instability such as age, gender, age at the time of first dislocation, a history of laxity in the shoulder or other joints, and prior orthopedic intervention. It is also essential to understand the motivations and goals of each patient. In athletes, it is important to discuss the specific sports played as well as the timing of the injury relative to the athlete's competitive season. An injury sustained early in the season may be managed differently than the same injury sustained late in the season or in the post-season. Similarly, in younger athletes, the timing of the school term may influence the treatment. Additionally, patients should be questioned regarding their athletic aspirations, as these may represent a significant social variable when deciding on a treatment plan in conjunction with the patient.
Physical examination should be conducted in an organized and focused fashion that is both comfortable and repeatable for the treating orthopedist. Typically, examination progresses with inspection, palpation, range of motion testing, strength testing, neurovascular testing, and shoulder-specific examination maneuvers. (9,12) Additionally, regarding instability, specialized tests include the apprehension test, relocation test, load and shift, posterior jerk, posterior load and shift, sulcus sign, and Beighton's criteria of hyperlaxity. (13) Farber et al. (14) examined the clinical usefulness of common exam maneuvers for anterior shoulder instability in patients who subsequently underwent arthroscopic treatment. The apprehension test was 72% sensitive, 96% specific, and 93% accurate for the diagnosis, while the relocation test was 81% sensitive, 92% specific, and 91% accurate. These investigators concluded that the exam maneuvers where specific but not sensitive for shoulder instability, and that apprehension was a better criterion than pain for a positive exam finding. The use of the apprehension test in predicting recurrence was examined in detail by Milgrom in a population of 52 young males who sustained first-time dislocation treated with 4 weeks of immobilization. (15) At 6 weeks following injury, the apprehension test was performed, and the patients were prospectively followed for at least 75 months. Seventy-nine percent of patients with a positive apprehension test re-dislocated, compared to 53% of patients with a negative test, and patients with a positive test significant re-dislocated more and earlier in their recovery.
All patients should undergo radiographic imaging in the form of a shoulder trauma series consisting of AP, scapular-Y, and axillary radiographs. Radiographs are evaluated for appropriate reduction of the glenohumeral joint, as well any osseous pathology such as fractures of the proximal humerus, humeral head, or glenoid. Uncertainty regarding the degree of bony injury may be an indication to an obtain three-dimensional computer tomography (CT) scan of the shoulder. In the majority of cases, a magnetic resonance imaging (MRI) scan is also obtained to fully evaluate shoulder pathology. Although studies have demonstrated that MRI correlates well with CT scans in the evaluation of glenoid bone loss, (16,17) CT remains the gold standard for glenoid imaging. (9)
Glenohumeral dislocation is associated with capsular attenuation, periosteal avulsions, and ligamentous tears. (12) Anterior labroligamentous periosteal sleeve avulsion (ALP-SA) lesions and glenoid labral articular defects (GLAD) are present in 79% to 100% of dislocated shoulders and are associated with increased instability. (9,18-21) Humeral avulsion of the glenohumeral ligament occurs more infrequently, but is also associated with high rates of recurrent instability. (22) ALPSA lesions occur when the inferior glenohumeral ligament (IGHL) and associated labrum and periosteum avulse and displace down the scapular neck in a medial and inferior fashion. In this position, the complex does not adequately resist translation. (23) In a series of 83 patients with shoulder instability, Bernhardson et al. (24) reported that patients with ALPSA lesions had more preoperative instability events than patients without ALPSA lesions. Additionally, shoulders with ALPSA lesions had larger glenoid bone defects compared to shoulders in which the IGHL was in intact. (24)
Termed a Bankart lesion, damage to the anteroinferior glenoid labrum is the defining lesion of anterior shoulder instability and is very commonly associated with these injuries. Barkart lesions have been arthroscopically identified in 87% to 97% of dislocated shoulders. (9,21,23,25,26) When an osseous fracture is associated with the anteroinferior labral tear, a bony Bankart lesion is present. Rates of bony Bankart lesions vary greatly, ranging between 4% to 70% of cases of anterior shoulder instability. (12,21,26) A relatively large bony Bankart lesion may change the shape of the glenoid to an "inverted pear," which represents significant and critical bone loss. (27-29) Itoi et al. (30) examined the effect of glenoid defect size on shoulder instability in a cadaveric study. They created progressively larger lesions, ranging from an intact anteroinferior glenolabrum complex to a Bankart lesion to glenoid defects of various sizes. Stability was noted to decrease as the size of the glenoid defect increased, and glenoid lesions greater than 21% were not adequately stabilized with a soft tissue Bankart repair. In a separate cadaveric study, Greis et al. (31) investigated the effects of shoulder instability pathology on glenohumeral contact area and pressure. Compared to intact shoulders, Bankart lesions resulted in a 7% to 15% decrease in contact area and an 8% to 20% increase in joint contact pressure. In specimens with a 30% glenoid defect, contact area decreased by 41%, and contact pressures in the anterioinferior quadrant increased by 300% to 400%. Accurate determination of glenoid bone loss is critical to treatment, as lesions larger than approximately 20% to 25% of the glenoid are associated with high failure rates when addressed with arthroscopy alone. (9,23,29,32)
In anterior glenohumeral dislocation, the relatively soft posterosuperior portion of the humeral head is impacted against the anterior glenoid rim. This results in a humeral head impaction fracture which is termed a Hill-Sachs lesion. Prevalence rates in shoulder dislocations range from 68% to 93%. (21,26,33) When this defect runs parallel to the damaged anterior rim in shoulder external rotation and abduction, it is referred to as an "engaging lesion" and is associated with shoulder instability. (34) Yamatomo et al. (35) introduced the concept of "glenoid track," which refers to the biomechanics of articular contact area between the glenoid and the humeral head as the arm is raised into the position of apprehension. If the Hill-Sachs lesion engages in this motion, it is referred to as an "off-track" lesion. Arciero et al. (36) examined the effect of concomitant glenoid defects and Hill-Sachs lesions on glenohumeral instability in a biomechanical cadaveric model and determined that there is an additive effect of bipolar lesions that negatively impacts glenohumeral stability. Di Giacomo et al. (37) also investigated the implications of bipolar lesions and recommended surgical treatment of the humeral defect in the setting of off-track Hill-Sachs lesions.
The First-Time Traumatic Dislocator
Risk of Recurrence
Recurrence rates following glenohumeral dislocation range from 14% to 100%, (6,38,39) and patient self-reported outcomes such as shoulder function and quality of life are lower in the setting of an unstable joint compared to a stable shoulder. (20,40) Age, gender, and a history of shoulder instability are the most important risk factors for recurrence. (10,41) McLaughlin and MacLellan (42) reported recurrence rates as high as 95% in patients under 20 years of age. In their series, of the 265 cases of recurrent dislocation, 96% began before the age of thirty. On the contrary, 90% of 315 cases of isolated, non-recurrent dislocation occurred after the age of thirty. (42) Henry and Genung (43) reported a recurrence rate of 88% in 121 athletes with shoulder instability under the age of thirty-two. Multiple studies have supported these results, and today it is well-established that young age is a significant risk factor for recurrence following an initial instability event. (39,44,45)
Similarly, young age is a risk factor for recurrence following operative management of shoulder instability. Examining arthroscopic postoperative patients, Porcellini et al. (46) identified age at the time of first dislocation to be a significant risk factor for recurrent instability. In a series of 83 patients treated arthroscopically, Voos et al. (47) reported a recurrence rate of 37.5% in patients under 20 years of age and concluded that patients who are under 25 years of age are at an increased risk for recurrent instability. (47) LeRoux et al. (48) reported on the epidemiology of anterior shoulder dislocation in Canada over a 10-year period. In this series, 19% of patients experienced a recurrent dislocation requiring closed reduction at a median of 0.9 years after their initial episode of instability. Of this recurrent subset, 41.7% were under 20 years of age. (48)
A history of shoulder instability predisposes patients to subsequent episodes of instability. Robinson et al. (49) prospectively examined 252 patients who had sustained an anterior dislocated treated non-operatively. At two-year follow-up, recurrent instability was identified in 55.7% of the shoulders. In young males (the highest-risk population), 86.7% of patients experienced recurrent instability within 2 years. (49) Cameron et al. (50) performed a prospective study examining shoulder instability in high demand young patients. Over a 4-year follow-up period, they reported that patients with a history of glenohumeral instability were over five times more likely to have a secondary instability episode. The majority of these re-dislocations occurred within the first year following the initial injury. (50)
Male sex is a significant risk factor for recurrent instability. (46,49,51) In a 2015 meta-analysis, Olds et al. (52) found males to have three times the risk of recurrence when compared to females. Additional risk factors for recurrence include collision sports, (5,12,40,49,53) generalized ligamentous laxity, (5,47,49,54) severity of initial dislocation, (12,55) noncompliance with rehabilitation, (55) and bilateral symptoms. (54,56)
Consequences of Instability
Untreated, unstable shoulders contribute to decreased quality of life and function. (20,40) As described above, initial instability events are accompanied by significant recurrence rates. As the number of recurrences increases, so too does the degree of intra-articular shoulder pathology. (57,58) Yiannakopoulos et al. (59) compared intra-articular lesions in both acute and chronic cases of anterior shoulder instability. No inverted-pear glenoid patterns were found in primarily dislocated shoulders, while 15.3% of joints subject to chronic dislocations demonstrated this configuration, which is associated with critical bone loss. (27,29) Nakagawa et al. (60) also investigated glenoid pathology in primary and recurrent shoulder dislocations. In primary dislocations, the mean glenoid bone defect was 3.5%, compared to 11.3% in recurrent instability. (60) This effect was additive, with defect percentages of 6.3%, 12.9%, and 19.6% in 2 to 5, 6 to 10, and 11 or more dislocations, respectively. In a separate study, the same investigators studied bipolar lesions in shoulder dislocations. (61) Bipolar lesions (shoulders in which glenoid and humeral head pathology was present) were present in 61.8% of recurrently unstable shoulders compared to 33.3% of shoulders with primary instability. As in their previous study, this effect was additive, and bipolar lesions were present in 44.2%, 69%, and 82.8% of shoulders with 1 to 5, 6 to 10, and 11 or more instability events, respectively. Multiple reports have demonstrated that the prevalence, size, and degree of engagement of Hill-Sachs lesions increases with repeated instability events. (9,62) Soft tissue pathology also directly increases with repeated dislocations. (63) Yiannakoulos reported 12.5% of anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions in recurrent dislocators compared to 0% in primary dislocators. (59)
Recurrent dislocation is associated with the development of arthritic changes to the shoulder joint. Hovelius et al. 64 examined the radiographic findings of 223 anterior shoulder dislocations at 25-year follow-up. Moderate to severe arthrosis was identified in 18% of shoulders without recurrence compared to 39% of recurrently unstable shoulders treated non-operatively and 26% of recurrently unstable shoulders treated operatively. Plath et al. (65) studied shoulders following arthroscopic Bankart repair at an average follow-up of 13 years and found that more severe shoulder arthrosis was associated with an increased number of dislocations, an association that has been demonstrated in an additional study as well. (66) The investigators concluded that limiting the number of preoperative dislocations was an important management step in the limitation of subsequent shoulder arthritis.
Historically, first-time anterior shoulder dislocation has been treated non-operatively with reduction, a period of immobilization, and a gradual, progressive return to function. In his 1948 series, Watson-Jones (67) described the treatment of shoulder dislocations with immobilization in internal rotation for 4 weeks and reported no cases of recurrence. Non-operative management often allows for quicker return to function and may be advantageous in the scenario of an in-season athlete who desires to return to sport as quickly as possible. (12) The implementation of a progressive physical therapy program focused on range of motion and strengthening of the dynamic shoulder stabilizers is often beneficial to recovering function. Depending on the physical demands of a patient's job or sport, bracing of the shoulder may be useful. Motion-limiting braces function to limit excessive shoulder abduction, extension, and external rotation, while stabilizing braces subject the shoulder to a posterior force to aid in controlling reduction of the humeral head. (68,69)
The duration of immobilization varies across treatment centers and orthopedists. Kiviluoto et al. (70) prospectively examined the impact of immobilization on recurrent shoulder instability in young and active patients. They found a recurrent instability rate of 50% in patients immobilized for 1 week, compared to 22% in patients immobilized for 3 weeks. In a systematic review, Paterson et al. (45) reported a recurrence rate of 41% in patients immobilized for a week or less and a 37% recurrence rate in patients immobilized for at least 3 weeks. Described length of immobilization protocols range from 0 to 6 weeks, but no consensus exists regarding the ideal duration of immobilization. (71)
Internal rotation of the shoulder with the elbow at 90[degrees] at the side of the body is the most common position of immobilization. However, recently the benefits of immobilizing in external rotation and in external rotation and abduction have been proposed. Using MRI after an initial dislocation, Itoi et al. (72) examined the influence of arm position on reduction of the Bankart lesion. Of four positions tests, shoulder abduction and 60[degrees] of external rotation was the best position of immobilization, this was followed closely by abduction and 30[degrees] of external rotation. (72) Hatta et al. (73) examined the comfort of these same patients and found that despite allowing for the best intra-articular reduction, abduction and 60[degrees] of external rotation was the most uncomfortable position for patients and negatively influenced compliance. Several studies have demonstrated no difference in recurrence rates in patients treated with external rotation immobilization compared to internal rotation. (74,75) However, other investigations, including a systematic review of 31 studies, have reported decreased rates of recurrence in patients who are immobilized in external rotation following shoulder dislocation. (45,76,77)
While the ideal position of immobilization remains controversial, so too does the overall efficacy of immobilization in general. Multiple publications have reported that immobilization does not affect the rate of recurrent instability, regardless of the duration of treatment. (43,44) In Paterson's systemic review, patients immobilized in internal rotation had a 40% recurrence rate, while 25% of patients braced in external rotation experienced recurrence, with young patients at particularly high risk. (45)
In certain circumstances, non-operative treatment of first-time traumatic anterior shoulder dislocation may be appropriate. (40) However, conservative management in young and active patients often results in unsatisfactory outcomes. (44) It is well established that in these high-risk patient populations, recurrent shoulder instability following initial dislocation is higher in patients managed non-operatively. (23,76) Wheeler et al. 78 investigated the natural history of shoulder instability in a young and athletic patient population treated both arthroscopically and non-operatively. Operative management consisted of stable capsulorraphy or anterior glenoid abrasion. Ninety-two percent of patients treated non-operatively experienced recurrent instability, despite strict compliance with postoperative instructions, compared to 22% recurrence rates in the operative group. In a young and active military population with first-time dislocation, Arciero et al. (18) reported recurrent instability in 14% of patients who underwent arthroscopic repair compared to 80% in patients treated non-operatively. Kirkley et al. (20) reported similar results, with recurrence rates of 47% in their non-operative group and 16% in their operative group. In a randomized controlled trial comparing outcomes after non-operative management versus open repair of shoulder dislocation, Jakobsen et al. (79) reported recurrence rates of 54% with conservative treatment compared to 3% with open repair.
In addition to rates of recurrence, Jakobsen et al. (79) also examined self-assessment scores following shoulder dislocation. At 10-year follow-up, the investigators found that 75% of patients treated non-operatively reported unsatisfactory results. (79) Sachs et al. (40) reported lower patient reported outcome scores in patients with recurrent instability who "coped" following initial dislocation, compared to those without recurrence or whom had undergone arthroscopic stabilization. In this study, over half of the young patients with recurrence chose to proceed with surgical stabilization.
Arthroscopic lavage has been proposed as a treatment option for traumatic anterior shoulder instability. Theoretically, this technique is believed to reduce joint effusion and enhance healing potential. Wintzell et al. (80) compared outcomes of arthroscopic lavage and non-operative treatment in patients with primary anterior shoulder dislocation and found that arthroscopic lavage decreased recurrent instability by up to 40%. However, Robinson et al. (81) performed a randomized controlled trial that demonstrated that rates of recurrent instability were five times higher in patients treated with arthroscopic lavage compared to arthroscopic repair. Patients who underwent repair had improved functional outcomes, range of motion, and satisfaction as well as lower overall complications and costs compared to the lavage group. Systematic reviews performed by Longo et al. (76) and Chahal et al. (82) support these findings and demonstrate that arthroscopic lavage alone is an inadequate treatment for shoulder instability.
Arthroscopic Bankart repair is commonly performed in the treatment of traumatic anterior shoulder instability. Ideally, this operation is most successful in patients with a soft tissue Bankart lesion but no glenoid fracture who participate in non-collision sports. (2) Risk factors for failure after arthroscopic Bankart repair include male sex, young age at the time of initial injury, presence of an ALPSA lesion, presence of an off-track Hill-Sachs lesion, glenoid bone loss greater than 20%, duration of time from injury to surgery, and generalized hyperlaxity. (83) While the specific operative technique may vary, (2,84,85) the procedure involves a diagnostic arthroscopy to ensure minimal glenoid bone loss followed by definition and decortication of the capsulolabral and glenoid interface and subsequent arthroscopic labral repair with a minimum of three suture anchors. (2) While the procedure may be effectively performed in either the lateral or beach-chair position, lower recurrent instability rates have been associated with the lateral position. (86)
Arthroscopic Bankart repair is an effective treatment in the appropriately indicated patients. DeBerardino et al. (54) examined outcomes following arthroscopic stabilization in 57 young patients with first-time anterior dislocations and reported a stability rate of 88% at 36-month follow-up. Poor tissue quality and hyperlaxity factors such as a large sulcus sign and bilateral laxity were associated with increased instability. In a randomize controlled trial involving a young and athletic population, Bottoni et al. (19) published re-dislocation rates of 11% in the operative group compared to 75% in patients treated non-operatively. In a similar study population, Kirkely et al. (20) found a recurrence rate of 16% with operative stabilization and 47% in those treated non-operatively, and patients treated operatively reported higher outcome scores. Similarly, Longo et al. (76) reported recurrence rates of 9.6% after operative intervention versus 37.5% with non-operative treatment. Arthroscopic stabilization is more successful if performed closer to the initial instability event. (2,46,83) The number of preoperative dislocations has been directly associated with the development of increased degenerative changes, (66) and Owens et al. (87) reported that arthroscopic stabilization is associated with improved outcomes if performed prior to three subluxation events.
Although performed less frequently than arthroscopic stabilization, open Bankart repair is a successful treatment option for traumatic shoulder instability. Jakobsen et al. (79) examined the outcomes of open stabilization and published an overall satisfaction rate of 72% and a recurrence rate of only 3%. Moroder et al. (88) followed the outcome of patients for 20 years following open Bankart repair and reported good outcome scores and a recurrence rate of 17.5%.
Several studies have compared arthroscopic and open stabilization of anterior traumatic shoulder instability. Owens et al. (87) found no difference in outcome between open and arthroscopic procedures. In a randomized controlled study with 2-year follow-up, Mohtadi et al. (51) reported recurrent instability rates of 11% and 24% in open and arthroscopic stabilization procedures, respectively. Despite this difference in recurrence, functional outcome scores were equivalent. Harris et al. (2) performed a systematic review of 26 studies that combined included almost 2,000 patients with shoulder instability. At an average follow-up of 11 years, there were no significant difference between open and arthroscopic stabilization groups in recurrent instability rates, clinical outcome scores, return to sport, and postoperative arthritis. (2) In a 2010 meta-analysis, Petrera et al. (89) reported no difference in outcome between arthroscopic and open shoulder stabilization.
Glenoid lesions of 20% to 25% represent critical bone loss and arthroscopic Bankart repair alone in these situations may result in unacceptably high rates of recurrent instability. (9,23,29,32) In an effort to identify particularly high-risk patients and guide treatment, Boileau developed the shoulder Instability Severity Index Score (ISIS). (5) The ISIS is a questionnaire consisting of sport played, age greater than or less than 20 years, shoulder hyperlaxity, and the presence of a Hill-Sachs lesion or loss of glenoid contour on an anteriorposterior shoulder radiograph. The investigators reported that an ISIS of 6 or more corresponded to a recurrence rate of at least 70% after arthroscopic Bankart repair, and they recommended bony stabilization in this situation. On the contrary, a score less than 3 corresponds to a 5% risk of recurrent instability after arthroscopic repair.
Bony augmentation may be performed in either an anatomic or non-anatomic manner. It should be noted that these procedures are rarely indicated for first-time dislocations. Anatomic techniques, such as the Eden-Hybinette procedure, involve the use of an allograft or autograft bone block contorted to match and augment the glenoid articular surface. (90) Although these procedures do effectively decrease translational forces on the humeral head, (91) they carry higher rates of recurrence and postoperative arthritis than their non-anatomic counterpart, the Bristow-Latarjet procedure. (92) Initially described in 1958, the Bristow procedure involves the transfer of the tip of the coronoid with the attached conjoint tendon through a subscapularis split. Originally, the procedure was described to primary function through a sling effect of the conjoint tendon. (93,94) The Latarjet procedure is a modification of the Bristow procedure in which the entire horizontal component of the coracoid is transferred and placed flush with the glenoid arc. The procedure provides both static and dynamic stabilizing forces from the bone and tendon sling respectively, and repair augmentation is possible by incorporating the capsulolabral tissues together with the remnant of the coracoacromial ligament. (95) Wellman et al. (91) used a cadveric model to test shoulder stability after Latarjet and reported that the procedure reduced humeral head translation by 354% and 374% at 30[degrees] and 60[degrees] of abduction, respectively. In comparison to contoured bone grafting, the Latarjet procedure was superior in controlling translation in the setting of anteroinferior glenoid bone defects. (91) Despite successful outcomes, concerns remain regarding osteolysis and postsurgical arthritic changes associated with the Latarjet procedure. (37,96) Recently, distal tibial allograft bone grafting has been proposed as a method of anatomic glenoid bone grafting. Cadaveric studies have demonstrated distal tibial allografts to be well contoured to the glenoid and congruent throughout range of motion even in unmatched specimens and to impart promising improvements in glenohumeral contact areas and pressures. (97-99) Additionally, the allograft has a significant cartilaginous component and adds a potential biological advantage to the reconstruction. (100) Early outcome studies are encouraging, (100) but more investigation is necessary to evaluate this technique's true efficacy.
Humeral Head Pathology
Large off-track Hill-Sachs lesions may contribute to recurrent shoulder instability and residual functional impairment, as well as failure of instability repair. Sekiya et al. (101) tested the influence of various size humeral defects on instability in a cadaveric model. Defect sizes as small as 12.5% altered articular biomechanics, and larger 25% to 50% defects resulted in clinically significant instability. (101) Provencher et al. (34) recommended surgical intervention for Hill-Sachs lesions of greater or equal to 40% of the humeral head. Bony augmentation options include iliac crest bone graft, allograft femoral head or humeral head, and partial humeral head implants. Giles et al. (102) examined the role of partial resurfacing in shoulder instability and noted improved overall stability but residual engagement in 50% to 75% of specimens with large humeral defects. Soft tissue transfers such as the Magnusson-Stack procedure (subscapularis transfer from the lesser tuberosity to the greater tuberosity) and the Putti-Platt procedure (medial capsular advancement of the lateral joint capsule with an associated subscapularis tendoesis) have been associated with decreased range of motion, altered joint biomechanics, and increased glenohumeral wear. (103) The Remplissage procedure is a more effective soft tissue transfer in which the surgeon performs a tendoesis of the infraspinatus tendon and the posterior capsule into the prepared humeral lesion. This tendoesis functions both to resist translation forces and converts the Hill-Sachs lesion into non-engaging extra-articular pathology. (104) Finally, large off-trach defects may be treated with a rotational humeral osteotomy, which increases humeral head retroversion and moves the defect into a posterior, non-engaging position. (105) However, due to relatively high operative morbidity, restricted postoperative range of motion, and concerns over nonunion, this procedure is not commonly performed. (34)
Di Giacomo et al. (37) examined the implications of bipolar lesions on glenohumeral stability and created a treatment protocol based on their findings. Patients were divided into four groups based on severity of pathology: a glenoid defect of less than 25% and an on-track Hill-Sachs lesion; a glenoid defect of less than 25% and an off-track Hill-Sachs lesion; a glenoid defect greater than 25% and an on-track Hill-Sachs lesion; and a glenoid defect greater than 25% and an off-track Hill-Sachs lesion. In these authors' practice, group one patients were treated with arthroscopic Bankart repair, group two treated with arthroscopic Bankart repair and remplissage, group three treated with the Latarjet procedure, and group four patients were treated with the Laterjet procdure as well as humeral grafting or remplissage if residual engagement continued after completion of glenoid augmentation. (37)
Costs of Treatment
Early surgical stabilization following first-time traumatic anterior shoulder dislocation in young patients is not only successful, it is also a cost-effect treatment. (81) Crall et al. (106) used a Markov model to examine the costs of treatment involved in both non-operative and arthroscopic management of first-time shoulder dislocation. Patients were separated into six groups according to sex and the ages of 15, 25, and 30. Using a willingness-to-pay threshold of $25,000 per quality-adjusted life-year, the investigators determined that surgery in primary dislocators was a cheaper and more effective treatment option compared to conservative management in 15-year-old males, 15-year-old females, and 25-year-old males. In 25-year-old females and all 35-year-old patients, operative management was more costly than non-operative treatment, but surgery remained successful and very cost-effective per quality-adjusted life-year. After at least one episode of recurrent instability, operative treatment was more successful and more-cost effective for all groups compared to non-operative treatment. Bishop et al. (107) also investigated the costs of treatment using an expected-value decision analysis. They found that primary operative management was cost-effective and favored when the rate of recurrent instability was 32% or more with non-operative treatment.
Specific Management Principles
The Contact Athlete
The sport played by a patient significantly influences their risk of recurrent shoulder instability following an initial dislocation. (49) Boileau et al. (5) highlighted the importance of contact sports as a risk factor for recurrent instability in the ISIS, in which participation in collision athletics accounts for 3 points. Over a follow-up period of 4 years, Sachs et al. (40) found that 86% of patients who experienced recurrent instability participated in contact or collision sports. Postoperative patients are also at risk, as Owens et al. (41) reported a 14.3% re-dislocation rate following arthroscopic stabilization, with all repeat dislocations occurring during sports. Kerr et al. (108) examined shoulder dislocations in American high school athletes, identifying high rates in both football and wrestling, and demonstrating that the majority of shoulder dislocations in these sports occur during contact with an opposing player. Similarly, studies have found that up to 97% of shoulder dislocations sustained while playing rugby occur during contact with the opposition. (109) Shoulder dislocation is a very common injury in American football, accounting for approximately 20% of all shoulder injury in athletes in the National Football League. (110) Participation in collision athletics also appears to affect the severity of dislocation. Nakagawa et al. (60) examined CT scans of patients with dislocations and compared glenoid morphology. Glenoid rim defects averaged 12% in rugby players and 8.9% in American football players, compared to 4% to 5% in non-contact athletes such as baseball players. (60)
While some studies have reported equivalent recurrence risk between contact and non-contact athletes, (111) the vast majority of publications have demonstrated increased risk in collision sports. Cho et al. (112) compared outcome in young primary dislocators treated with arthroscopic stabilization who played both contact and noncontact athletics. The groups demonstrated equivalent outcome scores, but there was a trend toward increased postoperative subluxation in the collision group. Seventy-three percent of noncontact athletes returned to play at an average of 62 months, compared to 57% of patients who played contact sports. Calvo et al. (113) also examined rates of recurrent instability following arthroscopic stabilization and reported rates of 58% in contact athletes compared to 11% in non-contact athletes. In Mazzocca et al.'s (114) series on arthroscopic stabilization outcomes in young athletes, all instances of postoperative recurrent instability occurred in collision athletes. Hubbell et al. (115) published similar results, reporting postoperative recurrent instability rates of 44% in collision athletes compared to 0% in noncontact athletes. In a systematic review of 20 studies examining redislocation risk after arthroscopic Bankart repair, participation in collision athletics was associated with an absolute risk of 8.09 (95% CI 3.61 - 12.57) for the development of postoperative instability when compared to non-collision athletics. (116)
Increasing severity of glenoid bone loss places an athlete at an even higher risk for recurrent postoperative instability. In 194 patients treated with arthroscopic Bankart repair, Burkhart et al. (32) reported postoperative instability rates of 6.5% in contact athletes without an inverted pear glenoid, compared to 89% in contact athletes with significant glenoid bone loss. In these situations, surgeons should consider alternatives to arthroscopic repair, such as open repair and bony augmentation procedures. Rhee et al. (117) compared surgical outcomes in 46 collision athletes following open and arthroscopic stabilization. These investigators reported that while outcome scores improved similarly in both groups, the rate of postoperative recurrent dislocation in the arthroscopic group was 19% compared to 9.4% in the open repair group. Yamamoto et al. (118) performed a similar study comparing outcome in both arthroscopic Bankart repair and open repair as well as non-contact and contact athletes. While the study was under-powered to reach significance, the rate of recurrent postoperative instability in contact athletes was two and three times higher than non-contact athletes when treated with open and arthroscopic repair, respectively. Due to the high risk of recurrent instability associated with collision athletics, some centers have elected to treat these athletes with primary bony augmentation even in the setting of non-critical glenoid bone loss. (119) However, open glenoid augmentation carries a 30% complication rate and a 7% reoperation rate, (120) so surgeons must be sure to appropriately indicate patients when deciding upon the optimal stabilization surgery.
The In-Season Athlete
Management of first-time traumatic anterior shoulder dislocation must be individualized to each patient's expectations and goals. Orthopedic injuries do not exist in a vacuum; patients are subject to significant personal, social, and occasionally financial stresses. For a variety of reasons, an in-season athlete may wish to forgo or delay surgery in an effort to return to play quicker, which can be achieved with bracing and accelerated physical therapy protocols. (9) In order to return to play, athletes must have minimal pain and nearbaseline range of motion and strength, as well as the ability to perform sport-specific motions. (121) Watson et al. (122) reported that athletes can typically return to play within 2 to 3 weeks following their initial dislocation, but that this non-operative management carries significant re-dislocation rates ranging from 37% to 90% over the remainder of the season. Studying young athletes who sustained in-season instability events, Buss et al. (68) reported that 87% of athletes were able to return to play during the same season at an average of 10.2 days after injury. Forty-one percent of these athletes experienced recurrent instability during the season. Of the patients who returned to in-season play, 46% elected to undergo surgical management in the off-season. (68) Dickens et al. (123) performed a similar study of 2-year outcomes in 45 collegiate athletes following first-time traumatic anterior shoulder instability. Patients were initially treated with no immobilization and accelerated rehabilitation. Seventy-three percent of athletes retuned to in-season play with a median of 5 days lost from competition. Twenty-seven percent of patients were able to complete the season without recurrent instability, while 64% experienced either recurrent subluxation or dislocation. Athletes who had sustained only a subluxation were 5.3 times more likely to return to in-season play than those in whom the shoulder had frankly dislocated. Functional scores collected immediately after the initial injury were predictive of an athlete's return to in-season competition, and the simple shoulder test (SST) was significantly inversely related to the time lost from competition following the initial instability event.
The shoulder is the most commonly dislocated large-joint in the body and is particularly prevalent in young and athletic patients. First-time traumatic anterior shoulder dislocations in these populations are associated with significant rates of recurrent instability when treated non-operatively. This risk is especially high in patients with significant glenoid bone loss and in those who play collision sports who may require additional surgical intervention such as bony augmentation procedures. While surgery is not the most effective treatment method for all first-time dislocators, it is successful, cost-effective, and recommended in patients at high risk for recurrent instability. Patients must always be appropriately counseled regarding treatment options, and the final individualized management plan should account for each patient's unique clinical situation and goals.
None of the authors have a financial or proprietary interest in the subject matter or materials discussed in the manuscript, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.
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John P. Begly, MD, and Michael J. Alaia, MD
John P. Begly, MD, and Michael J. Alaia, MD, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA.
Correspondence: John P. Begly, MD, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, New York, New York, 10003, USA; firstname.lastname@example.org.
Please Note: Illustration(s) are not available due to copyright restrictions.
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|Author:||Begly, John P.; Alaia, Michael J.|
|Publication:||Bulletin of the NYU Hospital for Joint Diseases|
|Date:||Jan 1, 2019|
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