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Recurrent posterior shoulder instability revisited

Authors:
Boileau Pascal at Institue de Chirurgie Réparatrice, Locomoteur & Sport
Boileau Pascal
  • Institue de Chirurgie Réparatrice, Locomoteur & Sport
M.B. Hardy
M.B. Hardy
M.B. Hardy
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Daniel Schwartz at Swedish Orthopedic Institute
Daniel Schwartz
  • Swedish Orthopedic Institute
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1
RECURRENT POSTERIOR SHOULDER
INSTABILITY REVISITED
P. Boileau, M.B. Hardy, d.G. ScHwartz
INTRODUCTION
Posterior shoulder instability is a complex
and confused problem because of its rarity
and its various clinical presentations.
Whether open surgery and arthroscopic
repair of posterior shoulder instability have
similar success rates remains unknown.
The goals of this study were: 1/ to study the
natural history and to classify recurrent
dynamic posterior shoulder instability 2/ to
analyze surgical results.
MATERIAL AND METHODS
Retrospective monocentric cohort study
of 60 patients operated for recurrent
posterior shoulder instability between
1997 and 2011. Patients with voluntary
posterior instability were excluded. We
included patients with involuntary
posterior instability and those who were
initially voluntary and that became
involuntary. In each case an accurate
analysis of the instability was performed
by analyzing clinical and imaging data
from medical les and by questioning
patients about their instability (during
clinical exam or by phone).
RESULTS
Epidemiology
- 33 patients had involuntary instability:
23 of them (70%) had subluxations, 4
(12%) had dislocations and 6 (18%) had
both of them. In 27 cases (82%) we found
a trauma trigger. In 13 cases, although
initially involuntary, subluxa tions were
reproducible. In 25 cases (76%) the
instability was painful. In 20 cases (61%)
there was associated hyperlaxity.
- 27 patients had a voluntary posterior
instability which became involuntary
with time: 23 of them (85%) had
subluxations, 4 (15%) subluxations
associated with dislocations. In 2 cases
(7%) we found a trauma trigger and in 15
cases (56%) we found a secondary
trauma triggering involuntary instability.
In all cases subluxations were reprodu-
cible. In 19 cases (70%) the instability
was painful. In 20 cases (74%) there was
associated hyperlaxity.
2
SHOULDER CONCEPTS 2014 - CURRENT CONCEPTS ARTHROSCOPY, ARTHROPLASTY & FRACTURES
Surgical Management
We did not operate on patients with volun-
tary posterior instability. We operated on
patients with involuntary posterior
instability and those who were initially
voluntary and had become involuntary.
Reproducibility of Instability
It means that the patient can show you the
direction of instability, if you ask for it. It
does NOT mean that the patient is a voluntary
posterior subluxator or dislo cator anymore.
A reproducible instability should not be
confused with a voluntary instability.
Clinical Results
We reviewed 37 of 45 patients who were
over 1 year follow-up after surgery: 23
involuntary instabilities and 14 voluntary
who became involuntary instabilities. We
report 3 cases (8%) of recurrent instability at
a mean follow-up of 54 months. The mean
SSV was 89% and 92% of patients were
very satised or satised with the result.
3
recurrent PoSterior SHoulder inStaBility reviSited
Soft Tissue versus Bone Block
Procedures
Our study demonstrated no statistical
difference in clinical outcomes for patients
treated with either posterior bone block or
arthroscopic soft tissue surgery for
recurrent posterior shoulder instability.
CONCLUSION
We distinguish three types of recurrent
dynamic posterior shoulder instability: 1/
voluntary instability that does not require
surgery 2/ involuntary instability 3/
voluntary that became involuntary
instability. These last two require surgical
treatment of which our study reported
satisfactory functional and subjective
outcomes. Results of surgical treatment are
encouraging: we observed only 8% of
recurrence of instability with a mean follow
up of 57 months. Both open and arthroscopic
treatments work; both soft tissue & bone
block procedures provide good results. Our
results conrm the data published in the
the literature which has suggested that
arthroscopic soft-tissue stabilization
procedures equal bone block procedure in
managing recurrent posterior shoulder
instability.
... This lack of an appropriate classification scheme for posterior instability has been a topic of recent discussion within the literature, with new efforts determined to provide surgeons with appropriate means to classify these difficult-to-treat patients. 4 The literature itself has not proved that one bone block technique is superior to another. Levigne et al 17 Additional reports that mirror ours include that of Barbier et al 2 ; in 2009, they presented a report of 8 patients with a mean follow-up of 3 years after posterior bone block augmentation with iliac crest bone graft. ...
Arthroscopic Posterior Bone Block Augmentation in Posterior Shoulder Instability
Article
Full-text available
  • Jan 2013
Background: Posterior instability is a relatively rare and challenging condition to treat. Soft-tissue procedures do not always provide satisfactory results. We present the results after arthroscopic posterior bone block augmentation with an iliac crest bone graft and a minimum of 12 months' follow-up. Materials and methods: Between 2008 and 2009, we performed 19 arthroscopic posterior bone blocks on 18 patients with posterior instability (bilaterally in 1 patient). The mean age was 29.85 years at the time of surgery. The mean follow-up was 20.5 months. All patients had a painful, unstable shoulder. Preoperative etiology included trauma, glenoid dysplasia, Ehlers-Danlos syndrome, and arthrosis with posterior glenoid erosion. Results: The Rowe score improved from 18.4 points to 82.1 points, and the Walch-Duplay score improved from 37.4 points to 82.9 points, both statistically significant (P < .01). Radiologic bone healing was achieved in all cases. Nine cases had an excellent result with return to the previous level of sports, six were satisfied, and three had a persistently painful shoulder. Subsequent removal of screws improved symptoms in two of these patients, and in one patient, a cause for the pain and persistent instability was not found. Conclusion: Arthroscopic posterior bone block augmentation presents a reliable technique for the treatment of symptomatic posterior instability with varying origin. Although this is a technically demanding procedure, in our experience, the potential benefits and minimally invasive nature outweigh the risks and benefits of more invasive procedures.
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The arthroscopic treatment of posterior shoulder instability: Two-year results of a multiple suture technique
Article
  • Sep 1997
This study was undertaken to review the results of an arthroscopic posterior capsular shift procedure. Twenty consecutive shoulders in 19 patients were treated with an arthroscopic posterior capsular shift for symptomatic posterior shoulder instability. Patients underwent the procedure if they exhibited a posterior Bankart lesion or had complaints of posterior instability and evidence of increased posterior joint laxity on physical examination and examination under anesthesia. Twelve of the 20 patients were injured during athletic activity. All surgeries were performed in an outpatient setting. Twelve of the 20 patients had posterior Bankart lesions and 10 had anterior Hill-Sachs lesions. The procedure entails releasing the posterior labroligamentous structures from the posterior glenoid and freshening the glenoid neck with a bur. A suture punch is used to place multiple absorbable monofilament stitches in the ligament complex. The stitches are brought through a supraclavicular portal and tied over the clavicle or scapular spine. All 20 shoulders were evaluated at an average of 31 months postoperatively with a minimum follow-up of 24 months. Based on the outcome scale described by Tibone and Bradley, the average postoperative score was 83 out of a possible 100, with 15 excellent, 2 good, 1 fair, and 3 poor results. There were two recurrent dislocations and three subluxations for an overall recurrence rate of 25%. All the recurrences occurred in patients with posterior Bankart lesions and four of the five had a voluntary component to their instability. There were no neurovascular complications or infections. Arthroscopic evaluation facilitated the diagnosis of posterior instability with the visualization of intra-articular pathology that is difficult to identify during open procedures. Although the majority of patients were able to return to vigorous activities, a recurrence rate of 25% is disturbing and consistent with recurrence rates for open procedures.
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