Traumatic anterior shoulder

instability

Wael Sulaiman Alhifzi PGY2

Introduction

Traumatic Anterior Shoulder Instability, also referred to as TUBS (Traumatic Unilateral

dislocations with a Bankart lesion requiring Surgery), are traumatic shoulder injuries that generally
occur as a result of an anterior force to the shoulder while its abducted and externally rotated and
may lead to recurrent anterior shoulder instability.
Diagnosis is made clinically with the presence of positive anterior instability provocative tests and
confirmed with MRI studies that may reveal labral and/or bony injuries of the glenoid and proximal
humerus (Hill-Sachs lesion).
Treatment may be nonoperative or operative depending on the chronicity of symptoms, the presence
of risk factors for recurrence, and the severity of labral and/or glenoid defects. In high-risk
populations, surgery is often offered after a single dislocation event.
Epidemiology

Incidence
one of most common shoulder injuries
1.7% annual rate in general population

Demographics
have a high recurrence rate that correlates with age at dislocation
up to 80-90% in teenagers (90% chance for recurrence in age <20)

Risk factors
markedly higher incidence in
military patients
contact athlete patients
Etiology
Pathophysiology
mechanism of injury :
anteriorly directed force on the arm when the shoulder is abducted and externally rotated
pathoanatomy :
"on-track" versus "off-track" concept of Hill-Sachs lesion (instability as a bipolar concept)
Hill-Sachs defect is "off-track" and will "engage" on the glenoid if the size of the Hill-Sachs defect > glenoid
articular track (HSI > GT)
conversely, the Hill-Sachs defect is "on track" and will NOT "engage" if the size of the Hill-Sachs defect <
glenoid articular track (HSI < GT)
Glenoid Track (GT) = 0.83D-d (D = diameter of inferior glenoid, d = width of anterior glenoid bone loss)
Hill-Sachs Interval (HSI) = HS+BB (HS = width of the Hill-Sachs, BB = width of bony bridge)
may have implications regarding surgical management
goal is to convert on off-track lesion into an on-track lesion
Associated injuries
1) labrum & cartilage Injuries
bankart lesion
is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid.
is present in 80-90% of patients with TUBS
humeral avulsion of the glenohumeral ligament (HAGL)
occurs in patients slightly older than those with Bankart lesions
also found in female collegiate athletes
associated with a higher recurrence rate if not recognized and repaired
an indication for possible open surgical repair
glenoid labral articular defect (GLAD)
is a sheared off portion of articular cartilage along with the labrum
presence is a risk factor for failure following arthroscopic stabilization procedures
anterior labral periosteal sleeve avulsion (ALPSA)
can cause torn labrum to heal medially along the medial glenoid neck
associated with higher failure rates following arthroscopic repair
common finding in patients with recurrent instability managed nonoperatively
97% of patients with recurrent instability have either a Bankart or ALPSA lesion
 Associated injuries
2) fractures & bone Defects :
bony bankart lesion
is a fracture of the anterior inferior glenoid
present in up to 49% of patients with recurrent dislocations
higher risk of failure of arthroscopic treatment if not addressed
defect >20-25% is considered "critical bone loss" and is biomechanically highly unstable
stability cannot be restored with soft tissue stabilization alone (unacceptable >2/3 failure rate)
requires bony procedure to restore bone loss (Latarjet-Bristow, other sources of autograft or allograft)
recent studies suggest critical bone loss may be as low as 13.5%
each dislocation event causes, on average, 6.8% bone loss
glenoid takes on an inverted-pear appearance as bone loss increases
89% failure rate following arthroscopic repair in patients with this glenoid morphology
Hill-Sachs defect
is a chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim.
is present in 80%-100% of traumatic dislocations and 25% of traumatic subluxations
is not clinically significant unless it engages the glenoid
greater tuberosity fracture
is associated with anterior dislocation in patients > 50 years of age
increases risk of recurrence
lesser tuberosity fracture
is associated with posterior dislocations
Associated injuries

3) nerve injuries :
axillary nerve injury
is most often a transient neurapraxia of the axillary nerve
present in up to 5% of patients
4) rotator cuff tears :
30% of TUBS patients > 40 years of age
80% of TUBS patients > 60 years of age
5) global hyperlaxity (i.e. Ehlers-Danlos Syndrome, collagen disorders)
often associated with atraumatic instability
global hyperlaxity confers an odds ratio (OR) of 2.68 for the development of anterior shoulder instability
individuals with global hyperlaxity have a 3x higher rate of recurrent instability
patients with global hyperlaxity are less likely to develop capsulolabral lesions
Anatomy
Static restraints
bony anatomy
capsule
glenohumeral ligaments
labrum
labrum contributes 50% of additional glenoid depth
Dynamic restraints
rotator cuff muscles
long head of biceps tendon
Anterior static shoulder stability is provided by
Anterior band of IGHL (main restraint)
provides static restraint with arm in 90° of abduction and external rotation
MGHL
provides static restraint with arm in 45° of abduction and external rotation
SGHL
provides static restraint with arm at the side
Classification
Classification
Presentation

History
patients often recount a traumatic event leading to a dislocation
important to clarify whether patient needed a formal reduction, or if they spontaneously reduced
Symptoms
traumatic event causing dislocation
feeling of instability
shoulder pain complaints
caused by subluxation and excessive translation of the humeral head on the glenoid
Presentation
Physical exam :
load and shift
Grade 0 - normal glenohumeral translation
Grade I - translation to the glenoid rim, without dislocation
Grade II - shifts over glenoid rim, spontaneously reduces
Grade III - shifts over glenoid rim, does not spontaneously reduce
apprehension sign
patient supine with arm 90 degrees abducted and 90 degrees externally rotated
positive when patients experiences apprehension
positive sign in mid-ranges of abduction is highly suggestive of concomitant glenoid bone loss
relocation sign
decrease in apprehension with anterior force applied on shoulder during apprehension testing
sulcus sign
tested with patient's arm at side
generalized ligamentous laxity
increased risk of recurrent instability in patients with hyperlaxity
assess via Beighton's criteria (score > 4)
shoulder specific laxity defined as
hyperexternal rotation at side > 85 degress
hyperabduction > 105 degrees (Gagey's maneuver)
OR > 2+ load shift in 2 or more planes (anterior, posterior, inferior)
Imaging
Radiographs (X-rays)
recommended views
a complete trauma series needed for evaluation
true AP
scapular Y
axillary
optional views
West Point view
shows glenoid bone loss
Stryker view
shows Hill-Sachs lesion
Imaging
CT scan +/- arthrogram
indications
helpful for evaluation of bony injuries and calculation of glenoid bone loss
arthrogram usually reserved for patients who are unable to undergo MRI i.e. patients with pacemakers and/or cochlear
implants
due to limited soft-tissue contrast, CT arthrogram not as effective at visualizing internal soft-tissue derangements as MR
arthrogram
MRI
indications
best for visualization of labral tear
has been validated as an imaging modality through which to assess bone loss
MR Arthrogram
increases sensitivity and specificity (86-91% and 86-96%) for detecting soft-tissue injuries when compared to conventional
MRI (44-100% and 66-95%)
Treatment
Nonoperative
acute reduction, ± immobilization, followed by therapy
indications
management of first-time dislocators remains controversial
current ASES recommendations are for surgical intervention for athletes aged 14 to 30 at the end of their competitive season
if they have positive apprehension testing and bone loss
reduction
simple traction-countertraction is most commonly used
other reduction techniques include:
Kocher: arm at side in external rotation is forward-flexed and then internally rotated
Hippocratic: traction against a heel placed in the patients axilla
Stimson's: weight is hung from the affected arm of a patient in the prone position
immobilization
studies have not shown any benefit of immobilization > 1 week for decreasing recurrence rates
some studies show immobilization in external rotation decreases recurrence rates in patients < 40
thought to reduce the anterior labrum to the glenoid leading to more anatomic healing
subsequent studies have refuted this finding and the initially published results have not been reproducible
Treatment
Nonoperative
physical therapy
strengthening of dynamic stabilizers (rotator cuff and periscapular musculature)
outcomes
goal is return to sport within 7 to 21 days
military and overhead and/or contact athletes experience an unacceptably high rate of recurrent instability
risk factors for re-dislocation are
age < 20 (highest risk)
male
contact sports
hyperlaxity
glenoid bone loss >20-25%
greater tuberosity fractures
Treatment
Operative
Arthroscopic Bankart repair +/- capsular plication
indications
relative indications
first-time traumatic shoulder dislocation with Bankart lesion confirmed by MRI in athlete younger than 25 years of age
high demand athletes
recurrent dislocation/subluxation (> one dislocation) following nonoperative management
< 20-25% glenoid bone loss
remplissage augmentation with arthroscopic Bankart may be considered if Hills-Sachs "off-track"
techniques
at least three (preferably four) anchor points shoulder be used
paramount that labrum is fully mobilized prior to repair
outcomes
results now equally efficacious as open repair with the advantage of less pain and greater motion preservation
increased failure rates seen in patients with global hyperlaxity, glenoid bone loss, or too few fixation points
too many anchors does pose a risk for fracture through the anchor holes (postage stamp fracture)
Treatment
Operative
Open Bankart repair +/- capsular shift
indications
Bankart lesion with glenoid bone loss < 20-25%
revision stabilization following failed arthroscopic Bankart repair without glenoid bone loss >20%
can be considered when there is a concomitant acute glenoid fracture, or if the patient is hyperlax and requires a formal capsular
shift during the same procedure
humeral avulsion of the glenohumeral ligament (HAGL)
can also be performed arthroscopically but is technically challenging
technique
generally accessed through a deltopectoral approach
can fix bony bankart with screws or suture in a linear or bridge technique
outcomes
results are equivalent to arthroscopic repair, although patients have more pain and less range of motion postoperatively
patients with greater than 13.5% glenoid bone loss have higher rates of recurrent instability
Treatment
Operative
Latarjet (coracoid transfer) or Bristow Procedure
indications
chronic bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid)
in the setting of glenoid bone loss, excessive stress is transferred to labrum and attenuated anterior soft tissues,
increasing the risk of failure of labral repair alone
transfer of coracoid bone with attached conjoined tendon and CA ligament
Latarjet procedure performed more commonly than Bristow
Latarjet triple effect = bony (increases glenoid track), sling (conjoined tendon on top of subscapularis), capsule
reconstruction (CA ligament)
technique
deltopectoral approach
subscapularis is split
outcomes
over recurrent instability rate ranges from 0% to 8%
good to excellent outcomes are seen in over 90% of patients
Treatment
Operative
Autograft (tricortical iliac crest or distal clavicle) or allograft (iliac crest or distal tibia)
indications
bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid)
revision of failed latarjet
technique
can be performed arthroscopic or open
distal tibia gaining popularity since graft is a true osteochondral graft
outcomes
89% healing rate at a mean of 1.4 years
Treatment
Operative
Remplissage + Bankart Repair
indication
engaging large (>25-40%) Hill-Sachs defect
"off-track" Hill-Sachs lesions with <20-25% glenoid bone loss
technique
posterior capsule and infraspinatus tendon sutured into the Hill-Sachs lesion
may be performed with concomitant Bankart repair
by decreasing size of Hill-Sachs, converts on off-track lesion into an on-track lesion
outcomes
when compared to latarjet with 2-year outcomes, remplissage + bankart had lower recurrent instability rates (1.4% vs.
3.2%) despite greater bipolar bone loss
Treatment
Operative
Bone graft reconstruction for Hill Sachs defects
indication
engaging large (>40%) Hill-Sachs lesions
technique
allograft reconstruction
arthroplasty
rotational osteotomy
Treatment
Operative
Tendon transfers
indication
chronic, irreparable subscapularis tear
technique
latissimus dorsi
may better replicate line of pull of native subscapularis
pectoralis major - sternal head
Treatment
Operative
Historical procedures: Putti-Platt / Magnuson-Stack / Boyd-Sisk
indications
led to over-constraint and arthrosis
technique
goal is to tighten subscapularis
Putti-Platt is performed by lateral advancement of subscapularis and medial advancement of the shoulder capsule
Magnuson-Stack is performed with lateral advancement of subscapularis (lateral to bicipital groove and at times to greater
tuberosity)
Boyd-Sisk is transfer of biceps laterally and posteriorly
outcomes
high rate of post-operative stiffness and subsequent osteoarthritis
typical presentation of open procedure performed in 1970s-80s, now with presenting complaint of pain and stiffness from
glenohumeral OA, especially lack of ER, and signigicant posterior glenoid wear and retroversion
high rate of recurrent instability with Boyd-Sisk
Complications
1) Recurrence
often due to unrecognized glenoid bone loss treated with a soft tissue only procedure (especially with glenoid bone
loss >20-25%)
can be due to poor surgical technique (ie, < 4 suture anchors)
increased risk with preoperative risk factors including age < 20, male sex, contact/collision sport, ligamentous laxity,
and unrecognized glenoid and/or humeral head bone loss (critical bone loss or "off-track" lesion)
medical management should be exhausted prior to surgery in patients with seizures, as there is a high recurrence risk
even when bony augmentation techniques are used
unrecognized pan-labral tear
high incidence of posterior and/or combined front-to-back tears in the military population
2) Shoulder pain
overtightening during labral repair can lead to post-capsulorrhaphy arthropathy
3) Nerve injury
musculocutaneous (most common)
axillary
Complications
4) Stiffness
especially in external rotation (particularly with Latarjet and additional remplissage)
5) Infections
6) Graft lysis (Latarjet)
present in up to 90% of patients at six-months
7) Hardware complications
anchor pull-out (Bankart repair)
screw pull-out (Latarjet)
8) Chondrolysis
historically due to use of thermal capsulorraphy (now contraindicated) or intra-articular pain pumps (now
contraindicated)
Thank you
Any questions ?