Acute or Recurrent Anteroinferior Glenohumeral Instability

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Bullet points

  • One of most common shoulder injuries, 1.7% annual rate in general population.
  • High recurrence rate that correlates with age at dislocation, up to 80-90% in teenagers (90% chance for recurrence in age <20).
  • Osseous lesions, either humeral or glenoid, are identified in 95.0%. The risk of failure of arthroscopic treatment is higher if not addressed. A glenoid bony defect of >20-25% is considered "critical" and is biomechanically highly unstable and require bony procedure to restore bone loss (Latarjet, Bristow, other sources of autograft or allograft).
  • A Malgaigne (Hill Sachs) defect is a chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim. It is present in 80% of traumatic dislocations and 25% of traumatic subluxations.
  • Axillary nerve injury is most often a transient neurapraxia of the axillary nerve and is present in up to 5% of patients.
  • Incidence of associated rotator cuff tears increase with age of 40 (30% at 40, 80% at 60).
  • Static glenohumeral stabilizers are the bone, the ligaments, the capsule, the labrum, and the negative pressure. The dynamic ones are the rotator cuff and long head of biceps tendon.
  • The labrum contributes to 50% of additional glenoid depth.
  • Anterior static shoulder stability with arm in 90 degrees of abduction and external rotation is provided by the anterior band of inferior glenohumeral ligament (main restraint).
  • The middle glenohumeral ligament provides static restraint with arm in 45° of abduction and external rotation.
  • The superior glenohumeral ligament provides static restraint with arm at the side.
  • The physical examination demonstrates instability if the apprehension test is positive, multidirectional hyperlaxity when the external rotation at side is equal or above 85 degrees, and a pathological laxity of the inferior glenohumeral ligament if the hyperabduction test is positive.
  • Three views plain radiographs, including true anteroposterior of the glenohumeral joint, scapular Y (scapular lateral), and Velpeau axillary views are the mainstay of imaging in the setting of acute traumatic anterior instability. Plain radiographs including anteroposterior in neutral, internal and external rotations, scapular Y and Bernageau views are obtained for recurrent instability. Magnetic resonance imaging (MRI) arthrogram is useful to assess for labral or rotator cuff tears, computed tomography (CT) for bone loss assessment.
  • Conservative treatment after the first traumatic anterior dislocation is recommended for patients who are not actively engaged in sports, above the age of 30 years old, with a low functional demand, with an associated humeral fracture, or for the athlete with an in-season shoulder dislocation.
  • Rehabilitation consist of strengthening of dynamic stabilizers (rotator cuff and periscapular musculature), exercises for proprioception and other specific treatments if apprehension persist.
  • Surgical treatment included Bankart repair, capsular plication +/- soft tissue procedures (such as remplissage or dynamic anterior stabilization (DAS) if < 20% bone loss.
  • If bone loss ≥ 20%, bone reconstruction with Latarjet, Bristow or free bone block transfers such as Eden-Hybinette is recommended.

Key words

Anterior glenohumeral instability; shoulder dislocation; subluxation; reduction; bone loss; Malgaigne; Hill-Sachs; Bankart; capsular shift; remplissage; dynamic anterior stabilization (DAS); Latarjet; Bristow; free bone block transfer; Eden-Hybinette; complication; recurrence; pull-out.

History

The first recorded depictions of shoulder reduction are ancient.[1]

Egyptian hieroglyphs dated 3000 years earlier, pictorially depict a leverage method of shoulder manipulation, They have been followed by the Greeks and Romans. Around 400 BC, Hippocrates, the father of Western medicine, introduced the traction method to reduce the shoulder. [2][3][4]

In 1855, Malgaigne was the first one to describe the humeral bone loss also called Hill-Sachs lesion.[5]

In the 1890s, the understanding of the unstable shoulder was elucidated by the work of two French researchers, Broca and Hartman who introduced the concept of capsulolabral damage following dislocations as possible cause of recurrent instability. Notably, most of the findings considered current hallmarks of shoulder instability, including Bankart lesion, bony Bankart, Kim lesion, as well as anterior and posterior labral periosteal sleeve avulsions and glenoid avulsions of glenohumeral ligaments, were described in their papers, decades before the eponymous figures to whom they are now commonly assigned depicted them.[6]

In 1906, Perthes in Germany and a few years later, Bankart in the UK ascertained that the detachment of the labrum caused instability of the shoulder and emphasized reattachment of the labrum to stabilize the joint.[7][8]

Current free bone grafting techniques are based on the initial descriptions by Eden in 1918 and Hybinette in 1932 using autologous iliac crest.[9][10]

Due to donor site morbidity with autologous iliac crest bone grafting techniques, different auto- and allogeneic bone materials have been evaluated as alternatives. Open and arthroscopic approaches using distal clavicle, femoral head, distal tibial allografts or coracoid process are currently used. The first coracoid process transplant was probably realized by the German surgeon Noeske in 1921.[11]

Nowadays, two most popular bony procedures included the Latarjet and its variant, the Bristow.[12][13]

Anecdote

(unpublished data, courtesy of Gilles Walch) At the beginning of the 1950s, Albert Trillat, the head of the orthopedic surgical clinic at the Edouard Herriot Hospital in Lyon (France) and also the promoter of the "no touch technique", reported combination of an anterior labro-ligamentous complex reinsertion when feasible with a reduction of a so-called coraco-glenoid outlet by means of a coracoid osteoclasy and nail fixation (Figures).

14. Trillat A. Traitement de la luxation récidivante de l'épaule. Considérations techniques. Lyon Chir 1954:986-93.

  1. ↑ Iqbal S, Jacobs U, Akhtar A, Macfarlane RJ, Waseem M. A history of shoulder surgery. Open Orthop J 2013;7:305-9.
  2. ↑ Hussein MK. Kocher's method is 3,000 years old. J Bone Joint Surg Br 1968;50:669-71.
  3. ↑ Celsus A. De Medicina.
  4. ↑ Hippocrates. Corpus Hippocraticum—De articulis.
  5. ↑ Malgaigne J. Traité des fractures et des luxations. Paris: J.-B. Baillière; 1855.
  6. ↑ Broca A, Hartmann H. Contribution à l'étude des luxations de l'épaule (luxations anciennes et luxations récidivantes). Bull Soc Anat 1890;4:416-23.
  7. ↑ Perthes G. Ueber Operationen beihabitueller Schulterluxation. Dtsch Z Chir 1906;85:199–227.
  8. ↑ Bankart AS. Recurrent or Habitual Dislocation of the Shoulder-Joint. British medical journal 1923;2:1132-3.
  9. ↑ Eden R. Zur Operation der habituellen Schulterluxation unter Mitteilung eines neuen Verfahrens bei Abriss am inneren Pfannenrande. Dsch Z Chir 1918;144:269.
  10. ↑ Hybinette S. De la transplantation d’un fragment osseux pour remédier aux luxations récidivantes de l’épaule. Acta Chir Scand 1932:411-45.
  11. ↑ Anonymous. Zentralbl Chir 1924;43:2402.
  12. ↑ Latarjet M. Treatment of recurrent dislocation of the shoulder. Lyon Chir 1954;49:994-7.
  13. ↑ Helfet AJ. Coracoid transplantation for recurring dislocation of the shoulder. J Bone Joint Surg Br 1958;40-B:198-202.
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