anterior instability of the shoulder

VOL. 86-B, No. 4, MAY 2004 469

REVIEW ARTICLE

Anterior instability of the shoulder after trauma

C. M. Robinson, R. J. Dobson

From the Royal Infirmary of Edinburgh, Edinburgh, Scotland

C. M. Robinson, BMedSci, FRCS Ed (Orth), Senior Lecturer and Consultant Orthopaedic Surgeon R. J. Dobson, Clinical Research AssistantThe Shoulder Injury Clinic, Royal Infirmary of Edinburgh, Old Dalkeith Road, Little France, Edinburgh EH16 4SU, UK.

Correspondence should be sent to Mr C. M. Robinson.

2004 British EditorialSociety of Bone andJoint Surgerydoi:10.1302/0301-620X.86B4.15014 $2.00J Bone Joint Surg [Br]2004;86-B:469-79.

Anterior dislocation of the glenohumeral jointis a common injury of young people playingcontact sport and may progress to recurrentepisodes of symptomatic instability. The usualtreatment for a primary dislocation is a shortperiod of immobilisation followed by a pro-gramme of rehabilitation and a gradual returnto full activity. An open operation to stabilisethe shoulder is a successful procedure for thetreatment of patients who develop recurrentinstability. The advent of arthroscopic surgery,initially as a diagnostic tool, but more recentlyto perform therapeutic intervention, hasresulted in a variety of minimally-invasivetechniques for the management of instability.

Arthroscopic stabilisation done as day-caresurgery offers attractive advantages over openrepair such as improved cosmesis, less post-operative pain, reduced stiffness after opera-tion and more rapid rehabilitation. As a conse-quence, this technique has been offered asinitial treatment after a primary dislocation inan attempt to prevent subsequent instability.However, the results after this procedure havebeen much more variable than those for openrepair.

In this review, we examine the recentadvances in the understanding of the epidemi-ology and pathoanatomy of anterior instabilityof the shoulder after trauma, and compare therelative merits of arthroscopic and open stabi-lisation in the management of this condition.

Who is at risk of shoulder instability?Primary anterior dislocation of the shoulderoccurs commonly during contact sport in theyoung and after low-energy falls in the elderly.Although anterior dislocation in the aged hasits own complications,1 recurrent instability isa particular problem in the young.

The typical patient with a high risk of devel-oping recurrent instability is a man, either inhis teenage years or early twenties, who suffersa primary dislocation while playing contactsports. The injury is usually sustained eitherwith the arm in the at-risk position of abduc-

tion and external rotation, or from a directimpact to the shoulder. The symptoms of insta-bility develop during the first two years afterthe original dislocation.2-4

Despite the numerous studies of the naturalhistory after an initial traumatic anterior dislo-cation, the exact incidence of recurrent insta-bility remains uncertain,2,4,5 with rates quotedranging from as low as 17%6 to close to100%.2,7-10 Many of the series which describea high incidence have been drawn from selec-tive populations, such as patients presenting tosports injury clinics and in military cadets,7,11

and may therefore be unrepresentative of thegeneral population. There may also be a sub-stantial pool of individuals who never seekmedical advice, either because they sustain anisolated dislocation, become occasional dislo-cators, or are relatively asymptomatic and donot want surgical intervention.12

An accurate reflection of the true risk inunselected populations is probably an inci-dence of recurrent instability of 75% to 80%among individuals aged between 13 and 20years and of 50% in those aged between 20and 30 years.4,5,13 The high rate of recurrentinstability during adolescence appears to beindependent of whether the proximal humeralphysis is open or not.9,10 The risk begins todecline in the late twenties, although recurrentinstability is not uncommon in the middle-agedor in the elderly when it may be associatedwith significant problems of the rotator cuff.1

Although the age at the time of primary dis-location is the chief prognostic factor in deter-mining the risk of recurrent instability,14 youthis also a marker for other important risk fac-tors. These include an early return to competi-tive contact sports, poor compliance withrehabilitation and a greater likelihood ofcapsulolabral avulsion at the original disloca-tion. Many other factors have also beensuggested as increasing the risk including afamily history of recurrent instability,15 radio-logically-visible avulsion fracture2,16 of the rimof the glenoid and a large Hill-Sachs lesion.4

470 C. M. ROBINSON, R. J. DOBSON

THE JOURNAL OF BONE AND JOINT SURGERY

Re-dislocation is rare if the greater tuberosity is fracturedat the time of the initial injury, but these patients typicallyhave a more protracted recovery, as a result of secondarydysfunction of the rotator cuff and impingement.17 The riskof re-dislocation may also be altered by the initial treat-ment.

Definitions and classificationLaxity of the shoulder, which is the normal translation ofthe humeral head over the surface of the glenoid,18 shouldbe distinguished from instability, which occurs when thedegree of translation becomes excessive and leads to symp-toms. Instability may vary in its degree (subluxation, dislo-cation and micro-instability), direction (anterior, inferior,posterior and multidirectional), aetiology (traumatic oratraumatic) and volition (voluntary or involuntary).

Two separate groups of individuals who develop gleno-humeral instability can be described;19 namely, those whoinjure their shoulder (TUBS or traumatic, typically unilat-eral, with a Bankart lesion and usually requiring surgery tostabilise the shoulder) and those in whom instability devel-ops insidiously as a result of an inherited constitutional lig-amentous laxity (AMBRI or atraumatic, multidirectional,commonly bilateral, treatment by rehabilitation and in-ferior capsular shift in some refractory patients). Many ofthose in the latter group also have evidence of ligamentouslaxity in other joints. Increasingly, these two acronyms areviewed as the ends of a spectrum of disease in which bothtraumatic and atraumatic elements may be present. Adegree of inherited predisposition to traumatic instability issuggested by its occurrence bilaterally in a quarter of allpatients, who often have a family history of recurrent dis-location.15,20 Conversely, many athletes who have evidenceof constitutional ligamentous laxity only develop symp-toms of instability after injury, and have predominantlyunidirectional anterior instability.

It is now recognised that participants in overhead sportsand athletes who throw are susceptible to a wide variety ofdisorders of the shoulder, including impingement dysfunc-tion of the rotator cuff and acquired instability, which mayoccur concurrently to varying degrees.21-23 The classicsymptoms of instability may be absent in these individuals,but if not recognised, may lead to failure of treatment.

The final group of patients with unstable shoulders arethose with voluntary instability. These individuals are nor-mally considered to be able to dislocate their shoulders atwill and should be treated non-operatively.24 Increasingly,this view is seen as oversimplistic since some individualsmay develop an acquired instability after many repetitivevoluntary dislocations, and others may have an involuntaryposterior positional element to their instability, whichmay respond to biofeedback or, more rarely, to surgery.25

Instability of the shoulder therefore encompasses a widespectrum of conditions which can be distinguished by theiraetiology, severity, constitutional factors and volition. Forthis reason there is no generally accepted all-inclusive

system of classification and an individual or algorithmicapproach to diagnosis and treatment is probably best.26

The pathoanatomy of instability of the shoulderThe shallow glenohumeral joint sacrifices its stability inorder to allow an extensive range of movement. The jointrestraints are normally divided into static stabilisers such asthe glenoid fossa, the labrum, the joint capsule and theglenohumeral ligament, and dynamic stabilisers includingthe rotator cuff, the long head of biceps and the stabilisersof the scapula. There is significant interaction betweenthese restraints and their relative importance alters withchanging positions of the arm. Knowledge of the anatomyand biomechanics of the shoulder has improved considera-bly in recent years with the increasing availability of MRI,more detailed biomechanical laboratory studies and theincreasing use of arthroscopy. Studies of both normal andabnormal shoulders have allowed an improved apprecia-tion of the complex factors contributing to glenohumeralinstability. An overview of the pathoanatomy is given here,but a more extensive review of this complex area has beenmade by Levine and Flatow.27

The Bankart lesion, with avulsion of the anteriorcapsulolabral complex inferior to the equator of the gle-noid, has traditionally been regarded as the essential lesionof anterior traumatic dislocation of the shoulder. Althoughthis lesion is almost invariably present in patients with trau-matic instability,28,29 it is now thought that it does not pro-duce instability in isolation.30 As the arm is brought intothe at-risk position of greater abduction, the resistance toexternal rotation is provided by the anteroinferior struc-tures, especially the inferior glenohumeral ligaments, whichact like a hammock to retain the humeral head in place.31

Plastic deformation of these structures occurs during theinitial dislocation before avulsion of the labrum andbecomes progressively more severe with subsequent epi-sodes of instability.32-34 Repair of the Bankart lesion aloneis consequently thought to be insufficient to stabilise thejoint and re-tensioning of the anteroinferior capsuloliga-mentous complex is now considered to be an importantadjunctive procedure in patients with repeated episodes ofinstability.35

There is renewed interest in the importance of the mor-phology of the anteroinferior part of the bony glenoid rimin glenohumeral instability. Subtraction three-dimensionalCT has been used to image the glenoids of normal volun-teers and patients with glenohumeral instability. Half of thelatter group had an avulsion of the osseous glenoid rim, abony Bankart lesion, and a further 40% had evidence oferosion or compression of the rim with loss of the normalpear-shaped configuration of the glenoid. A cadaverstudy36 has shown that an osseous defect in which thewidth is at least 20% of the length of the glenoid can causeinstability of the shoulder. Clinically, impression lesionsand avulsion fractures have been associated with recurrentinstability16,37 and failure of arthroscopic surgical stabilisa-

ANTERIOR INSTABILITY OF THE SHOULDER AFTER TRAUMA 471

VOL. 86-B, No. 4, MAY 2004

tion.38 Patients with large anteroinferior osseous defects ofthe glenoid, the inverted pear sign, may therefore be betterserved by an open bony procedure which directly addressesthe defect in the glenoid, rather than a conventional soft-tissue stabilisation.38

An impression fracture of the humeral head (the Hill-Sachs lesion) is present in most patients with anterior insta-bility. It is usually relatively small and does not contributeto instability. However, when the defect is larger andinvolves more than 30% of the humeral articular surface, itmay engage with the anterior glenoid during externalrotation of the shoulder causing re-dislocation.39

Other lesions associated with instability have only beenrecognised since the development of arthroscopy of theshoulder. These include humeral avulsion of the gleno-humeral ligaments (HAGL lesion), which are typically rec-ognised after first-time dislocations and probably representa variant from the normal pattern of anterior capsularstretching or rupture,40 anterior labroligamentous perio-steal sleeve avulsions (ALPSA lesion) in which the detachedsleeve heals medially to the scapular neck, allowing exces-sive humeral translation,41 superior labral anterior andposterior detachment (SLAP lesion), which may occur incontinuity with the inferior labral avulsion,42,43 and defectsof the rotator interval.44,45 The exact importance of manyof these lesions in the pathogenesis of shoulder instability isnot fully understood at present.

Treatment of the initial dislocationClinical assessment and primary treatment. A detailed his-tory and examination are important in the assessment ofany patient presenting with a primary dislocation in theEmergency Department, with careful documentation of anyneurovascular deficit. Although palsy of the axillary nerveis the most common nerve injury, many types of brachialplexus lesion and isolated nerve palsies have beendescribed. Anteroposterior and modified axial radio-graphs46 are important in confirming the dislocation andthe presence of any associated fractures before relocation.Reduction using the Hippocratic method with sedation andadequate muscle relaxation remains the most widely prac-tised method, although many other techniques have beensuccessfully used.47 After-manipulation radiographs aremandatory to confirm a congruent relocation and to re-assess the position of any associated fractures.

Although some studies have suggested that prolongedimmobilisation of the shoulder,48 restriction of activity oran intensive programme of rehabilitation6,49 may reducethe risk of recurrent instability, these measures have notbeen consistently effective.4,7,50 Restriction of shouldermovement in a sling for a period of two to three weeks fol-lowed by a graduated rehabilitation programme is theaccepted management of a primary dislocation in the youngpatient.

During the period of immobilisation, the shoulder is nor-mally held in the so-called safe position of internal rota-

tion, neutral flexion/abduction with the elbow flexed to 90.Recent evidence has shown that immobilisation with thearm held in external rotation may reduce the risk of subse-quent instability by approximating the Bankart lesion tothe neck of the glenoid giving a greater likelihood of its ana-tomical healing.51 Early comparison of the rates of second-ary instability after immobilisation in either the safeposition or in external rotation have yielded promisingresults in favour of the latter.52 Patient compliance may bean issue with this form of treatment, and independent vali-dation of the initial results is awaited.Primary surgical management. In theory, performing anearly primary stabilisation after a first-time traumatic dis-location in patients at high risk of recurrent instability is alogical procedure since the tear of the glenoid labrum isfresh, and plastic deformation of the capsuloligamentouscomplex may be minimal. An open stabilisation procedureis unacceptable in most initial dislocations and has rarelybeen used.53-55 It was not until the development of arthro-scopic techniques in the shoulder that the prophylacticsurgical treatment became an option. Arthroscopic stabi-lisation has a higher degree of acceptability to the patientas a primary treatment, and, if delivered within two weeksof the injury, does not prolong the subsequent period ofimmobilisation or rehabilitation. However, the provisionof an acute arthroscopic shoulder service is expensive. Inaddition to the training and specialist expertise, a modernarthroscopic stack system with television monitor, afluid-delivery pump system, arthroscopic electrocautery,instrumentation and implants are all required. The opera-tion is often technically challenging, is not free from com-plications and, because of our inability to predict withcertainty those who will develop instability, may beunnecessary in some patients. Proof of an economic andclinical benefit from the use of prophylactic surgery will berequired for the technique to become more widelyadopted as well as a cultural change towards the earlyreferral of primary dislocators for this form of specialistsurgery.

It has been suggested that early arthroscopic lavage mayin itself be sufficient to reduce the risk of re-dislocation56,57

by clearing the acute haemarthrosis and joint effusion,58

thereby encouraging anatomical healing of the detachedlabrum. However, repair of the Bankart lesion to the decor-ticated rim of the glenoid is the usual primary arthroscopicprocedure. Repair was initially attempted using metal sta-ples but these have been largely superceded by eithercustom-designed tacks or suture anchors to achieve directrepair of the labrum, or anteroposterior pull-through trans-glenoid sutures with knots tied either over the infraspinatusfascia59 or to the posterior glenoid (Fig. 1).60 Many of thetacks and suture anchors are engineered from bioabsorba-ble materials because of concerns regarding the long-termeffects of the use of metal implants in young individuals.The technology is still evolving, most notably with knot-less suture anchors and suture welding systems, and it



seems certain that the procedure will become technicallyeasier to perform in the future.

Arthroscopic stabilisation is often more technically chal-lenging in the acute phase than when performed for recur-rent instability (Fig. 2). Visualisation may be difficultbecause of the haemarthrosis, synovitis or active bleeding,and the shoulder may be relatively tight and difficult tovisualise. Rupture of the capsule may lead to excessiveextravasation of arthroscopic fluid, the tissues may be fria-ble and difficult to repair and the capsulolabral detachmentmay be more substantial (Fig. 3), with either global detach-ment extending into the superior and posterior labrum43 oran associated fracture of the glenoid rim.37

A number of relative contraindications to arthroscopicrepair have been identified. These include red-out atarthroscopy, usually due to active intra-articular bleeding

preventing adequate visualisation and the presence of eithera fracture of the greater tuberosity, a bony avulsion of theanterior glenoid rim or an HAGL lesion. Increasingly, theseproblems are being overcome by refinements to arthro-scopic techniques.37,61-63

The results of primary surgical treatment. There are anumber of concerns regarding previous studies which haveexamined the use of primary arthroscopic techniques.Many have been small case series without a control group.There are few comparative studies and even fewer prospec-tive, randomised controlled trials which have comparedarthroscopic stabilisation with standard non-operativetreatment. Previous studies have varied widely in their cri-teria for inclusion and exclusion, the surgical techniquesused, outcome measures, and length of follow-up. The chiefoutcome measure used has been the incidence of recurrent

Fig. 1a Fig. 1b Fig. 1c Fig. 1d

Diagrams of arthroscopic techniques for the treatment of anterior shoulder instability showing a) staple capsulorraphy, b) transglenoid suture repair,c) bioabsorbable tacks and d) suture anchors.

Fig. 2a Fig. 2b Fig. 2c

Diagrams of an acute arthroscopic repair using suture anchors: a) suture anchors have been placed into the anterior glenoid rim.The attached sutures penetrate the labrum and a crochet hook is used to pass one strand of the attached suture back through theanterior working cannula to capture the labrum; b) a knot pusher is used to tie an arthroscopic knot over the labrum; c) the com-pleted repair.


VOL. 86-B, No. 4, MAY 2004

instability after operation. The use of this as the benchmarkof the success of the technique is somewhat simplistic,although these patients usually score poorly in terms of theother outcome measures which have commonly been used,including levels of pain, subjective instability, functionaloutcome and the range of the shoulder movement. A sum-mary of the overall rates of recurrence after operationreported in the literature is shown in Table I.

Case series of the use of primary arthroscopic Bankartrepair without control groups report low rates of recur-rence, comparable with those achieved after open repair to

treat recurrent instability (Table I). However, in the studieswhich have compared primary arthroscopic stabilisationwith non-operative treatment, the incidence of recurrentinstability after surgery has been much higher (Table I).Despite this, the evidence of these studies still points to amore than fivefold reduction in the risk of recurrent insta-bility after arthroscopic stabilisation, when compared withnon-operative treatment (Fig. 4). It is notable that the ratesof recurrence after operation which are reported after pri-mary arthroscopic repair are similar to those after arthro-scopic stabilisation to treat recurrent instability (Table I).


Diagrams of the variants of the Bankart lesion seen acutely showing a) an isolated Bankart lesion, b) a Bankart lesion in continuitywith a SLAP lesion and c) a bony avulsion of the anterior glenoid rim (bony Bankart lesion).

Table I. Rates of recurrence after the surgical treatment of patients with primary anteror dislocations and those with recurrent instability. This is asummary of the previous English Language articles, or articles with an English language abstract, which have reported on the effects of treatment fortraumatic anterior shoulder instability in terms of recurrence post-operatively. In order to find all relevant articles, MEDLINE, EMBASE, PubMed andthe Cochrane Central Register of Controlled Trials were searched. In addition, abstracts from past annual meetings of the American Academy ofOrthopaedic Surgeons and the Arthroscopy Association of North America were searched. Review articles and the reference lists of articles were alsochecked. For the open stabilisation techniques, only studies published in the last ten years were included. Studies predominantly evaluatingparticipants with posterior instability or multidirectional instability were excluded, as were those evaluating participants undergoing revision surgery.In addition, we specified a minimum mean follow-up period of 12 months. Post-surgical recurrence has been inconsistently defined, with studiesvariously including patients suffering re-dislocation, re-subluxation, post-surgical pain and those exhibiting positive apprehension signs. For thepurpose of this review we defined post-surgical recurrence to be either redislocation or resubluxation

Clinical setting Type of study Technique

Total number of patients in series

Total number of recurrences

Percentage recurrence rate (with 95% CI)

First-time dislocation Case-series (with no control gp)

Arthroscopic Bankart repair 170 13 7.6 (4.5 to 12.6)

Clinical trials Non-operativeArthroscopic Bankart repair

148 177

118 23

79.713.0

(72.5 to 85.4)(8.8 to 18.7)

Recurrent instability Case-series (with no control gp)

Arthroscopic staple repairArthroscopic transglenoid suture repairArthroscopic bioabsorbable tack repairArthroscopic suture anchor repairArthroscopic repairs with adjunctive procedures

8421755 616 692 141

151302 84 68 9

17.917.213.6 9.8 6.4

(15.5 to 20.7)(15.5 to 19.0)(11.2 to 16.6)(7.8 to 12.3)(3.4 to 11.7)

All arthroscopic repairs 4046 614 15.2 (14.1 to 16.3)Open Bankart repairOther open stabilisation techniques

14511295

91151

6.311.7

(5.1 to 7.7)(9.6 to 12.8)

All open stabilisation procedures 2746 242 8.8 (7.8 to 9.9)Clinical trials Open Bankart repair

Arthroscopic Bankart repair 529 506

37 94

7.018.6

(5.1 to 9.5)(15.4 to 22.2)



Primary arthroscopic stabilisation has shown no consist-ent benefit over non-operative treatment in terms of otherfunctional outcomes including levels of shoulder pain,functional scores or restriction of movement.

Treatment of the patient with recurrent instabilityClinical assessment. The clinical assessment of the patientpresenting with symptoms of instability is primarilydirected towards identifying those individuals with pre-dominantly traumatic instability, who would benefit fromsurgical treatment. These patients need to be distinguishedfrom those with predominantly atraumatic or voluntaryinstability, who are best treated non-operatively in the firstinstance, and from those with more subtle forms of insta-bility who require further investigation before a decisioncan be made about treatment.

Details about the onset, duration and frequency of thesymptoms should be sought in the history. Physical exami-nation should include screening for evidence of generalisedligamentous laxity64,65 and performing provocative tests todefine the direction and extent of instability.

Plain radiography is useful in delineating any associatedbony abnormality, including defects of the rim of theglenoid and head of the humerus. Further specialist radio-logical investigation, examination under anaesthesia ordiagnostic arthroscopy may be used for patients in whomthe precise diagnosis is in doubt. MRI of the shoulder issuperior to CT in the assessment of instability of theshoulder because of the better soft-tissue definition pro-vided.

Surgical treatment for recurrent instability. A programme ofphysiotherapy rehabilitation alone will not usually restoresufficient stability to allow an athlete with traumatic insta-bility to return to physical contact sports.66 The mainstayof treatment in these individuals is surgical stabilisation.This may not apply to more sedentary individuals, to thosewith occasional symptoms of instability or to olderpatients. In these individuals, an initial trial of non-opera-tive treatment including strengthening of the rotator cuffmay be more appropriate.Open surgical stabilisation. Irrespective of the exact tech-nique used, there has been a general trend towards attempt-ing to identify and treat the lesion responsible for instabilityby using anatomical repair and re-tensioning of soft tissues,rather than achieving stability through scarring or restric-tion of movement.

During the last 20 years, the most commonly used opentechnique in the treatment of recurrent anterior instabilityhas been repair of the Bankart lesion, usually combinedwith an adjuvant capsular shift. The deltopectoralapproach is used almost exclusively, but a more cosmeticand minimally-invasive vertical skin incision extending inthe skin crease from the anterior axillary fold is now recom-mended. Most studies advocate dissecting the subscapularistendon as a separate layer before performing a capsulot-omy. Several varieties of T-shaped, vertical or horizontalincisions have been described to perform the capsulotomy.Many variations of the Bankart repair have been used, butmost surgeons now tend to favour suture anchors to securethe glenoid labrum to the decorticated anterior rim of the

2 5 10

Weight(%)

Relative risk (fixed)95% Cl


Non-operativen/N Rate (%)

Arthroscopicn/N Rate (%)

100.0 5.5 (3.6 to 8.4)

17.1 4.1 (1.2 to 14.1)35/3812/1517/2011/194/617/189/1213/20

118/148

Wheeler et al 8Arciero et al 11Sandow 1996 J Shoulder Elbow Surg. 5(2): 581Kirkley et al 13DeBerardino 2001 Am J Sports Med. 29(5): 586-592Larrain 2001 Arthroscopy 17(4): 373-377Bottoni 2002 Am J Sports Med. 30(4): 576-580Chroustovsky et al 55

Total (95% Cl)

Study

Test for heterogeneity: chi-squared=7.55, df=7 (P=0.37)

(92)(80)(85)(58)(67)(94)(75)(65)

(80)

2/93/213/195/196/491/281/92/23

23/117

(22)(14)(16)(26)(12)(4)(11)(9)

(13)

13.2 5.6 (1.9 to 16.5)16.3 5.4 (1.9 to 15.5)26.5 2.2 (1.0 to 5.1)6.9 5.4 (2.1 to 13.9)4.1 26.4 (3.9 to 181.8)6.0 6.8 (1.0 to 44.1)9.8 7.5 (1.9 to 29.2)

10.2 0.50.1

Favours non-operative Favours arthroscopic

Fig. 4

Summary of the previous English language articles, or articles with an English language abstract, which have compared the effects of arthroscopicand traditional non-operative treatment for primary anterior dislocation of the shoulder in terms of recurrence postoperatively. In order to find allrelevant articles, MEDLINE, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were searched. In addition, abstracts from pastannual meetings of the American Academy of Orthopaedic Surgeons and the Arthroscopy Association of North America were searched. Reviewarticles and the reference lists of articles were also checked. Due to the lack of randomised and quasi-randomised trials which have been conductedin this area, it was decided to include all types of clinical trial. Studies predominantly evaluating participants with posterior instability or multidirec-tional instability were excluded. In addition, we specified a minimum mean follow-up period of 12 months. Postsurgical recurrence has been incon-sistently defined, with studies variously including patients suffering re-dislocation, re-subluxation, post-surgical pain and those showing positiveapprehension signs. For the purposes of the analysis we defined post-surgical recurrence to be either redislocation or resubluxation. The figures tothe right of the reference show the number of patients with instability postoperatively (n) as a proportion of the total population (N). The chi-squaredtest showed evidence of some statistical heterogeneity of the studies, demonstrated by a chi-square statistic greater than its degree of freedom (df).However, this is not statistically significant (p=0.37). The results suggest that the risk of recurrent post-operative instability is 5.5 times greater afternon-operative treatment compared with primary arthroscopic stabilisation. (relative risk=5.5, 95% confidence levels (CI) 3.6 to 8.4).


VOL. 86-B, No. 4, MAY 2004

glenoid (Fig. 5). A plication is performed to re-tension theanteroinferior capsuloligamentous complex. Care must betaken not to overtighten the repair in order to avoid therestriction of external rotation post-operatively.

Many other open techniques are still widely used, with ahigh degree of success.67,68 The Bristow-Helfet procedureof coracoid osteotomy and fixation to the anteroinferiorrim of the glenoid, although technically demanding,remains popular.69,70 Many consider that this procedure, orthe use of a structural bone graft to reconstitute the rim ofthe glenoid, is preferable for patients with a large defect inthe rim. This applies particularly to epileptics with recur-rent traumatic instability who often have a large antero-inferior deficiency.71,72 In patients with large, engaging Hill-Sachs defects, allograft bone grafting or rotational osteot-omy may also be considered.Arthroscopic stabilisation. The arthroscopic techniques usedto repair the Bankart lesion in the treatment of recurrenttraumatic instability are similar to those advocated for pri-mary stabilisation. However, in patients with recurrentinstability, the anteroinferior capsule becomes progres-sively more attenuated with each episode of subluxation ordislocation. Tightening of the anterior capsule, achievedeither by superior advancement of the labrum at the timeof Bankart repair or as a separate adjunctive thermal orlaser-assisted shrinkage of the anterior capsule, suture pli-cation of the capsule or closure of the rotator interval aretherefore increasingly advocated. Judging the extent towhich this is required may be difficult and incurs the riskof producing excessive capsular tightness, limiting exter-nal rotation. Thermal or laser-assisted capsular shrinkagemay initially reduce laxity but it may engender anincreased susceptibility to creep failure at low physiologi-cal loads.73,74

The results of stabilisation procedures for recurrent trau-matic instability. The most widely reported results usingopen techniques are those for the Bankart repair and areslightly better than those for other open procedures (TableI). However, combination of all the reported series usingopen techniques during the last ten years still reveals a rateof recurrence after operation of less than 10%. Notablesuccess has been achieved recently using open Bankartrepair to treat high-demand, collision sportsmen withunstable shoulders, with most returning successfully tohigh-level competition.75,76

If arthroscopic stabilisation procedures are to replaceopen procedures, the rates of recurrence after operationneed to be similar. The overall average rate of recurrenceafter arthroscopic stabilisation in case series without con-trol groups is 15.2%, compared with 6.3% for openBankart repair and 8.8% for all open procedures (Table I).However, the rates of recurrence vary considerably betweenthe four categories of arthroscopic techniques and there isoften considerable heterogenicity in the results of studiesreporting the same method. Although the rates of recur-rence are greater in studies with longer follow-up, thereappears to have been a gradual improvement with the useof the more modern arthroscopic techniques and implants,particularly suture anchors. The few available studies sug-gest that the results of arthroscopic Bankart repair with aseparate adjuvant capsular tightening, either by closure ofthe rotator interval, capsular shrinkage or plication, may bebetter than a Bankart repair alone (Table I).

Most of the comparative studies have shown rates ofrecurrent instability to be higher after arthroscopic stabilisa-tion than after open repair, and a meta-analysis of theseseries shows the risk of recurrence to be statistically signifi-cant, and more than twice that of an open procedure (Fig. 6).


Diagrams of an open Bankart repair with capsular shift. (a) The t-shaped capsular incision (note the rotator interval defect andlarge inferior capsular pouch). (b) A capsulotomy has been performed and drill holes have been inserted into the decorticatedanterior glenoid rim for placement of suture anchors to repair the labral avulsion (Bankart repair). (c) On completion of theBankart repair, a capsular shift procedure is performed to re-tension the lax anterior capsuloligamentous structures and obliter-ate the inferior capsular recess. The rotator interval has also been closed.



As with primary stabilisation, no consistent benefits ofthe arthroscopic procedure over an open stabilisation havebeen demonstrated in terms of long-term residual shoulderpain, functional scores or restriction of movement. How-ever, many studies report a shorter hospital stay, decreasedpost-operative pain and analgesic requirements, togetherwith an improved cosmetic result when using the arthro-scopic method.

Factors associated with recurrent instability after surgical repairThe factors associated with recurrent instability after surgi-cal stabilisation may be classified into those caused by inap-propriate patient selection and those attributable tosurgical error.77,78 However, athletes playing contact sportsmay often re-injure themselves with sufficient force to re-dislocate their shoulder irrespective of the quality of theirprevious repair.79,80

Failure because of inappropriate patient selection usuallyresults from inadequate pre-operative assessment. Themost common cause of this is a failure to recognise a multi-directional or voluntary element in a patient thought tohave anterior instability. The most common reason for sur-gical error is inadequate treatment of all the constituentcomponents of the instability at the time of surgery. Abnor-

malities commonly encountered at re-exploration afterfailed arthroscopic or open repair include an unhealedBankart lesion,77,81 humeral avulsion of the glenohumeralligaments,82,83 extensive glenoid erosion or deficiency froma bony Bankart lesion,38,84,85 excessive capsular laxity,81,86

a defect of the rotator interval,87 an engaging Hill-Sachslesion38,39 and reduced retroversion of the head of thehumerus or excessive retroversion of the glenoid cavity.88

Several additional factors have been associated withrecurrent instability after arthroscopic stabilisation includ-ing a younger age at surgery,59,89 non-compliance withpost-operative immobilisation,84,90 early return to contactsport,86,91 absence or deficiency of the capsulolabral com-plex and poor inferior glenohumeral ligaments,86,92 andmultiple episodes of instability before stabilisation.80,93 Thewide variation in the rates of recurrence after arthroscopicstabilisation may also be a reflection of the inherent techni-cal difficulty in performing these procedures. Many authorsreport a steep learning curve, with patients included later intheir series having a lower rate of recurrence than thosetreated earlier.

Although revision arthroscopic stabilisation has beendescribed,86,94 most failed open and arthroscopic stabilisa-tions caused by technical failure are treated by a furtheropen procedure.95 High-quality MRI should be performed

2 5 10

Weight(%)



Arthroscopicn/N Rate (%)

Open n/N Rate (%)

100.0 2.3 (1.6 to 3.2)

1.2 5.6 (0.3 to 111.4)10.0 3.2 (1.3 to 8.0)2.9 4.0 (0.5 to 29.8)5.6 2.7 (0.7 to 9.8)7.3 2.6 (0.8 to 8.5)3.9 0.3 (0.0 to 7.7)5.0 2.7 (0.6 to 12.7)5.9 4.3 (1.3 to 14.0)1.3 9.0 (0.5 to 162.9)5.3 1.0 (0.2 to 6.1)14.5 1.6 (0.6 to 3.8)1.5 7.5 (0.4 to 127.70)6.4 1.8 (0.4 to 8.1)14.3 1.4 (0.5 to 4.0)8.3 2.0 (0.6 to 7.0)6.8 0.5 (0.1 to 3.5)

2/2312/185/154/267/160/185/307/434/502/2115/315/306/379/607/302/58

94/506

Weber 1991 Orthopaedic Transactions 15: 763Luetzow 1995 62nd AAOS Annual MeetingGuanche 1996 Am J Sports Med. 24(2): 144-148Horns 1996 Knee Surg Sports Traumatol Arthrosc. 4(4): 228-231Geiger 1997 Clin Orthop. 337: 111-117Kartus 1998 Knee Surg Sports Traumatol Arthrosc. 6(3): 181-188Steinbeck 1998 Am J Sports Med. 26(3): 373-378Weber 1998 65th AAOS Annual MeetingField 1999 J Shoulder Elbow Surg. 8: 195Jorgensen 1999 Knee Surg Sports Traumatol Arthrosc. 7(2): 118-124Roberts 1999 J Shoulder Elbow Surg. 8(5): 403-409Ahmad 2000 67th AAOS Annual MeetingCole 2000 J Bone Joint Surg Am. 82-A(8): 1108-1114Karlsson 2001 Am J Sports Med. 29(5): 538-542Sperber 2001 J Shoulder Elbow Surg. 10(2): 105-108Kim 2002 Arthroscopy 18(7): 755-763

Total (95% Cl)

Study

Test for heterogeneity: chi-squared=10.11, df=15 (P=0.81)

(17)(67)(33)(15)(44)(0)(17)(16)(8)(10)(48)(17)(16)(15)(23)(3)

(19)

0/264/191/124/693/181/182/324/1060/502/204/130/202/225/483/262/30

37/529

(0)(21)(8)(6)(17)(6)(6)(4)(0)(10)(31)(0)(9)(10)(12)(7)

(7)

10.2 0.50.1

Favours arthroscopic Favours open

Fig. 6

Summary of the previous English language articles, or articles with an English language abstract, which have compared the effects of open andarthroscopic stabilisation for post-traumatic anterior shoulder instability in terms of recurrence post-operatively. In order to find all relevant articles,MEDLINE, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were searched. In addition, abstracts from past annual meetingsof the American Academy of Orthopaedic Surgeons and the Arthroscopy Association of North America were searched. Review articles and the ref-erence lists of articles were also checked. Due to the lack of randomised and quasi-randomised trials which have been conducted in this area, it wasdecided to include all types of clinical trial. Studies predominantly evaluating participants with posterior instability or multidirectional instabilitywere excluded, as were those evaluating participants undergoing revision surgery. In addition, we specified a minimum mean follow-up period of12 months. Post-surgical recurrence has been inconsistently defined, with studies variously including patients suffering re-dislocation, re-subluxa-tion, post-surgical pain and those showing positive apprehension signs. For the purposes of the analysis we defined post-surgical recurrence to beeither redislocation or resubluxation. The figures to the right of the reference show the number of patients with instability post-operatively (n) as aproportion of the total population (N). The chi-squared test showed no evidence of statistical heterogeneity which would be suggested by a chi-square statistic greater than its degrees of freedom (df) and a small p value (


VOL. 86-B, No. 4, MAY 2004

before re-exploration to delineate abnormalities of boneand soft tissue clearly and to help to plan surgery. An exam-ination under anaesthesia and diagnostic arthroscopy willoften provide extra information before re-exploration. Spe-cific guidelines for the treatment of postsurgical recurrencehave previously been described,68 but a flexible approach isimportant, as every case is idiosyncratic.

Other complications of surgical stabilisationIn addition to the general complications of surgery andrecurrent instability, a number of other problems have beendescribed after operative stabilisation. Following openrepair, pain, loss of movement, infection, failure of theimplant, neurovascular injury and late degenerative jointdisease are the more commonly encountered complica-tions.68,96 After arthroscopic stabilisation, neurovascularinjury,97-99 adhesive capsulitis100 and synovial fistula101

have all been encountered. Other complications are specificto the particular technique used to repair the Bankart lesionand include loosening, breakage and impingement after theuse of staples;102,103 injury to the suprascapular nerve andpain from the posterior knot after transglenoidrepair;101,104 foreign-body reaction, rapid decay leading tointra-articular dissociation of the head after repair withbioabsorbable tacks;105,106 and pull-out after repair withsuture anchors.80 These complications are comparativelyrare, but often require surgical re-exploration and are asso-ciated with a poor functional outcome or recurrent instabil-ity.

Conclusions and the futureThe last 20 years have seen many advances in our under-standing and treatment of post-traumatic instability of theshoulder. Innovative treatments designed either to preventor to treat recurrent instability vary from those which arerelatively simple, inexpensive and require little expertise,such as, immobilisation of the shoulder in external rotationand arthroscopic washout of the shoulder alone, to themore technically-demanding and financially-burdensomeprocedures for arthroscopic stabilisation.

The challenge for the future rests in defining the mostappropriate timing and type of intervention from the rangeof new and traditional options available. The current liter-ature contains many small case series and comparativestudies, but larger collaborative, randomised controlledtrials are required to compare the efficacy of the newertechniques with standard treatments. The methods chosenwill vary from patient to patient dependant on their age,their degree of activity and their expectations from treat-ment. Ultimately, a greater degree of patient empowermentin the decision-making process may be the way forward.107

Until good evidence is produced to the contrary thestandard method of treatment of an initial traumatic dislo-cation is non-operative and open repair is used to treatmost patients with recurrent traumatic instability. Cur-rently, there is some evidence that early arthroscopic stabi-

lisation can substantially reduce the risk of recurrentinstability after a primary dislocation. However, the risk ofrecurrence after an immediate arthroscopic stabilisation inthese studies does not appear to be substantially better thanthat for an arthroscopic procedure to treat patients withrecurrent instability. With the inherent degree of over-treatment involved in offering an immediate arthroscopicstabilisation to all high-risk patients, an effective compro-mise may be to offer this procedure at a much earlier stageto those individuals who develop instability after a primarydislocation, before they have developed the degree of cap-suloligamentous plastic deformation likely to compromisean arthroscopic repair.

Many patients still present late, with multiple episodes ofinstability, and either attenuated capsuloligamentousrestraints or a deficiency of the anteroinferior glenoid rim.The results of arthroscopic stabilisation in these patientsare improving with the use of newer implants and adjuvanttreatment to address the problem of anterior capsular lax-ity. However, currently there is little evidence to support theroutine widespread use of this technique over a standardopen stabilisation and at the moment most patients withrecurrent traumatic instability are better served by an openBankart repair with re-tensioning of the capsule.

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anterior instability of the shoulder

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