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Recent Advances In Management Of Shoulder Instability

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Significant contemporary advances have permitted a more comprehensive understanding and development of some …

Significant contemporary advances have permitted a more comprehensive understanding and development of some
interesting concepts about the shoulder instability. The clinical syndrome of shoulder instability represents a wide
spectrum of symptoms and signs which may produce various levels of dysfunction, from slight Subluxation to gross
joint instability. The occurrence and reoccurrence of the joint instability may be due to age, forceful collision, falling on
an outstretched arm or a sudden wrenching movement. Dislocation of the shoulder is a common and often disabling
injury which is more common in athletes. Depending upon the state of the instability either exercise can be rec-
ommended or a surgery can be performed.


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  • 1. R cn A vne IM n g me t fh u e I t i y ee t d a csn a a e n O S o l r s b i d nal t
  • 2. Apollo Medicine 2012 December Review ArticleVolume 9, Number 4; pp. 315e317Recent advances in management of shoulder instabilitySughran Banerjeea,*, Neha Sharmab, Aparajita Sharmab ABSTRACT Significant contemporary advances have permitted a more comprehensive understanding and development of some interesting concepts about the shoulder instability. The clinical syndrome of shoulder instability represents a wide spectrum of symptoms and signs which may produce various levels of dysfunction, from slight Subluxation to gross joint instability. The occurrence and reoccurrence of the joint instability may be due to age, forceful collision, falling on an outstretched arm or a sudden wrenching movement. Dislocation of the shoulder is a common and often disabling injury which is more common in athletes. Depending upon the state of the instability either exercise can be rec- ommended or a surgery can be performed. Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved. Keywords: Shoulder instability, Arthroscopic stabilization, Open shoulder stabilization, Types of suturesINTRODUCTION a tear of the labrum or rotator cuff, a Bankart lesion or a HilleSachs defect.1The end of the shoulder blade or scapula that creates the There are mainly two types of dislocation:shoulder socket is known as the Glenoid. It is surrounded 1. Dislocation due to trauma called as Bankart lesion, andby a small, flexible tissue known as the labrum, which 2. Dislocation due to Lax ligaments.acts like a speed bump to keep the ball in the shoulder In some cases there is partial dislocation where thesocket. A group of four muscles and their respective shoulder slips out of the joint partially and slips back intotendons; known as the rotator cuff, stretches from the normal position again, this is called as Subluxation. Thehumerus to the glenoid and serves two purposes. First, younger the patient at first dislocation the more will bethe rotator cuff helps to raise, lower, and swing the arm, chance of recurrent dislocation.giving the shoulder a large range of motion. Secondly, The diagnosis can be made through the symptomsthe cuff serves to keep the humerus inside the glenoid of instability, physical examination, X-ray, CT-scan,socket. The cuff is covered by a pack of tight ligaments, MRI etc.known as the capsule that attaches the humerus to the gle- A patient with Bankart lesion usually needs an operationnoid. Repeated dislocation or Subluxation of the humerus to repair the ligaments to the bone, even after the first dislo-out of the glenoid is known as Instability. cation as the lesion usually does not heal. On the other hand Instability is the weakening of capsule at the shoulder in case of Lax ligaments, can be first managed with exer-joint, which allows the ball to slip out of the socket, cise, strengthening and operations are required only whencausing pain, frustration and loss of faith in the shoulder symptoms becomes unbearable. The operations can beas a sturdy joint. Instability is often accompanied by done either arthroscopically or open i.e. it can be ana Consultant Shoulder Surgeon, Apollo Gleneagles Hospital, Kolkata, bTrainee AHERF, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi,India.* Corresponding author. email: sughran@gmail.comReceived: 13.7.2012; Accepted: 4.8.2012; Available online 28.8.2012Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2012.08.001
  • 3. 316 Apollo Medicine 2012 December; Vol. 9, No. 4 Banerjee et al.arthroscopic Bankart repair/arthroscopic stabilization, open group. There was no significant loss of external rotationshoulder stabilization or Bristow-Latarjet procedure.1 and return to prior activity.2 The fixation of shoulder by various suture anchor’s provided similar results while tested for pullout strength.In arthroscopic repair Thus in conclusion arthroscopic Bankart repair is an estab-How the shoulder should be fixed is also shrouded in lished benchmark for shoulder surgery, however withcontroversy. Some recommend arthroscopic stabilization inverted pear glenoid Latarjet procedure is recommendedwhile other’s advocate open Bankart’s repair.2 and in acute sport’s injuries acute repair prevents recurrence There are reported failure rates following arthroscopic of shoulder dislocation. With further development ofstabilization, but these are early literature and not so well arthroscopic techniques gradually the shift is consideredtechnically.3 Later reports suggest a much better success to be toward fixing everything arthroscopically.4rate for arthroscopic shoulder stabilization.4 The arthroscopic Thus arthroscopic shoulder stabilization is here to stayshoulder stabilization and open shoulder stabilization are and improve further technically with time, graduallycomparable.5 Thus the benchmark for shoulder stabilization making open stabilization an obsolete procedure or keptprocedure from open repair has gradually shifted to arthro- for those cases which cannot be repaired arthroscopically.scopic stabilization.3 The arthroscopic shoulder stabilizationprocedures are more patient friendly, less of operative stressand lesser morbidity.2,6 A study in young athletes demon- CONCLUSIONstrated a significant reduction in recurrence following acuterepair of Bankart lesion as compared to those who were There have been significant advances in methods to restoretreated conservatively.1 In patients with glenoid bone defect function in case of shoulder instability. The techniquesa Bristow-Latarjet procedure is recommended, this consists involved in stabilization of shoulder have complex proce-of an open procedure taking the coracoid and fixation of dures that require a degree of experience and expertise.the coracoids to the glenoid by a screw.7 This increases the Hence the development of arthroscopic training is thereforeradius of curvature of the glenoid and thereby increases the an important skill which needs to be developed amongstability biomechanically.8 The Bankart’s repair is supple- surgeons and increase the awareness to refer shoulder stabi-mented by this method in cases of glenoid bone defect. lization to arthroscopically trained surgeons.High success rate has been reported following Bristow-Latar-jet procedure in inverted pear glenoid and in these situationsarthroscopic Bankart repair seems inadequate mode of CONFLICTS OF INTERESTfixation.7 Boileau (2007) has recommended primary Latarjet All authors have none to declare.procedure in high-energy athletes determining a scoringsystem as to who needs to undergo which surgery. TheLatarjet procedure is being successfully done Arthroscopi-cally9 and thus is gaining popularity. In the procedure the REFERENCEScoracoid is dissected out and resected to be fitted next to 1. Arciero RA, Spang JT. Complications in arthroscopic anteriorglenoid and use of a percutaneous screw to fix the coracoids shoulder stabilization: pearls and pitfalls. Instr Course Lect.to the glenoid.10 2008;57:113e124. The fixation of shoulder has been done by various suture 2. Hawkins Richard B. Arthroscopic stapling repair for shoulderanchors that ranges from non-absorbable titanium anchors instability: a retrospective study of 50 cases. Arthroscopy.to absorbable knotless anchors and non-absorbable knotless June 1989;5(2):122e128.anchors. In a study knotless anchors were found to be more 3. Cole Brian J, Warner Jon JP. Arthroscopic versus open Bank-stable than titanium anchor’s in term of pullout strength.11 art repair for traumatic anterior shoulder instability. Clin Post-operative recovery e the pain may last for few days Sports Med. 2000;19(1):19e48.and precautions must be followed. 4. Kim Seung-Ho, Ha Kwon-Ick, Park Jong-Hyuk, et al. Arthro- scopic posterior labral repair and capsular shift for traumaticDISCUSSION unidirectional recurrent posterior subluxation of the shoulder. J Bone Jt Surg. 2003;85:1479e1487.The overall feeling of instability has been reported to be 5. Dolk T, Gremark O. Arthroscopy and stability testing of the10% in open group and 10.2% in the arthroscopic repair shoulder joint. Arthroscopy. 1986;2:35e40.
  • 4. Management of shoulder instability Review Article 3176. Hawkins RJ, Koppert G, Johnston G. Recurrent posterior 9. Lafosse Laurent, Boyle Simon. Arthroscopic Latarjet instability (subluxation) of the shoulder. J Bone Jt Surg. procedure. J Shoulder Elbow Surg. March 2010;19(2): 1984;66A:169e174. 2e12.7. Hovelius Lennart K. Long-term results with the Bankart and Bris- 10. Hovelius L. Operative treatment of recurrent anterior shoulder tow-Latarjet procedures: recurrent shoulder instability and arthrop- dislocation with the Bristow-Latarjet procedure. In: athy. J Shoulder Elbow Surg. September 2001;10(5):445e452. Bateman JE, Welsh RP, eds. Surgery of the Shoulder. Phila-8. Boileau P. The instability severity index score. A simple pre- delphia: BC Decker Inc.; 1984:87e90. operative score to select patients for arthroscopic or open 11. Thal Raymond. Arthroscopic Bankart repair using Knotless or shoulder stabilisation. J Bone Jt Surg Br. November 2007;89- BioKnotless suture anchors: 2- to 7-year results. Arthroscopy. B(11):1470e1477. April 2007;23(4):367e375.
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