Original articlePrimary anterior dislocation of the shoulder
Abstract
The authors were unable to find authoritative or documented evidence that any form of conservative treatment prevented all dislocations of the shoulder from recurring. The trends indicated by this preliminary study suggested, on the contrary, that treatment of the primary episode was of little importance and that the site and nature of the primary pathologic disorder was of utmost importance in determining whether or not recurrences would take place.
The incidence of recurrence was 90 per cent in patients under twenty years of age, 60 per cent in patients between twenty and forty and only 10 per cent in patients over forty. This would appear incompatible with theories that recurrence depends upon specific details of treatment or mechanisms of injury. It might be postulated that one explanation of this age incidence depends upon the balance of strength between the anterior and posterior Joint supports at different ages. In the young both the tendon cuff and the humeral head are strong but also supple and elastic as compared to those in older persons in whom both become progressively weaker and more brittle. This fact of attrition may predicate that during youth the glenohumeral ligaments are the weaker components of the joint supports which give way first under stress. In any event recurrence of a traumatic lesion depends essentially upon rupture or avulsion of these ligairents. Comparable damage to the ligamentous supports of most other larger Joints warrants early operative repair since neither in the shoulder nor any other joint do such lesions often heal in a functionally satisfactory manner. It is submitted, therefore, that in the appropriate age groups these avulsed or ruptured glenohumeral ligaments deserve early operative repair as the only reasonably sure method of achieving healing and preventing the great majority of recurrent dislocations.
There was definite evidence that the posterior supports of the Joint were the weaker component which gave way to allow dislocation in about 70 per cent of all patients past the age of forty. Was this because the attritional changes of advancing years had made both tendon cuff and tuberosity weaker and more brittle? Such dislocations in theory should not and, in fact, did not recur but were prone to nerve injuries, delay in recovery and permanent disability of some degree resulting from internal derangement of the subacromial mechanism. This syndrome proved more common and disabling than recurrent dislocation but could be anticipated consistently by roentgenographic demonstration of residual tuberosity displacement or clinical evidence of cuff damage. Early identification and operative repair proved by far the best treatment for properly selected lesions of this type with operative revision following the establishment of late symptoms a poor second choice.
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Cited by (119)
Trends and projections in surgical stabilization of glenohumeral instability in the United States from 2009 to 2030: rise of the Latarjet procedure and fall of open Bankart repair
2023, Journal of Shoulder and Elbow SurgeryAdvances in surgical techniques have improved the ability to address recurrent glenohumeral instability via arthroscopic capsulolabral repair and bone-restoring procedures such as the Latarjet procedure. Given the paucity of studies analyzing temporal trends in the surgical management of glenohumeral instability, the purpose of this study was to assess trends in the treatment of anterior, posterior, and multidirectional instability over a 10-year period and model projections to 2030.
Using the IBM Watson MarketScan national database, we identified all patients who underwent glenohumeral instability procedures from 2009 to 2018. Procedures were identified using Current Procedural Terminology codes for open Bankart, Latarjet, anterior bone block, posterior bone block, multidirectional capsular shift, and arthroscopic Bankart procedures. Sample weights provided by the database were used to calculate national estimates. US Census Bureau annual population data were used to calculate incidence. Future projections to 2030 were modeled using Poisson and linear regression.
There were an estimated 446,072 glenohumeral instability cases from 2009 to 2018. The per capita incidence (per 100,000) remained constant, from 14.8 in 2009 to 14.5 in 2018. Arthroscopic Bankart procedures comprised the highest number of procedures throughout the study period, accounting for 89% of all procedures in 2009 and 93% in 2018. The number of open Bankart procedures decreased by 65% from 2009 to 2018, whereas the number of Latarjet procedures showed a 250% increase over the same period. Patient demographics did not change over the study period, and male patients aged 18-25 years comprised the largest demographic group undergoing anterior instability procedures. Multidirectional instability procedures exhibited the least pronounced sex differences. Future modeling from 2018 to 2030 projected a continued steady rise in arthroscopic Bankart procedures (from 40,000 to 49,000 cases/yr), rapid growth in Latarjet procedures (from 1370 to 4300 cases/yr), and continued decline in open Bankart procedures (from 1000 to 250 cases/yr).
Arthroscopic Bankart repair continues to be the most common glenohumeral instability procedure in the United States. From 2009 to 2018, the incidence of open Bankart procedures declined whereas the incidence of Latarjet procedures markedly increased. Future projections to 2030 mirrored these findings. These data may provide an enhanced understanding of the evolution of surgical treatment of glenohumeral instability within the United States, laying the foundation for continued prospective studies into the appropriate indications and advancements in surgical techniques.
Comparison of perioperative complications following surgical treatment of shoulder instability
2022, JSES InternationalSurgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow.
This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time.
This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (Ptrend < .001).
In addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.
Multiple Instability Events at Initial Presentation Are the Major Predictor of Failure of Nonoperative Treatment for Anterior Shoulder Instability
2021, Arthroscopy - Journal of Arthroscopic and Related SurgeryTo define the success rate of initial nonoperative treatment for traumatic anterior shoulder instability in a defined U.S. geographic population, describe factors that predict conversion to surgery after initial nonoperative management, and describe the long-term outcomes of nonoperative treatment after the index traumatic anterior instability event.
The Rochester Epidemiology Project database was used to identify patients aged 14 to 39 years treated for anterior shoulder instability between 1994 and 2016. Patient demographic characteristics, comorbidities, injury characteristics, and imaging were evaluated. Patients treated nonoperatively for the first 6 months after the index instability event were analyzed to determine long-term outcomes (recurrence rate, pain at last follow-up, radiographic outcomes), the success rate of continued nonoperative treatment (no conversion to surgery), and factors associated with conversion to surgery (patient and injury characteristics). Survivorship free of surgery was reported with a Kaplan-Meier survival curve, and Cox proportional hazards models were used to evaluate association of variables with conversion to surgery.
A total of 379 patients met the study criteria, with an average follow-up period of 10.2 years (range, 0.53-25.00 years). The average age was 23.9 years, the mean body mass index was 26.2, and 100% of instability events were due to trauma. Of the shoulders, 79 (20.1%) ultimately failed initial nonoperative treatment and progressed to surgery. At final follow-up, the rate of recurrent instability was 52.3% in the group treated definitively without surgery, and the recurrence rate decreased from 92.4% to 10.1% in patients who underwent conversion to surgical treatment. Factors associated with conversion to surgery included 2 or more subluxations prior to the first evaluation (hazard ratio [HR], 1.82; P = .002), 2 or more dislocations prior to the first evaluation (HR, 1.76; P = .006), and recurrent instability at follow-up (HR, 4.21; P < .001).
Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. Ultimately, 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment. In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management.
Level III, retrospective database review.
Anterior Instability: Preoperative Issues
2020, Complications in Orthopaedics: Sports MedicineThe accurate identification and navigation of preoperative complications is crucial for optimizing patient outcomes in the setting of shoulder stabilization procedures. Although both open and arthroscopic techniques have proven effective in restoring stability and preventing recurrence, there are multiple clinically relevant preoperative complications that must be considered to ensure optimal patient outcome. Therefore osseous defects of both the glenoid and humeral architectures, as well as soft tissue pathologies commonly associated with anterior instability, must be recognized and accounted for before surgical intervention. Detailed history taking, thorough physical examination, and diagnostic imaging are necessary for this identification and subsequent management. This chapter is intended to serve as a guide to assessing and avoiding potential preoperative complications commonly associated with both open and arthroscopic shoulder stabilization surgery.
Managing patients with shoulder instability
2018, Orthopaedics and TraumaThe shoulder is the most mobile joint in the body but, as a consequence is also the most unstable. Stability is aided by boney, ligamentous and muscular structures and as a result may be related to trauma, hyper mobility or muscle patterning. Acute management requires careful history and examination with gentle reduction by a number of means and then may be treated conservatively or surgically. There is a high rate of recurrence with the conservatively treated shoulder in the younger population. Over 150 surgical procedures have been described to treat recurrent shoulder instability and these range from open ‘anatomic’ repair to tightening procedures though bone/coracoid ligament transfers and arthroscopic procedures. Several factors have been identified to help guide decision-making and these are summarized in the ISIS score which can be used to aid decision-making in these challenging patients.
Bipolar Bone Loss in Patients With Anterior Shoulder Dislocation: A Comparison of Adolescents Versus Adult Patients
2017, Arthroscopy - Journal of Arthroscopic and Related SurgeryCitation Excerpt :The patients were grouped into 2 groups: adolescents (aged 10-19 years) and adults (aged ≥20 years). We used 20 years of age as a cutoff on the basis of prior studies that have established age, in particular less than 20 years, as a risk factor for recurrent instability.2,16-19 The groups were compared regarding bipolar bone loss by measuring glenoid bone loss and Hill-Sachs injury size as determined on MRI.
To compare bipolar bone loss by evaluating the degree of glenoid bone loss, Hill-Sachs lesion size, and glenoid track in adolescents and adults with shoulder dislocations.
We performed a retrospective review between 2012 and 2016 of surgical and nonsurgical patients with a history of anterior shoulder dislocations (primary or recurrent) who underwent magnetic resonance imaging of the affected shoulder. The exclusion criteria included multidirectional instability, prior surgery, and posterior dislocation. Patients were grouped into 2 groups: adolescents (aged 10-19 years) and adults (aged ≥20 years). The groups were compared regarding measures of glenoid bone loss (best-fit circle technique) and Hill-Sachs lesion size (medial margin of rotator cuff footprint to medial margin of Hill-Sachs lesion). If the medial margin of a Hill-Sachs lesion was within the glenoid track, it was defined as on track; if it was more medial than the glenoid track, it was defined as off track.
We identified 45 adolescents (mean age, 16.1 years) and 30 adults (mean age, 28.9 years) with anterior shoulder dislocations. There was no significant difference in percentage of bone loss between adolescents (mean, 8.4%) and adults (mean, 9.9%; P = .23). There was no significant difference in Hill-Sachs lesion size between adolescents (mean, 12.7 mm) and adults (mean, 9.9 mm; P = .12). There were 12 patients with off-track lesions. Off-track lesions were present in 11 of 45 adolescents (24.4%) and 1 of 30 adults (3.3%). Adolescents had an increased risk of having an off-track lesion (odds ratio, 9.38; 95% confidence interval, 1.14-77.1). A subgroup analysis identified multiple dislocations as an independent risk factor for an off-track lesion (odds ratio, 4.15; 95% confidence interval, 0.85-20.23).
This study shows that adolescence and a history of multiple dislocations are independent risk factors for a greater likelihood of glenoid off-track lesions. The findings support the use of bipolar assessment of shoulder dislocators, especially in adolescents and multiple dislocators.
Level III, retrospective comparative study.
- 1
From the Department of Orthopedic Surgery, College of Physicians and Surgeons, Columbia University, and the Fracture Service of the Presbyterian Hospital, New York, N. Y.