Treatment of Recurrent Instability

Nonoperative management

Coordinated, strong muscle contraction is a key element of stabilization of the humeral head in the glenoid. Optimal neuromuscular control is required of the rotator cuff muscles, deltoid and pectoralis major and the scapular musculature.

Stabilizing with muscle strength

These dynamic stabilizing mechanisms require muscle strength, coordination and training. Such a program is likely to be of particular benefit in patients with atraumatic (AMBRII) instability (Hurley, Anderson, Dear et al, 1992; Neer, 1970), because loss of neuromuscular control is one of the major features of this condition. Nonoperative management is also a particularly attractive option for children, for patients with voluntary instability (Neer, 1970), for those with posterior glenohumeral instability, and for those requiring a supranormal range of motion (such as baseball pitchers and gymnasts) in whom surgical management often does not permit return to a competitive level of function. (Hawkins, Koppert and Johnston, 1984; Huber and Gerber, 1994; Rowe, Pierce and Clark, 1973; Saha, 1971)

Strengthening exercises

Strengthening of the rotator cuff, deltoid and scapular motors can be accomplished with a simple series of exercises. During the early phases of the program, the patient is taught to use the shoulder only in the most stable positions, that is those in which the humerus is elevated in the plane of the scapula (avoiding, for example, elevation in the sagittal plane with the arm in internal rotation if there is a tendency to posterior instability). As coordination and confidence improve, progressively less intrinsically stable positions are attempted. Taping may provide a useful reminder to avoid unstable positions. The shoulder is then progressed to smooth repetitive activities, such as swimming or rowing, which can play an essential role in retraining the neuromuscular patterns required for stability.

Finally, it is important to avoid all activities and habits that promote glenohumeral subluxation or dislocation; patients are taught that each time their shoulder goes out it gets easier for it to go out the next time.

Rockwood and colleagues (Rockwood et al, 1986) and Burkhead and Rockwood (Burkhead and Rockwood, 1992) found that 16 per cent of patients with traumatic subluxation, 80 per cent of those with anterior atraumatic subluxation, and 90 per cent of those with posterior instability responded to a rehabilitation program. Brostrom et al (Brostrom et al, 1992) found that exercises improved all but five of 33 unstable shoulders, including traumatic and atraumatic types. Anderson et al have demonstrated the effectiveness of an exercise program using rubber bands in improving internal rotator strength. (Anderson et al, 1992) Rockwood et al have demonstrated that nonoperative management can be successful even when there is a congenital factor in instability. They reported 16 patients with hypoplasia of the glenoid. (Wirth, Lyons and Rockwood, 1993) A subset of this group consisted of five patients with bilateral glenoid hypoplasia and multidirectional instability as indicated by symptomatic increased translation of the humeral head during anterior, inferior, and posterior drawer testing. In addition, generalized ligamentous laxity of the metacarpophalangeal joints, elbows, or knees was noted in all five patients. Four of the patients had been involved in occupational or recreational activities, or both, that had placed heavy demands on the shoulders. Four of these patients had considerable improvement in the ratings for pain and the ability to carry out work and sports activities at an average of 3 months after they had begun a strengthening program designed by Rockwood. None of the patients needed vocational rehabilitation, despite the heavy demands on their shoulders associated with their occupational or recreational activities.

Open operative management

Surgical stabilization of the glenohumeral joint is considered in traumatic instability if the condition repeatedly compromises shoulder comfort or function in spite of a reasonable trial of internal and external rotator strengthening and coordination exercises.

Deciding to treat with surgery

In contemplating a surgical approach to anterior traumatic glenohumeral instability, it is essential to identify preoperatively any factors that may compromise the surgical results, such as a tendency for voluntary dislocation, generalized ligamentous laxity, multidirectional instability, or significant bony defects of the humeral head or glenoid. When these conditions exist, it is necessary to modify the management approach. It is noteworthy that these factors can and should be identified preoperatively.

Surgical options

In the past, many surgical procedures have been described for the treatment of recurrent anterior glenohumeral instability. Tightening and to some degree realigning the subscapularis tendon and partially eliminating external rotation were the goals of the Magnuson-Stack and the Putti-Platt procedures. The Putti-Platt operation also tightened and reinforced the anterior capsule. Reattachment of the capsule and glenoid labrum to the glenoid lip was the goal of the DuToit staple capsulorrhaphy, and the Eyre-Brook capsulorrhaphy. (Eyre-Brook, 1943; Eyre-Brook, 1948) The Bristow procedure transferred the tip of the coracoid process with its muscle attachments to create a musculotendinous sling across the anteroinferior glenohumeral joint. An anterior glenoid bone buttress was the objective of the Oudard and Trillat procedure. Augmentation of the bony anterior glenoid lip was the objective of anterior bone block procedures, such as the Eden-Hybinette. Haaker and Eickhoff (Haaker et al, 1993) used autogenous bone graft to the glenoid rim for recurrent instability. In their series recurrent instability in 24 young soldiers, they used screws to fix an anterior iliac crest graft to the anterior glenoid rim. At the conclusion of the graft placement, the glenoid labrum is replaced over the graft.

Large posterolateral humeral head defects have been approached by limiting external rotation, by filling the defect with the infraspinatus tendon,or by performing a rotational osteotomy of the humerus. (Cautilli, Joyce and Mackell, 1978a; Cautilli, Joyce and Mackell, 1978b; Stufflesser and Dexel, 1977; Weber, 1969)

Evaluation of techniques

Capsulolabral reconstruction

The objective of anatomic repair for traumatic instability is the reconstruction of the avulsed capsule and labrum at the glenoid lip, often referred to as a Bankart repair.

History of the procedure

It is important to emphasize several important differences between Bankart's original method and the capsulolabral reconstruction currently recommended. Today we do not osteotomize the coracoid, we do not shave off bone from the anterior glenoid, and finally, we strive to reattach the capsule and any residual labrum up on the surface of the glenoid lip, rather than on the anterior aspect of the glenoid as shown by Bankart.

Efficacy of the procedure

Variations on the procedure

While many variations on the method of attaching the capsule to the glenoid have been described, no method has been demonstrated to be safer or more secure than suture passed through drill holes in the lip of the glenoid. (Levine et al, 1994; McEleney et al, 1995; Richmond et al, 1991) Modifications of the technique do not seem to constitute substantial improvements in the efficacy, cost or safety of the procedure; for example, suture anchors do not have strength equal to sutures passed through holes in the glenoid lip. (Gohlke et al, 1993; Harner and Fu, 1995; Hecker et al, 1993) Furthermore, when suture anchors are placed in the ideal location for capsulolabral reattachment, there is a substantial risk of their rubbing on the articular surface of the humerus. It is difficult to restore the effective glenoid depth using suture anchors.

Although some have advocated the addition of a capsular shift or capsulorrhaphy to the Bankart repair (Altchek, Warren, Skyharet al, 1991; Speer et al., 1994), this does not seem necessary or advisable in the usual case of traumatic instability. In fact, one of the outstanding features of Bankart's results were that "All these cases recovered full movement of the joint, and in no case has there been any recurrence of dislocation." Excessive tightening of the anterior capsule and subscapularis can lead to limited comfort and function as well as to the form of secondary degenerative joint disease known as capsulorrhaphy arthropathy. (Bigliani et al, 1995; Hawkins and Angelo, 1990b; Kronberg and Brostrom, 1990; Lusardi et al, 1993) Rosenberg et al (Rosenberg et al, 1995) found that 18 of 52 patients had at least minimal degenerative changes at an average of 15 year followup; as a cautionary note against unnecessary capsular tightening, these authors found a correlation between loss of external rotation and the incidence of degenerative changes. To help guard against post operative loss of motion, Rowe and associates (Rowe, Patel and Southmayd, 1978) limit immobilization to just two to three days, after which the patient is instructed to gradually increase the motion and function of the extremity.

Recent advances and refinements

Thomas and Matsen described a simplified method of anatomically repairing avulsions of the glenohumeral ligaments directly to the glenoid lip without coracoid osteotomy, without splitting the capsule and the subscapularis, without metallic or other anchors, and without tightening the capsule. (Matsen, Lippitt, Sidles et al, 1994; Thomas and Matsen, 1989) This method (described in detail in the "Authors Preferred Method" section) offers excellent range of motion and stability. Subsequently Berg and Ellison (Berg and Ellison, 1990) have again emphasized this simplified approach to capsulolabral repair.

When pathologically increased anterior laxity is combined with a Bankart lesion, the addition of a capsular plication to the reattachment of the capsulolabral avulsion has been recommended. Jobe and colleagues (Jobe et al, 1991) and Montgomery and Jobe(Montgomery and Jobe, 1994) have found good or excellent results in athletes with shoulder pain secondary to anterior glenohumeral subluxation or dislocation. Two years after surgery over 80% had returned to their preinjury sport and level of competition.

Rockwood et al have reported their results in 108 patients (142 shoulders) with recurrent anterior shoulder instability. (Wirth et al, 1996) All patients were managed by repair of capsulolabral injury, when present, and reinforcement of the anteroinferior capsular ligaments by an imbrication technique that decreases the overall capsular volume. According to the grading system of Rowe and associates, 93% of the results were rated as good or excellent at an average follow-up of 5 years (range, 2 to 12 years). The incidence of recurrent instability was approximately 1%.

Other anterior repairs

Many other anterior repairs have been described. Most are of historical interest only. The reader is also referred to an review of the glenohumeral capsulorrhaphy by Friedman. (Friedman, 1993)

Staple capsulorrhaphy

In the DuToit staple capsulorrhaphy, the detached capsule is secured back to the glenoid using staples. (DuToit and Roux, 1956; Sisk and Boyd, 1974) Actually, the staple repair had been described 50 years earlier by Perthes. Rao and associates (Rao et al, 1986) reported follow-up on 65 patients having a DuToit staple repair of the avulsion of the capsule from the glenoid rim. Two patients showed radiographic evidence of loose staples. Ward et al (Ward et al, 1990) reviewed 33 staple capsulorrhaphies at an average of 50 months post op. Fifty per cent continued to have apprehension and 12 had staple malposition. O'Driscoll and Evans (O'Driscoll and Evans, 1988; O'Driscoll and Evans, 1993) reviewed 269 consecutive DuToit capsulorrhaphies in 257 patients for a median follow-up of 8.8 years. Fifty-three per cent of the patients had postoperative pain. Internal and external rotation were limited. Recurrence was reported in 28 per cent if stapling alone was done and in 8 per cent if a Putti-Platt procedure was added; 11 per cent had staple loosening, migration, or penetration of cartilage. Staple complications contributed to pain, physical restrictions, and osteoarthritis. Zuckerman and Matsen have pointed out that the use of staples for surgical repairs may be associated with major complications. (Zuckerman and Matsen, 1984)

Subscapularis muscle procedures

Putti-Platt Procedure

In 1948 Osmond-Clark (Osmond-Clarke, 1948) described this procedure, which was used by Sir Harry Platt of England and Vittorio Putti of Italy. Platt first used this technique in November 1925. Some years later Osmond-Clarke saw Putti perform essentially the same operation that had been his standard practice since 1923. Scaglietta, one of Putti's pupils, revealed that the operation may well have been performed first by Codivilla, Putti's teacher and predecessor. Neither Putti nor Platt ever described the technique in the literature.

In the Putti-Platt procedure, the subscapularis tendon is divided 2.5 cm from its insertion. The lateral stump of the tendon is attached to the "most convenient soft-tissue structure along the anterior rim of the glenoid cavity." If the capsule and labrum have been stripped from the anterior glenoid and the neck of the scapula, the tendon is sutured to the deep surface of the capsule, and "it is advisable to raw the anterior surface of the neck of the scapula, so that the sutured tendo-capsule will adhere to it." After the lateral tendon stump is secured, the medial muscle stump is lapped over the lateral stump, producing a substantial shortening of the capsule and subscapularis muscle. The exact placement of the lateral stump into the anterior soft tissues and of the medial stump into the greater tuberosity is determined so that, after conclusion of the procedure, the arm should externally rotate to the neutral position. Variations on the Putti-Platt procedure have been described by Blazina and Satzman (Blazina and Satzman, 1969), Watson-Jones (Watson-Jones, 1948), Muller (Muller, 1929) and Symeonides. (Symeonides, 1972)

Quigley and Freedman (Quigley and Freedman, 1974) reported the results of 92 Putti-Platt operations; of these patients, 11 had more than a 30 per cent loss of motion. Seven had recurrent instability after their surgery. Leach and coworkers (Leach et al, 1982) in 1981 reported a series of 78 patients who had been treated with a modified Putti-Platt procedure. Loss of external rotation averaged between 12 and 19 degrees. Collins and associates (Collins et al, 1986) reviewed a series of 58 Putti-Platt procedures and 48 Putti-Platt--Bankart procedures. The redislocation rate was 11 per cent (some because of significant trauma), 20 per cent had residual pain, and the average restriction of external rotation was 20 degrees. Hovelius and colleagues, (Hovelius, Thorling and Fredin, 1979) in a follow-up of 114 patients who underwent either a Bankart or Putti-Platt reconstruction, found a recurrence rate of 2 per cent in 46 patients treated with the Bankart procedure and of 19 per cent in 68 patients treated with a Putti-Platt procedure. The follow-up was between 1.5 and 10 years. Fredriksson and Tegner (Fredriksson and Tegner, 1991) reviewed 101 patients who had had a Putti-Platt procedure with a mean follow-up of approximately 8 years (range, 5 to 14 years). Recurrent instability occurred in 20% of cases and all patients demonstrated a decrease in the range of all measured movements, especially external rotation. Additionally, a significant decrease in strength and power was noted by Cybex dynamometer assessment. The authors noted that the restricted motion following this procedure did not improve with time as previous reports had suggested and concluded that this method of reconstruction should not be recommended for young active patients.

It is important to recognize that if this operation is carried out as described, a 2.5-cm lateral stump of subscapularis tendon is attached to the anterior glenoid. Since the radius of the humerus is approximately 2.5 cm, a 2.5-cm stump of subscapularis fused to the anterior glenoid would limit the total humeral rotation to one radian, or 57 degrees. Angelo and Hawkins (Angelo and Hawkins, 1988; Hawkins and Angelo, 1990a) presented a series of patients who developed osteoarthritis an average of 15 years after a Putti-Platt repair. It is now recognized that limitation of external rotation in repairs for anterior instability is a predisposing factor to capsulorrhaphy arthropathy. (Kronberg and Brostrom, 1990; Lusardi, Wirth, Wurtz et al, 1993)

Magnuson-Stack Procedure

Transfer of the subscapularis tendon from the lesser tuberosity across the bicipital groove to the greater tuberosity was originally described by Paul Magnuson and James Stack in 1940. (Karadimas et al, 1980; Magnuson, 1945; Magnuson and Stack, 1940; Magnuson and Stack, 1943; Miller et al, 1984; Rao, Francis, Hurley et al, 1986) In 1955, Magnuson (Rao, Francis, Hurley et al, 1986) recommended that in some cases the tendon should be transferred not only across the bicipital groove but also distally into an area between the greater tuberosity and the upper shaft. DePalma (DePalma, 1973) recommended that the tendon be transferred to the upper shaft below the greater tuberosity. Karadimas, (Karadimas, Rentis and Varouchas, 1980) in the largest single series of Magnuson-Stack procedures (154 patients), reported a 2 per cent recurrence rate. Badgley and O'Connor (Badgley and O'Connor, 1965) and Bailey (Bailey, 1962-1969) have reported on a combination of the Putti-Platt and the Magnuson-Stack operations; they used the upper half of the subscapularis muscle to perform the Putti-Platt procedure and the lower half of the muscle to perform the Magnuson-Stack procedure.

The complications of the Magnuson-Stack procedure include excessive anterior tightening with posterior subluxation or dislocation, damage to the biceps, and recurrent instability.

Bone block

Eden-Hybbinette Procedure

The Eden-Hybbinette procedure was performed independently by Eden (Eden, 1918) in 1918 and by Hybbinette (Hybbinette, 1932) in 1932. Eden first used tibial grafts, but both authors finally recommended the use of iliac grafts. This procedure is supposed to extend the anterior glenoid. It has been used by Palmer and Widen, (Palmer and Widen, 1948) Lavik, (Lavik, 1961) and Hovelius (Hovelius, Akermark and Albrektsson, 1983) in treating shoulder subluxation and dislocation. Lavik modified the procedure by inserting the graft into the substance of the anterior glenoid rim. Lange (Lange, 1944) inserted the bone graft into an osteotomy on the anterior glenoid. Hehne and Hubner (Hehne and Hubner, 1980) reported a comparison of the Eden-Hybbinette--Lange and the Putti-Platt procedures in 170 patients; their results seemed to favor the latter. Paavolainen and coworkers (Paavolainen et al, 1984) reported on 41 cases of Eden-Hybbinette procedures; 3 had recurrent instability, and external rotation was diminished an average of 10 per cent. They found the results similar to their series of Putti-Platt operations. Ten per cent in each group developed degenerative joint disease!

Niskanen and coworkers (Niskanen et al, 1991) reported a series of 52 shoulders with a mean follow-up of 6 years that had been treated with a modification of the Eden-Hybbinette procedure. The operation involved the creation of a trough through the capsule and into the anteroinferior aspects of the scapula neck. A tricortical iliac crest bone graft was then wedged into the trough without fixation. A 21% recurrence rate was attributed to one spontaneous dislocation and 10 traumatic redislocations. Postoperative arthrosis was noted in nine shoulders and early degenerative changes in an additional 18 shoulders.

Oudard Procedure

In 1924 Oudard (Oudard, 1924) described a method in which the coracoid process was prolonged with a bone graft from the tibia. The graft (4 3 1 cm) was inserted between the sawed-off tip and the remainder of the coracoid and was directed laterally and inferiorly. The graft acted as an anterior buttress that served to prevent recurrent dislocations. Oudard also shortened the subscapular tendon. Later he published another method of obtaining the elongation of the coracoid by performing an oblique osteotomy of the coracoid and displacing the posterolateral portion to serve as a bone block.

Bone blocks are not the procedure of choice for the routine case of recurrent anterior glenohumeral instability. One must be concerned about procedures that may bring the humeral head into contact with bone that is not covered by articular cartilage because of the high risk of degenerative joint disease. Soft tissue repairs and reconstructions are safer and more effective for dealing with the usual case of recurrent traumatic instability. However, when a major anterior glenoid deficiency reduces the anterior or anteroinferior balance stability angle to unacceptably small value, reconstruction of the anterior glenoid lip may be necessary. Matsen(Matsen and Thomas, 1990) has described a technique for using a contoured bone graft to replace the missing glenoid bone covered with joint capsule or other soft tissue in order to offer a smooth surface to articulate with the humeral head.

Coracoid transfer

In the transfer of the coracoid process to the anterior glenoid, an attempt is made to create an anteroinferior musculotendinous sling. Some authors also refer to a bone block effect and an intentional tethering of the subscapularis in front of the glenohumeral joint. Thus it is apparent that these procedures do not address the usual pathology of traumatic instability. The redislocation rates after coracoid transfer for the usual case of traumatic instability are no lower than for soft tissue reconstructions, but the rate of serious complications is substantially higher. Furthermore in contrast to soft tissue procedures, coracoid transfer procedures are extremely difficult and hazardous to revise: the subscapularis, musculocutaneous and axillary nerves are scarred in abnormal positions; the subscapularis muscle is scarred and tethered; and the axillary artery may be displaced in scar tissue.

Trillat Procedure

Trillat and Leclerc-Chalvet (Bodey and Denham, 1983; Noesberger and Mader, 1976; Trillat, 1954; Trillat and Leclerc-Chalvet, 1973) performed an osteotomy at the base of the coracoid process and then displaced the coracoid downward and laterally. The displaced coracoid is held in position by a special nail-pin or screw. The pin is passed into the scapula above the inferiorly displaced subscapularis muscle, which effectively shortens the muscle.

Bristow-Helfet Procedure

This procedure was developed, used, and reported by Arthur Helfet (Helfet, 1958) in 1958 and was named the Bristow operation after his former chief at St. Thomas Hospital, W. Rowley Bristow of South Africa. Helfet originally described detaching the tip of the coracoid process from the scapula just distal to the insertion of the pectoralis minor muscle, leaving the conjoined tendons (i.e., the short head of the biceps and the coracobrachialis) attached. Through a vertical slit in the subscapularis tendon, the joint is exposed and the anterior surface of the neck of the scapula is "rawed up." The coracoid process with its attached tendons is then passed through the slit in the subscapularis and kept in contact with the raw area on the scapula by suturing the conjoined tendon to the cut edges of the subscapularis tendon. Effectively, a subscapularis tenodesis is performed.

In 1958, T. B. McMurray (son of T. P. McMurray of hip osteotomy fame) visited Dr. Newton Mead (Mead and Sweeney, 1964) of Chicago and described modifications of the Bristow operation that were being used in Capetown, Johannesburg, and Pretoria. Mead and Sweeney (Mead and Sweeney, 1964) reported the modifications in over 100 cases. The modifications consist of splitting the subscapularis muscle and tendon unit in line with its fibers to open the joint and firmly securing the coracoid process to the anterior glenoid rim with a screw. May (May, 1970) has modified the Bristow procedure further by vertically dividing the entire subscapularis tendon from the lesser tuberosity; after exploring the joint, he attaches the tip of the coracoid process with the conjoined tendon to the anterior glenoid with a screw. The subscapularis tendon is then split horizontally and reattached--half of the tendon above and half below the transferred conjoined tendon--to the site of its original insertion. Again, the net effect is a tenodesis of the subscapularis.

Helfet (Helfet, 1958) reported that the procedure not only "reinforced" the defective part of the joint but also had a "bone block" effect. Mead, (Mead and Sweeney, 1964) however, does not regard the bone block as being a very important part of the procedure and believes that the transfer adds a muscle reinforcement at the lower anterior aspect of the shoulder joint that prevents the lower portion of the subscapularis muscle from displacing upward as the humerus is abducted. Bonnin (Bonnin, 1969; Bonnin, 1973) has modified the Bristow procedure in the following way: he does not shorten or split the subscapularis muscle tendon unit but for exposure he divides the subscapularis muscle at its muscle-tendon junction and, following the attachment of the coracoid process to the glenoid with a screw, he reattaches the subscapularis on top of the conjoined tendon. Results with this modification in 81 patients have been reported by Hummel and associates. (Hummel et al, 1982)

Torg and coworkers (Torg et al, 1987) reported their experience with 212 cases of the Bristow procedure. In their modification the coracoid was passed over the superior border rather than through the subscapularis. Their postoperative instability rate was 8.5 per cent (3.8 per cent redislocation and 4.7 per cent subluxation). Ten patients required reoperation for screw-related problems; 34 per cent had residual shoulder pain and 8 per cent were unable to do overhead work. Only 16 per cent of athletes were able to return to their preinjury level of throwing. Carol and associates (Carol et al, 1985) reported on the results of the Bristow procedure performed for 32 recurrent dislocating shoulders and 15 "spontaneous" shoulder instabilities. At an average follow-up of 3.7 years, only one patient had recurrent instability and the average limitation of external rotation was 12 degrees. Banas et al (Banas et al, 1993) reported 4% recurrence with a 8.6 year followup; however, additional surgery was required in 14%. Wredmark et al (Wredmark et al, 1992) found only 2 out of 44 recurrent dislocations at an average followup of 6 years, but 28% percent of patients complained of pain. Hovelius and coworkers (Hovelius, Akermark and Albrektsson, 1983) reported follow-up on 111 shoulders treated with the Bristow procedure. At 2.5 years their postoperative instability rate was 13 per cent (6 per cent dislocation and 7 per cent subluxation). External rotation was limited an average of 20 degrees, and 6 per cent required reoperation because of screw-related complications. Muscle strength was 10 per cent less in the operated shoulder. Chen and colleagues (Chen et al, 1984) found that after the Bristow procedure, the reduced strength of the short head of the biceps was compensated for by increased activity in the long head.Other series of Bristow procedures have been reported, each of which emphasizes the potential risks. (Weaver and Derkash, 1994)

Lamm and coworkers (Lamm et al, 1982) and Lemmens and de Waal Malefijt (Lemmens and de Waal Malefitj, 1984) have described four special x-ray projections to evaluate the position of the transplanted coracoid process: anteroposterior, lateral, oblique lateral, and modified axial. Lower and coworkers (Lower et al, 1985) used CT to demonstrate the impingement of a Bristow screw on the head of the humerus. Collins and Wilde (Collins and Wilde, 1973) and Nielsen and associates (Nielsen and Nielsen, 1982) reported that while they had minimal problems with recurrence of dislocation, they did encounter problems with screw breakage, migration, and nonunion of coracoid to scapula. Hovelius and colleagues (Hovelius, 1982; Hovelius et al, 1983) reported only a 50 per cent union rate of the coracoid to the scapula.

Norris and associates (Norris et al, 1987) evaluated 24 patients with failed Bristow repairs; only two had union of the transferred coracoid. Causes of failure included (1) residual subluxation and (2) osteoarthritis from screw or bone impingement or overtight repair. They pointed to the difficulty of reconstructing a shoulder after a failed Bristow procedure. Singer et al (Singer et al, 1995) conducted a 20-year follow-up study of the Bristow-Latarjet procedure; in spite of an average Constant-Murley score of 80 points there was radiographic evidence of degenerative joint disease in 71%.

Ferlic and DiGiovine (Ferlic and DeGiovine, 1988) reported on 51 patients treated with the Bristow procedure. They had a 10% incidence of redislocation or subluxation and a 14% incidence of complications related to the screw. An additional surgical procedure was required in 14% of the patients. In a long-term follow up study of 79 shoulders, Banas and colleagues (Banas, Dalldorf, Sebastianelli et al, 1993) also reported complications necessitating reoperation in 14% of patients. Seventy-three percent of reoperations were for hardware removal secondary to persistent shoulder pain.

There also appears to be a significant problem with recurrent subluxation after the Bristow procedure. (Ferlic and DeGiovine, 1988; Hovelius, Eriksson, Fredin et al, 1983; Mackenzie, 1984; McFie, 1976; Norris, Bigliani and Harris, 1987) Hill and coworkers (Hill et al, 1981) and MacKenzie (Mackenzie, 1980) noted failures to manage subluxation with this procedure. Schauder and Tullos (Schauder and Tullow, 1992) reported 85% good or excellent results with a modified Bristow procedure in 20 shoulders with a minimum 3-year follow-up. Interestingly, the authors attributed the success to healing of the Bankart lesion, since there were many instances in which the position of the transferred coracoid precluded it from containing the humeral head. The authors suggested that the 15% fair or poor results were secondary to persistent or recurrent subluxation.

In 1989, Rockwood and Young (Rockwood and Young, 1989; Young and Rockwood, 1991), reported on 40 patients who had previously been treated with the Bristow procedure. They commented on the danger and the technical difficulty of these repairs. Thirty-one underwent subsequent reconstructive procedures: 10 had a capsular shift reconstruction, four required capsular release, four had total shoulder arthroplasty, one had an arthrodesis, and six had various combined procedures. The authors concluded the Bristow procedure was nonphysiologic and was associated with too many serious complications and recommended that it not be performed for routine anterior reconstruction of the shoulder.

Latarjet Procedure

The Latarjet procedure, (Latarjet, 1958; Latarjet, 1968; Pascoet et al, 1975) described in 1954, involves the transfer of a larger portion of the coracoid process than used with the Bristow procedure with the biceps and coracobrachialis tendons to the anteroinferior aspect of the neck of the scapula. Instead of the raw cut surface of the tip of the coracoid process being attached to the scapula as is done in the Bristow-Helfet procedure, the coracoid is laid flat on the neck of the scapula and held in place with one or two screws. Tagliabue and Esposito (Tagliabue and Esposito, 1980) have reported on the Latarjet procedure in 94 athletes.

Wredmark and colleagues (Wredmark, Tornkvist, Johansson et al, 1992) analyzed 44 patients at an average follow-up of 6 years after a Bristow-Latarjet procedure for recurrent shoulder dislocation. Seventy-two percent of patients had no discomfort, but the remaining 28% complained of moderate exertional pain. Vittori has modified the procedure by turning downward the subscapularis tendon and holding it displaced downward with the transferred coracoid. Pascoet and associates reported on the Vittori modification in 36 patients with one recurrence.

Other open repairs

Gallie procedure

Gallie and LeMesurier (Gallie and LeMesurier, 1927; Gallie and LeMesurier, 1948) originally described the use of autogenous fascia lata to create new ligaments between the anteroinferior aspect of the capsule and the anterior neck of the humerus in 1927. Bateman (Bateman, 1963) of Toronto has also used this procedure. While fascia lata may not be the ideal graft material, the use of exogenous autograft or allograft to reconstruct deficient capsulolabral structures may be necessary in the management of failed previous surgical repairs.

Nicola Procedure

Toufick Nicola's name is usually associated with this operation, but the procedure was first described by Rupp (Rupp, 1926) in 1926 and Heymanowitsch (Heymanowitsch, 1927) in 1927. In 1929, Nicola (Nicola, Ellman, Eckardt et al, 1981) published his first article in which he described the use of the long head of the biceps tendon as a checkrein ligament. The procedure has been modified several times. (Nicola, Ellman, Eckardt et al, 1981; Nicola, 1929b; Nicola, 1942; Nicola, 1949) Recurrence rates have been reported to be between 30 and 50 per cent. (Carpenter and Millard, 1982; Jones, 1940; Weber, 1969)

Saha Procedure

1. K. Saha (Saha, 1961; Saha, 1967; Saha, 1971; Saha, 1973; Saha et al, 1956) has reported on the transfer of the latissimus dorsi posteriorly into the site of the infraspinatus insertion on the greater tuberosity. He reports that, during abduction, the transferred latissimus reinforces the subscapularis muscle and the short posterior steering and depressor muscles by pulling the humeral head backward. He has used the procedure for traumatic and atraumatic dislocations, and in 1969 he reported 45 cases with no recurrence.

Boytchev Procedure

Boytchev first reported this procedure in 1951 in the Italian literature, (Boytchev, 1951; Boytchev et al, 1962) and later modifications were developed by Conforty. (Conforty, 1980) The muscles that attach to the coracoid process along with the tip of the coracoid are rerouted deep to the subscapularis muscle between it and the capsule. The tip of the coracoid with its muscles is then reattached to its base in the anatomical position. Conforty (Conforty, 1980) reported on 17 patients, none of whom had a recurrence of dislocation. Ha'eri and associates( Ha'eri and Maitland, 1981) reported 26 cases with a minimum of two years' follow-up.

Osteotomy of the Proximal Humerus

Debevoise and associates (Debevoise et al, 1971; Kronberg and Brostrom, 1990) stated that humeral torsion is abnormal in the repeatedly dislocating shoulder. B. G. Weber (Kavanaugh, 1978; Miller, Donahue, Good et al, 1984; Rao, Francis, Hurley et al, 1986; Weber, 1969; Weber et al, 1984) of Switzerland reported a rotational osteotomy whereby he increased the retroversion of the humeral head and simultaneously performed an anterior capsulorrhaphy. The indications were a moderate to severe posterior lateral humeral head defect, which he found in 65 per cent of his patients with recurrent anterior instability. By increasing the retroversion, the posterolateral defect is delivered more posteriorly and the anterior undisturbed portion of the articular surface of the humeral head then articulates against the glenoid. It is recognized that the effective articular surface of the humerus is reduced by the posterior lateral head defect, and that the osteotomy repositions the remaining articular surface in a position more compatible with activities of daily living. Weber and colleagues (Weber, Simpson and Hardegger, 1984) reported a redislocation rate of 5.7 per cent with good to excellent results in 90 per cent. Most patients required reoperation for plate removal.

Osteotomy of the Neck of the Glenoid

In 1933, Meyer-Burgdorff reported on decreasing the anterior tilt of the glenoid by a posterior wedge closing osteotomy. (Saha, 1961) Saha has written (Saha, 1961) about an anterior opening wedge osteotomy with bone graft into the neck of the glenoid to decrease the tilt.

Complications of anterior repairs

Complications of surgical repairs for anterior glenohumeral instability may be grouped into several categories. (Lazarus and Harryman, 1996)

Postoperative complications

The first includes complications that may follow any surgical procedure. Of primary importance in this category is postoperative infection. Thorough skin preparation, adhesive plastic drapes, and prophylactic antibiotics are useful in reducing contamination by axillary bacterial flora. It also is important to prevent the accumulation of a significant hematoma by achieving good hemostasis, obliterating any dead space, and using a suction drain if significant bleeding persists. Finally, it is important to keep the axilla clean and dry postoperatively by using a gauze sponge as long as the arm is held at the side.

Postoperative recurrent instability

The second category of complications consists of postoperative recurrent instability. The published incidence of recurrent dislocation after anterior repairs ranges from zero to 30% per cent. It is noteworthy that many of the reports included in their tally only recurrent dislocation, rather than including recurrent subluxation or recurrent apprehension. A 1975 review of 1634 reconstructions compiled from the literature revealed that the incidence of redislocation averaged 3 per cent. (Rockwood, 1984) In a 1983 review of 3076 procedures this incidence was unchanged. (Roca and Ramos-Vertiz, 1962) This review included 432 Putti-Platt operations, 571 Magnuson-Stack operations or modifications, 513 Bankart operations or modifications, 45 Saha operations, 203 Bankart--Putti-Platt combinations, 639 Bristow operations, 115 Badgley combined procedures, 254 Eden-Hybbinette operations, 277 Gallie operations or modifications, and 27 Weber operations.

The incidence of recurrence is underestimated by studies with only two years followup. Morrey and Jones, (Morrey and Janes, 1976) in a long-term follow-up study of 176 patients that averaged 10.2 years, found a redislocation rate of 11 per cent. The operative reconstructions were of the Bankart and Putti-Platt types. In 7 of the 20 patients, redislocation occurred two years or more after surgery. The need for long-term follow-up was further emphasized in a recent study by O'Driscoll and Evans, (O'Driscoll and Evans, 1988) who followed 269 consecutive staple capsulorrhaphies for a minimum of 8.8 years. Twenty-one per cent of 204 shoulders demonstrated redislocation; this incidence increased progressively with the length of follow-up.

Rowe and colleagues (Rowe et al, 1984) reported on the management of 39 patients with recurrence of instability after various surgical repairs. Of 32 who were reoperated, 84 per cent had not had effective repair of the Bankart lesion at the initial surgery. When the previously unrepaired Bankart lesion was repaired at revision surgery, almost all (22 of 24) the shoulders became stable and remained so for at least 2 years. Excessive laxity was thought to be the primary cause of instability in only four shoulders. Ungersbock et al (Ungersbock, Michel and Hertel, 1995) also found that rounded or deficient glenoid rims and large unhealed Bankart lesions were associated with failure of surgical repairs for anterior instability. Zabinski et al reported similar findings: over half of their failed instability repairs were associated with unhealed Bankart lesions; most regained stability after revision repair. (Zabinski et al, 1995) By contrast only nine of the twenty-one shoulders with recurrent multidirectional instability obtained a good/excellent result from revision surgeries.

Refractory instability can be a major problem, whether due to bone deficiency, poor quality soft tissues, musculotendinous failure, or decompensation of neuromuscular control (Fig. 14-157). Richards et al (Richards et al, 1993) have described the challenges associated with trying to manage such cases of refractory or "terminal" instability using glenohumeral arthrodesis.

Failure of diagnosis

The third major category of complications arises from failure of diagnosis. It is essential to differentiate traumatic unidirectional instability (TUBS syndrome) from atraumatic multidirectional instability (AMBRII syndrome) before carrying out any surgical repair. The consequences of mistaking multidirectional instability for pure anterior instability are substantial. In this situation, if only the anterior structures are tightened, limited external rotation along with the resulting obligate posterior subluxation may lead to the rapid loss of glenohumeral articular cartilage and capsulorrhaphyarthropathy. (Hawkins and Angelo, 1990b; Kronberg and Brostrom, 1990; Lusardi, Wirth, Wurtz et al, 1993) This complication can be prevented only by accurate preoperative diagnosis and by appropriate surgery which avoids unnecessary capsular tightening.

The importance of an accurate diagnosis and subsequent treatment cannot be overemphasized: 20 shoulders (53%) in the study of Cooper and Brems (Cooper and Brems, 1992) and 22 shoulders (15%) in the report of Wirth and Rockwood (Wirth, Lyons and Rockwood, 1993) had been previously operated on for mistaken diagnosis. In the latter report, diagnostic errors included (in order of decreasing frequency) rotator cuff disease, biceps tendinitis, thoracic outlet syndrome, and cervical disk herniation.

Neurovascular injuries

The fourth category of operative complications consists of neurovascular injuries. The musculocutaneous nerve runs as a single or multipartite structure obliquely through the coracobrachialis, a variable distance distal to the coracoid process. In this location it may be injured by (1) dissection to free up the coracoid process, (2) retraction, or (3) inclusion in suture. (Shively and Johnson, 1984) Helfet (Helfet, 1958) described one case in which the nerve had a high penetration into the coracobrachialis and became injured where the conjoined tendon entered the slit made in the subscapularis tendon for a Bristow procedure. The axillary nerve may be injured in dissection and suture of the inferior capsule and subscapularis. (Loomer and Graham, 1989) Richards and associates (Richards et al, 1987) presented nine patients sustaining nerve injuries during anterior shoulder repair (three Bristows and six Putti-Platts). Seven involved the musculocutaneous nerve and two the axillary nerve. Two of the nerves were lacerated, five injured by suture, and two injured by traction. These nerve injuries are relatively more common during reoperation after a previous repair; in this situation the nerves are tethered by scar tissue and thus are more difficult to mobilize out of harm's way. Neurovascular complications can best be avoided by good knowledge of local anatomy (including the possible normal variations), good surgical technique, and a healthy respect for the change in position and mobility of the neurovascular structures after a previous surgical procedure in the area. The authors recommend that the axillary nerve be routinely palpated and protected during all anterior reconstructions. (Matsen, Lippitt, Sidles et al, 1994; Rockwood, 1984)

Hardware complications

The fifth category of complications includes those related to hardware inserted about the glenohumeral joint. (Cayford and Tees, 1931; Hawkins et al, 1982) The screw used to fix the coracoid fragment in Bristow procedures has a particular potential for being problematic. (Nielsen and Nielsen, 1982; Quigley and Freedman, 1974) Loosening of the screw may result from rotation of the coracoid fragment as the arm is raised and lowered; this rotation may contribute to screw loosening. Artz and Huffer (Artz and Huffer, 1972) and Fee et al (Fee et al, 1978) have reported a devastating complication in which the screw became loose and caused a false aneurysm of the axillary artery with a subsequent compression of the brachial plexus and paralysis of the upper extremity. Similar complications have been reported as late as three years after surgery. (Fee, McAvoy and Dainko, 1978) In other instances the Bristow screw has damaged the articular surface of the glenoid and humeral head when placed too close to the glenoid lip, irritated the infraspinatus or its nerve when too long, or affected the brachial plexus when it became loose.

Staples used to attach the capsule to the glenoid may miss their target, damaging the humeral or glenoid articular cartilage. Staples also may become loose from repeated pull of the muscles and capsule during shoulder usage, particularly if they were not well seated in the first place. O'Driscoll and Evans (O'Driscoll and Evans, 1988) reported an 11 per cent incidence of staple complications after the DuToit procedure. If screws and staples migrate into the intra-articular region, significant damage to the joint surfaces may result. Metal fixation may injure the biceps tendon in a Magnuson-Stack procedure.

Zuckerman and Matsen (Zuckerman and Matsen, 1984) reported a series of patients with problems related to the use of screws and staples about the glenohumeral joint; 21 had problems related to the Bristow procedure and 14 to the use of staples (either for capsulorrhaphy or subscapularis advancement). The time between placement and symptom onset ranged from 4 weeks to 10 years. Screws and staples had been incorrectly placed in 10 patients, had migrated or loosened in 24, and had fractured in 3. Almost all patients required reoperation, at which time 41 per cent had a significant injury to one or both of the joint surfaces.

Recent attempts to soften the potential complications of hardware with bioabsorbable implants have been reported. However, Edwards and colleagues (Edwards et al, 1994) reported the adverse effects of a polyglyconate polymer in six shoulders after repair of the glenoid labrum. All patients reported increasing pain and loss of motion requiring arthroscopic debridement. Dual-contrast arthrotomography revealed bony cystic changes around the implant, and histologic evaluation was consistent with a granulomatous reaction.

Taken together, these data suggest that primary repairs using hardware are more risky yet no more effective than anatomic soft tissue repairs: the recurrence rates of techniques using screws and staples are no better than with hardware-free repairs. Risks are incurred with hardware that simply do not exist with other repair techniques. The depth and variable orientation of the glenoid at surgery provides substantial opportunity for hardware misplacement (into the joint, under the articular cartilage, subperiosteally, out the back, too high, too low, too medial, too prominent anteriorly, and too insecurely). The large range of motion of the shoulder with frequent vigorous challenges to its stability creates an opportunity for hardware loosening and for irreversible surface and neurovascular damage.

Limited range of motion

The sixth category of complications is limited motion. Limited range of motion, especially external rotation, has been reported after the Magnuson-Stack and the Putti-Platt procedures. It has also been noted after the Bristow procedure, which was supposed to be free of this problem. (Bardenheuer, 1886; Braly and Tullos, 1985; Hill and McLaughlin, 1963) Hovelius and colleagues (Hovelius, Thorling and Fredin, 1979) reported an average loss of external rotation of 21 degrees with the arm in abduction. In their series of 46 patients with continuing problems after shoulder reconstruction, Hawkins and Hawkins (Hawkins and Hawkins, 1985) found that 10 had stiffness related to limited external rotation.

MacDonald and colleagues (MacDonald et al, 1992) described release of the subscapularis muscle in 10 patients who had an internal rotation contracture after shoulder reconstruction for recurrent instability. At an average follow-up of 3 years, all patients reported less pain and demonstrated an average increase of 27° of external rotation.

Lazarus and Harryman (Lazarus and Harryman, 1996) pointed out that each centimeter of surgical lengthening of excessively tightened capsule regains approximately 20° of rotation.

Rockwood et al reported on 19 patients (20 shoulders) who had been treated for severe loss of external rotation of the glenohumeral joint after a previous anterior capsulorrhaphy for recurrent instability. (Lusardi, Wirth, Wurtz et al, 1993) All 20 shoulders were managed by release of the anterior soft tissue. The average increase in external rotation was 45°(range, 25° to 65°).

Secondary degenerative joint disease

The seventh complication is that of capsulorrhaphy arthropathy, or secondary degenerative joint disease resulting from surgery for recurrent instability. (Angelo and Hawkins, 1988; Kronberg and Brostrom, 1990; Lazarus and Harryman, 1996; Lusardi, Wirth, Wurtz et al, 1993; Matsen, Lippitt, Sidles et al, 1994) This condition most commonly arises from excessive surgical tightening of the anterior capsule causing obligate posterior translation with secondary degenerative joint disease (see Fig. 14-48, Fig. 14-50). This condition can be prevented by assuring that the shoulder has a functional range of motion following repair for instability and by performing a surgical release of shoulders with major limitations of external rotation. Severe capsulorrhaphy may require shoulder arthroplasty with normalization of the posteriorly inclined glenoid version. (Kronberg and Brostrom, 1990; Lazarus and Harryman, 1996; Lusardi, Wirth, Wurtz et al, 1993; Matsen, Lippitt, Sidles et al, 1994)

Angelo and Hawkins (Angelo and Hawkins, 1988) reported eight patients with disabling degenerative arthritis presenting an average of 15.1 years after a Putti-Platt procedure. None of the patients had ever gained external rotation beyond zero degrees after their repair. Lusardi et al (Lusardi, Wirth, Wurtz et al, 1993) described 20 shoulders with severe loss of external rotation after anterior capsulorrhaphy and spoke to the risk of posterior subluxation and secondary degenerative joint disease under this circumstance.

Rockwood et al (Lusardi, Wirth, Wurtz et al, 1993) reported on 7 shoulders in which the humeral head had been subluxated or dislocated posteriorly and 16 shoulders had been affected by mild to severe degenerative joint disease after surgical repair for recurrent anterior dislocation. Nine required shoulder arthroplasty because of severe joint surface destruction. At a mean follow-up of 48 months, all shoulders had an improvement in the ratings for pain and range of motion.

Failure of the subscapularis

The eighth complication following surgical repair is failure of the subscapularis. As pointed out by Lazarus and Harryman (Lazarus and Harryman, 1996) the clinical manifestations of subscapularis failure may include pain, weakness of abdominal press and lumbar push off, apprehension or frank instability. A failed subscapularis can sometimes be repaired directly and on other occasions may require a hamstring autograft or allograft.

Rockwood and Wirth (Wirth et al, 1995) reported a series of failed repairs in which the subscapularis was completely disrupted and contracted medially into a dense connective tissue scar that precluded mobilization. Most of the shoulders had undergone multiple previous procedures. The subscapularis deficiency was reconstructed by transfer of either the upper portion of the pectoralis major or the pectoralis minor in five shoulders.

Preferred method of management

The patient with traumatic anterior glenohumeral instability usually has symptoms primarily when the arm is elevated near the coronal plane, extended, and externally rotated. Characteristically the shoulder is relatively asymptomatic in other extreme positions or in midrange positions. Thus, for some patients appropriate management may consist solely of education about the nature of the lesion and identification of the positions and activities that need to be avoided.

Exercise program

Strengthening the shoulder musculature may help prevent the shoulder being forced into positions of instability. The exercise program previously described for atraumatic instability may be considered as an option for traumatic instability as well.

Prescribing surgery

The option of surgical repair is discussed when careful clinical evaluation has documented the diagnosis of refractory anterior instability resulting from an initial episode which was sufficiently traumatic to tear the anterior inferior glenohumeral ligament and which produces significant functional deficits (recurrentapprehension, subluxation, or dislocation) when the arm is in abduction, external rotation, and extension.

The patient desiring surgical stabilization is presented with a frank discussion of the alternatives and the risks of infection, neurovascular injury, stiffness, recurrent instability, pain and the need for revision surgery.

Preparation for surgery

Surgical technique

Goal of surgery

The goal of surgical management of traumatic anterior inferior glenohumeral instability is the safe, secure and anatomic repair of the traumatic lesion, restoring the attachment of the glenohumeral ligaments, capsule, and labrum to the rim of the glenoid from which they were avulsed. By assuring that reattachment occurs to the rim, the effective depth of the glenoid is restored. This anatomic reattachment should reestablish not only the capsuloligamentous check rein but also the fossa-deepening effect of the glenoid labrum. Unnecessary steps are avoided, such as coracoid osteotomy and splitting the subscapularis from the capsule. No attempt is made to modify the normal laxity of the anterior capsule in the usual case of traumatic instability. The repair must be secure from the time of surgery so that it will allow the patient to resume activities of daily living while the repair is healing. Such a secure repair allows controlled mobilization, thereby minimizing the possibility of unwanted stiffness. The tools needed for this repair are simple and commonly available.

Anesthesia

Positioning the patient

The patient is positioned in a slight head-up position (approximately 20 degrees) with the shoulder off the edge of the operating table. This position provides a full range of humeral and scapular mobility, and, if necessary, access to the posterior aspect of the shoulder. The neck, chest, axilla, and entire arm are prepared with iodine solution.

The procedure

The shoulder is approached through the dominant anterior axillary crease which is marked prior to the application of an adherent, transparent plastic drape to facilitate a cosmetically acceptable scar. (Harryman, 1992)

The skin is incised and the subcutaneous tissue are undermined up to the level of the coracoid process, which is then used as a guide to the cephalic vein and the deltopectoral groove. The groove is opened by spreading with the two index fingers medial to the cephalic vein. A neurovascular bundle (a branch of the thoracoacromial artery and the lateral pectoral nerve) is commonly identified in the upper third of the groove;(Grant, 1972) this bundle is cauterized and transected. It is not necessary to release the upper pectoralis major, unless a prominent falciform border extends up to the superior extent of the bicipital groove.

The clavipectoral fascia is incised just lateral to the short head of the biceps, up to but not through the coracoacromial ligament, entering the humeroscapular motion interface and exposing the subjacent subscapularis tendon and lesser tuberosity. The axillary nerve is routinely palpated as it crosses the anteroinferior border of the subscapularis. At this point it is useful to insert a self-retaining retractor, with one blade on the deltoid muscle and the other on the coracoid muscles. Care must be taken to assure the medial limb of this retractor does not compress the brachial plexus. Rotating the arm from internal to external rotation reveals, in succession, the greater tuberosity, the bicipital groove, the lesser tuberosity, and the subscapularis. The anterior humeral circumflex vessels can usually be protected by bluntly dissecting them off of the subscapularis muscle at its inferior border. The interval between the supraspinatus and subscapularis tendons is identified by palpation, and a blunt elevator is inserted through this interval into the joint. This elevator brings the upper subscapularis into the incision. With care to protect the tendon of the biceps, the subscapularis tendon and subjacent capsule are then incised together approximately 1 cm medial to the lesser tuberosity, beginning at the superior rounded edge of the tendon. A tag suture is placed in the upper rolled border of the subscapularis to mark it for subsequent repair. The incision is then extended inferiorly to the level of the anterior circumflex humeral vessels. It is important that the incision through the subscapularis tendon leaves strong tendinous material on both sides of the incision to facilitate a secure repair at the conclusion of the procedure.

Without separating them, the subscapularis tendon and anterior shoulder capsule are retracted medially, providing an excellent view of the joint. If necessary for greater exposure, the joint capsule may be further divided parallel to the upper rolled border of the subscapularis. The biceps tendon is inspected and note taken of the integrity of the transverse humeral ligament. Particularly in patients over 40 years of age the shoulder is inspected for evidence of rotator cuff tears. In traumatic anterior instability, a posterolateral humeral head defect is usually palpable by passing an index finger over the top of the humeral head. If the humeral head defect is so large that it contributes to instability in functional positions, anterior capsular tightening may be necessary to keep the defect from entering the joint on external rotation.

The capsule and subscapularis are retracted together medially and a humeral head retractor is placed so that it leans on the posterior glenoid lip and pushes the humeral head posterolaterally. This reveals the anterior inferior glenoid lip from which the labrum and capsule are avulsed in the great majority of patients with anterior traumatic instability. The labrum usually remains attached to the capsular ligaments but may remain on the glenoid side of the rupture, may be a separate ("bucket handle") fragment, or may be absent. Occasionally flimsy attempts to heal the lesion will temporarily obliterate the defect. However, in these cases a blunt elevator will easily separate the capsule from the glenoid lip, revealing the typical lesion in the anterior-inferior quadrant of the glenoid. A spiked retractor is then placed through the capsular avulsion to expose the glenoid lip. The glenohumeral joint is inspected thoroughly for loose bodies, defects of the bony glenoid, and loss of cartilage from the remaining anterior glenoid.

The reconstruction of the capsulolabral detachment from the glenoid is necessary and sufficient for the surgical management of most cases of traumatic instability. This repair is carried out from inside the joint, without needing to separate the capsule from the subscapularis muscle and tendon. The glenoid is well exposed by a humeral head retractor laterally and a sharp-tipped levering retractor inserted through the capsular defect onto the neck of the glenoid. Bucket handle or flap tears of the glenoid labrum. (Adams, 1891; Barrett, 1971) are preserved for incorporation into the reconstruction of the glenoid lip.

The anterior, non-articular aspect of the glenoid lip is roughened with a curette or a motorized burr, taking care not to compromise the bony strength of the glenoid lip. A 1.8-mm drill is used to make holes on the articular aspect of the glenoid 3 to 4 mm back from the edge of the lip to ensure a sufficiently strong bony bridge. We place these holes 5 to 6 mm apart; thus the size of the defect dictates the number of holes used for the reconstruction. Corresponding slots are placed on the anterior non-articular aspect of the glenoid.Using a 000 angled curette, continuity is established between the corresponding slots and holes.

A strong #2 absorbable braided suture is passed through the holes in the glenoid lip using a trocar needle and an angled needle holder. After each suture is placed through the glenoid lip, the integrity of the bony bridge is checked by a firm pull on the suture.

When sufficient sutures have been placed to span the capsular defect, the sharp-tipped levering retractor is removed and replaced by a right-angled retractor positioned to reveal the trailing medial edge of the avulsed capsule. This edge is most easily identified by tracing the intact labrum around the glenoid to its point of detachment at the Bankart defect. Next, using the trocar needle, the anterior end of the suture (the limb exiting the anterior non-articular aspect of the glenoid lip) is passed through the trailing medial edge of the capsule, taking care to incorporate the glenoid labrum, if present, and the strong medial edge of the capsule. No more capsule is taken than necessary to obtain a firm purchase. This prevents unwanted tightening of the anteroinferior capsule. In larger glenohumeral ligament avulsions, the detached medial edge of the capsule tends to sag inferiorly; in this situation an effort is made to pass each suture through the capsule slightly inferior to the corresponding bony hole in the glenoid lip. Thus, when the sutures are tied, the inferiorly sagging medial capsule is repositioned anatomically.

Once the sutures have been passed through the capsule, they are tied so that the labrum and medial edge of the capsule are brought up on the glenoid lip to restore the fossa-deepening effect of the labrum. (Lazarus, Sidles, Harryman et al, 1996) The knots are tied so that they come to rest over the capsule, rather than on the articular surface of the glenoid. Because they lie over soft tissue, these sutures do not present a mechanical problem, even though they lie within the joint.

Once these sutures are tied, the smooth continuity between the articular surface of the glenoid fossa and the capsule should be reestablished along with a reconstructed labrum-like structure. No stepoff or discontinuity in the capsule should be present. If a substantial anterior capsular defect exists anywhere but at the normal subcoracoid recess, it is closed.

At the conclusion of the surgical repair the capsule and subscapularis tendon are repaired anatomically to their mates at the lesser tuberosity, using the upper rolled border of the subscapularis as a reference. At least six sutures of number two braided non-absorbable suture are used in this repair, assuring good bites in both the medial and lateral aspects of the repair. If the tissue on the lateral side is insufficient, the tendon and capsule are repaired to drill holes at the base of the lesser tuberosity. A strong subscapularis and capsular repair is essential to early rehabilitation. The shoulder should have at least 30 degrees of external rotation at the side after the subscapularis/capsular repair. Once this repair has been completed, the shoulder stability is examined. If excessive anterior laxity remains, for example external rotation in excess of 45° (which is rarely the case), the lateral capsular and subscapularis reattachment may be advanced laterally or superolaterally as desired.

In the highly unusual situation in which a shoulder with the TUBS syndrome is found not to have capsular detachment, the shoulder should be inspected carefully for mid substance capsular defects. If none is found, the anterior instability may be treated by reefing the anterior capsule and the subscapularis tendon. Shortening these structures by 1 cm limits external rotation of the humerus by approximately 20 degrees. Generally, restricting external rotation to 30 degrees at the operating table will permit a very functional shoulder after rehabilitation is complete. If the patient has marked anterior ligamentous laxity, proportionately greater anterior tightening may be necessary, although the surgeon must be certain that the patient does not have multidirectional laxity before a unidirectional tightening is carried out.

A standard wound closure is carried out, using a subcuticular suture, which is removed at three days.

Post-operative recovery and rehabilitation

Recovery

After surgery, most patients are started on a self-conducted '90-0" rehabilitation program with instructions from a physical therapist or a physician. We move the shoulder soon after surgical repair because 1) it has proven safe for the reliable patient, and 2) there is evidence that early motion can increase the ultimate strength of a ligament repair. (Frank, 1996)

Patient post-op limitations

On the day after surgery, five times daily exercises are started, including assisted flexion to 90° and external rotation to 0°. The contralateral arm is used as the assistant until the operated arm can conduct the exercises alone. The patient is allowed to perform many activities of daily living as comfort permits within the 90°/0° range without lifting anything heavier than a glass of water.

Allowed activities include eating and personal hygiene, as well as certain vocational activities, such as writing and keyboarding. Gripping, isometric external rotation, and isometric abduction exercises are started immediately after surgery to minimize effects of disuse. If a patient does not appear able to comply with this restricted use program, the arm is kept in a sling for three weeks, otherwise a sling is used only for comfort between exercise sessions and to protect the arm when the patient is out in public and at night while sleeping. Driving is allowed as early as two weeks after surgery, if the arm can be used actively and comfortably, particularly if the patient's car has automatic transmission and if the operated arm is not used to set the emergency brake.

This rapid return to functional activities is made possible because of the strength of the repair and is encouraged to maintain the shoulder's strength and neuromuscular control. It minimizes the immediate postoperative disability and discomfort without jeopardizing the healing process.

Re-evaluation and rehabilitation

At three weeks the patient should return for an examination and should have at least 90 degrees of elevation and external rotation to zero degrees. From three weeks to six weeks postoperatively, the patient is instructed to increase the range of motion to 140 degrees of elevation and 40 degrees of external rotation. At six weeks after surgery, if there is good evidence of active control of the shoulder, controlled repetitive activities such as swimming and using a rowing machine are instituted to help rebuild coordination, strength, and endurance of the shoulder. More vigorous activities such as basketball, volleyball, throwing, and serving in tennis should not be started until three months and only then if there is excellent strength, endurance, range of motion, and coordination of the shoulder.

Vigilance must be exercised for patients over 35 years of age to be sure that they do not develop unwanted postoperative stiffness. Thus, particularly for these patients, the three week and six week checks are very important to make sure that the ranges of elevation and external rotation are respectively 90 and 0 degrees at three weeks, and 140 and 40 degrees at six weeks.

Efficacy of this program