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Fractures of the anteroinferior aspect of the glenoid rim, known as a bony Bankart lesions, can occur frequently in the setting of traumatic anterior shoulder dislocation. If these lesions are large and are left untreated in active patients, then recurrent glenohumeral instability due to glenoid bone deficiency may occur. Therefore, the clinician must recognize these lesions when they occur and provide appropriate treatment to restore physiological joint stability. This article aims to provide an overview focusing on clinical and technical considerations in the diagnosis and treatment of bony Bankart lesions.

Anterior shoulder dislocations, subluxations, and recurrent instability of the shoulder joint are common problems usually affecting a young active population. However, it can be a problem for patients up to the late decades in life and can lead to major shoulder arthropathy if left untreated or improperly treated. This article discusses the natural history, pathologic morphologic changes of the shoulder joint associated with anterior instability along with normal anatomic variants. We will also discuss current treatment recommendations and possible causes of the patient with recurrent instability despite prior stabilization procedures.

Glenohumeral instability is one of the more common conditions seen by sports medicine physicians, especially in young, active athletes. The associated anatomy of the glenohumeral joint (the shallow nature of the glenoid and the increased motion it allows) make the shoulder more prone to instability events as compared with other joints. Although traumatic dislocations or instability events associated with acute labral tears (ie, Bankart lesions) are well described in the literature, there exists other special shoulder conditions that are also associated with shoulder instability: superior labrum anterior/posterior (SLAP) tears, pan-labral tears, and multidirectional instability. SLAP tears can be difficult to diagnose and arthroscopic diagnosis remains the gold standard. Surgical treatment as ranged from repair to biceps tenodesis with varying reports of success. Along the spectrum of SLAP tears, pan-labral tears consist of 360-degree injuries to the labrum. Patients can present complaining of either anterior or posterior instability alone, making the physical examination and advanced imaging a crucial component of the work up of the patients. Arthroscopic labral repair remains a good initial option for surgical treatment of these conditions. Multidirectional instability remains one of the more difficult conditions for the sports medicine physician to diagnose and treat. Symptoms may only be reported as vague pain versus frank instability making the diagnoses particularly challenging, especially in a patient with overall joint laxity. Conservative management to include physical therapy is the mainstay initial treatment in patients without an identifiable structural abnormality. Surgical management of this condition has evolved from open to arthroscopic capsular shifts with comparable results.

Glenoid and humeral bone loss are well-described risk factors for failure of arthroscopic shoulder stabilization. Recently, consideration of the interactions of these types of bone loss (bipolar bone loss) has been used to determine if a lesion is "on-track" or "off-track." The purpose of this study was to study the relationship of the glenoid track to the outcomes of arthroscopic Bankart reconstructions.Over a 2-year period, 57 shoulders that were treated with an isolated, primary arthroscopic Bankart reconstruction performed at a single facility were included in this study. The mean patient age was 25.5 years (range, 20 to 42 years) at the time of the surgical procedure, and the mean follow-up was 48.3 months (range, 23 to 58 months). Preoperative magnetic resonance imaging was used to determine glenoid bone loss and Hill-Sachs lesion size and location and to measure the glenoid track to classify the shoulders as on-track or off-track. Outcomes were assessed according to shoulder stability on examination and subjective outcome.There were 10 recurrences (18%). Of the 49 on-track patients, 4 (8%) had treatment that failed compared with 6 (75%) of 8 off-track patients (p = 0.0001). Six (60%) of 10 patients with recurrence of instability were off-track compared with 2 (4%) of 47 patients in the stable group (p = 0.0001). The positive predictive value of an off-track measurement was 75% compared with 44% for the predictive value of glenoid bone loss of20%.The application of the glenoid track concept to our cohort was superior to using glenoid bone loss alone with regard to predicting postoperative stability. This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Glenohumeral instability is multifactorial and has both static and dynamic elements. The initial management of first-time dislocations has become increasingly controversial, although recent evidence supports operative treatment for adolescents who participate in contact sports. Risk factors for recurrent glenohumeral instability include adolescent age, hyperlaxity, glenoid bone loss, off-track Hill-Sachs lesions, and fixation with

Anterior glenohumeral instability is a complex problem that requires careful attention to osseous and soft-tissue lesions in order to treat it effectively. The arthroscopic soft-tissue Bankart repair is considered first-line treatment for patients with anterior glenohumeral instability. However, recent long-term outcome studies have shown surprisingly high failure rates, specifically in the setting of anterior glenoid bone loss. The definition of "critical" glenoid bone loss that cannot be overcome by a soft-tissue procedure alone continues to evolve and may in fact be lower than the previously published total of 20%. Arthroscopic reconstruction of the anterior glenoid margin can be performed with either autograft or allograft. The arthroscopic Latarjet procedure has emerged as a reliable and effective technique for autograft augmentation, while the distal aspect of the tibia appears to be a promising source of allograft.

A 39-year-old man presented with 1-year history of shoulder pain, swelling, and limitation of movement. There was a 20-year history of left shoulder and arm numbness. Examination showed decreased vibratory sensitivity on left shoulder, glenohumeral instability, and dislocation. Radiography showed humeral head destruction (figure 1); a spine MRI showed tonsillar herniation and cervical syringomyelia (figure 2). Arthropathy related to syringomyelia was diagnosed.

Treatment of multidirectional glenohumeral instability is a challenge for the orthopaedic surgeon and generally involves nonoperative therapy as the first line of treatment. In patients who fail conservative treatment, successful results can be achieved with open surgery. More recently, there has been increased interest in the use of arthroscopic techniques, including capsular plication, capsular shifting, and thermal modification with the use of laser or radiofrequency devices. Reports have indicated that these arthroscopic techniques can offer good short-term results. However, with longer-term outcome studies showing high long-term failure rates regardless of method, it is necessary to explore other procedural options of providing these patients with some form of relief. We present a salvage procedure involving Achilles tendon allograft reconstruction of the glenohumeral ligament complex in patients with severe multidirectional shoulder instability (most of whom also exhibited an underlying connective tissue disorder) who had previous failed attempts at stabilization using open soft tissue capsular shifting techniques. Although the long-term failure rate of our procedure was high, it did offer significant short-term relief and stability to most patients who stated that they would have the procedure again rather than undergo arthrodesis or replacement.

Both arthroscopic and open surgical repairs are utilized for the management of anterior glenohumeral instability. To determine the evidence supporting the relative effectiveness of these two approaches, we conducted a rigorous and comprehensive analysis of all reports comparing arthroscopic and open repairs.A systematic analysis of eighteen published or presented studies was performed to determine if there were significant differences between the two approaches with regard to recurrence (recurrent dislocation, subluxation, and/or apprehension and/or a reoperation for instability), return to work and/or sports, and Rowe scores. We also performed subgroup analysis to determine if the quality of the study or the arthroscopic technique influenced the results.We identified four randomized controlled trials, ten controlled clinical trials, and four other comparative studies. Results were influenced both by the quality of the study and by the arthroscopic technique. Meta-analysis revealed that, compared with open methods, arthroscopic repairs were associated with significantly higher risks of recurrent instability (p0.00001, relative risk = 2.37, 95% confidence interval = 1.66 to 3.38), recurrent dislocation (p0.0001, relative risk = 2.74, 95% confidence interval = 1.75 to 4.28), and a reoperation (p = 0.002, relative risk = 2.32, 95% confidence interval = 1.35 to 3.99). When considered alone, arthroscopic suture anchor techniques were associated with significantly higher risks of recurrent instability (p = 0.01, relative risk = 2.25, 95% confidence interval = 1.21 to 4.17) and recurrent dislocation (p = 0.004, relative risk = 2.57, 95% confidence interval = 1.35 to 4.92) than were open methods. Arthroscopic approaches were also less effective than open methods with regard to enabling patients to return to work and/or sports (p = 0.03, relative risk = 0.87, 95% confidence interval = 0.77 to 0.99). On the other hand, analysis of the randomized clinical trials indicated that arthroscopic repairs were associated with higher Rowe scores (p = 0.002, standardized mean difference = 0.43, 95% confidence interval = 0.16 to 0.70) than were open methods. Similarly, analysis of the arthroscopic suture anchor techniques alone showed the Rowe scores to be higher (p = 0.04, standardized mean difference = 0.29, 95% confidence interval = 0.01 to 0.56) than those associated with open methods.The available evidence indicates that arthroscopic approaches are not as effective as open approaches in preventing recurrent instability or enabling patients to return to work. Arthroscopic approaches resulted in better function as reflected by the Rowe scores in the randomized clinical trials. The study design and the arthroscopic technique had substantial effects on the results of the analysis.

The prevalence of posterior glenohumeral instability has been estimated to occur in up to 5% of all patients who present with shoulder instability. However, there has been a heightened awareness of this disorder with improvements in physical examination, imaging, and the use of arthroscopy.

During use of the normal shoulder, the humeral head is centered within the glenoid and the coracoacromial arch. When the shoulder cannot maintain this centered position during use, it is unstable. An unstable shoulder prevents normal function of the upper extremity. Shoulder instability is not the same as joint laxity. Joint laxity is a property of normal joints and allows the shoulder to attain its full range of functional positions. The concavity of the glenoid and the coracoacromial arch along with the passive and active forces that press the humeral head into the glenoid and the coracoacromial arch maintain the head in its centered position. This concavity-compression mechanism is dependent on the integrity of the glenoid and the coracoacromial arch, muscular compression, and restraining ligaments of the shoulder. Loss of any of these elements due to developmental, degenerative, traumatic, or iatrogenic factors may compromise the ability of the shoulder to center the humeral head in the glenoid. The questions to answer during an evaluation of a patient with suspected instability are: (1) Is the problem in the glenohumeral joint? (2) Is the problem one of failure to maintain the humeral head in its centered position? (3) What mechanical factors are contributing to this instability? (4) Are the identified mechanical factors amenable to surgical repair or reconstruction? This evaluation is based primarily on a carefully elicited history, a physical examination of the stability mechanics, and plain radiographs. If more complex imaging methods are needed to discover subtle or “occult” instability, the condition is often not responsive to surgical correction. For surgical treatment of glenohumeral instability to be appropriate, the instability must be attributable to mechanical factors that can be modified by surgery. The causes may be deficiencies of the glenoid concavity, deficiencies in the muscles that compress the head into the …

Some patients with Hill-Sachs lesions experience recurrent glenohumeral instability even after anterior capsulolabral repairs. Numerous procedures exist for recurrent anterior instability with large Hill-Sachs lesions but few of these procedures are directly aimed at correcting the lesion it

Background: Glenohumeral instability associated with a large osseous defect of the glenoid can be treated with bone graft to restore the glenoid concavity. The shape and positioning of the graft is critical: a graft that encroaches on the extrapolated glenoid curvature can prevent the head from seating completely in the glenoid, whereas a graft that is too far from the curvature does not restore the glenoid concavity. The purpose of the present study was to investigate how the intrinsic stability that is provided by the glenoid is affected by (1) a standardized anteroinferior glenoid defect and (2) different configurations of anteroinferior glenoid bone graft. Methods: The anteroinferior stability provided by the glenoid was quantitated by measuring the balance stability angle in that direction. The balance stability angle is the maximal angle that the direction of the net humeral joint-reaction force can make with the glenoid centerline before dislocation takes place. The anteroinferior stability was assessed in each of four fresh-frozen, grossly normal cadaveric glenoids in (1) the unaltered state, (2) after the creation of a standardized defect of a magnitude that has been reported by other investigators to be sufficient to require a bone graft, and (3) after each step of a series of bone-grafting procedures involving grafts of varying height and contour. Results: The anteroinferior glenoid defect significantly diminished the anteroinferior stability by almost 50% (p = 0.006). Bone-grafting significantly increased the stability provided by the glenoid. The increase in stability as compared with that of the glenoid with the standardized defect was particularly marked for contoured graft heights of 6 and 8 mm, for which the increases were 150% (p = 0.0001) and 229% (p < 0.00025), respectively. Contouring of the graft minimized the potential for unwanted contact between the ball and the graft. Conclusions: Anteroinferior shoulder instability caused by an osseous defect in the glenoid can be corrected with bone-grafting. The effectiveness of the graft in restoring the lost stability is related both to its height and to the extent to which it is contoured as long as the graft is not so prominent that it forces the ball posteriorly from the center of the glenoid.

Anatomic pathology following shoulder instability includes capsulolabral injury as well as bone defects on both the glenoid and humeral head. The common surgical repairs address the soft tissue labral tears (Bankart lesions) as well as the capsular redundancy that occurs with these injuries.

Traumatic posterior instability may occasionally cause a large osteochondral lesion when the anterior humeral head is compressed against the posterior glenoid rim. This is termed a reverse Hill–Sachs lesion. Such osteochondral defects may be very large in the case of chronic locked dislocati

The contemporary therapeutic approach of glenohumeral instability is directed at the restoration of anatomy. Thermal capsular modification to treat shoulder instability is a relatively recent modality. Early successful clinical applications have led to a wide use of this low demanding technique. Currently, however, the indications for thermal capsulorrhaphy are defined poorly, clinical outcome has not been shown to be superior to conventional stabilization procedures, and long-term effects on joint biology and mechanics are not known. Based on a critical review of the literature and personal clinical experience, the authors conclude that additional experimental and clinical investigations are necessary to add this procedure to the accepted modalities applied for the treatment of shoulder instability.

Anterior glenohumeral instability is a common, yet complicated orthopaedic disorder. During the past few years, basic science research has improved the understanding of the glenohumeral joint stabilizing systems. The current authors review new contributions specifically detailing study of the interplay between the static and dynamic restraints. Simulation of the shoulder muscles in a recent study also has manifested the powerful contribution of the joint reaction force to concavity-compression. Continued advances, such as these, will improve the understanding, and allow better outcome, in treatment of glenohumeral instability.

Management of recurrent anterior glenohumeral instability with bone loss is challenging and may necessitate osseous augmentation.Glenoid and humeral-head osseous deficits should be managed simultaneously when there is severe bipolar bone loss. This is determined on the basis of the size of glenoid b

Complications of surgery for glenohumeral instability are relatively uncommon. When they occur, salvaging failures and obtaining a stable joint can be awesome challenges. Accurate recognition of the cause of the instability and application of the appropriate surgical technique are critical. Deficiencies of the glenoid concavity, the anterior capsule, or the subscapularis may be present and require correction. Overtightening a shoulder and eliminating its normal laxity should be avoided. Loose or malpositioned hardware about the glenohumeral joint must be recognized as soon as possible and removed. The goal of treatment is to correct the deficient stabilizing mechanisms without altering normal glenohumeral function. J Am Acad Orthop Surg 2000;8:122-132

It has been proposed that the long head of the biceps functions as a humeral head depressor and stabilizer. In addition, in many overhead sports, the biceps helps to accelerate and decelerate the arm. With improper training or fatigue, inordinate stresses can be placed on the biceps as it attempts to compensate for other muscles. This can lead to attrition and failure, either within the tendon substance or at its origin. Bicipital problems in athletes usually occur in conjunction with other types of shoulder disorders, such as rotator cuff impingement and glenohumeral instability, making determination of the role and degree of biceps involvement difficult. Conditions affecting the biceps tendon in athletes can be generally classified as degeneration, instability, and disorders of the origin. Because of the close association of biceps lesions with other abnormalities, a thorough evaluation of the shoulder with a suspected biceps disorder is essential. Treatment of bicipital problems in athletes must often be accompanied by treatment of associated shoulder conditions. J Am Acad Orthop Surg 1999;7:300-310

The treatment of glenohumeral instability has changed significantly in the past several years. The introduction of arthroscopic techniques has changed the way in which many physicians approach glenohumeral instability and has allowed a better understanding of the pathology underlying this condition. Although arthroscopy has been a great advance in the treatment of many pathologic processes in the shoulder, arthroscopic treatment for glenohumeral instability continues to present significant challenges. Advances such as arthroscopically placed suture anchors in arthroscopic Bankart reconstruction and thermal capsulorrahaphy show great promise, but continued clinical and basic science research is needed to prove the efficacy and safety of these new techniques. Curr Opin Orthop 1999, 10:310–315 © 1999 Lippincott Williams & Wilkins, Inc.

Historically, much of the literature on glenohumeral instability has concerned recurrent locked anterior glenohumeral dislocation. As the standard objective of operative intervention was the elimination of such a dislocation, many operations yielded a high proportion of successful results. However, increased attention to the special needs of active, athletic individuals has led to a higher standard for the success of operative reconstruction: the maintenance of full motion and strength in addition to the restoration of stability. Modern repair procedures avoid overtightening and emphasize restoration of the integrity of the capsular-ligamentous-labral complex. Although there is controversy as to whether an operation for unidirectional anterior instability should include a capsulorrhaphy in addition to repair of a Bankart lesion, most investigators agree that no more than a minor capsular tightening, with no procedure on bone, is needed for this most common type of shoulder instability60,75,88,100. The situation is understandably more complex in the small number of patients in whom the instability of the shoulder is associated with more severe anatomical distortions. The recognition that symptomatic glenohumeral translations could occur in multiple directions in shoulders with global capsular laxity led to the development of more extensive capsular reconstructions. Furthermore, although capsular and ligamentous structures are usually the major sites of abnormality, in unusual instances severe loss of glenoid bone or a large humeral impression fracture may necessitate operative treatment. Little information is available to guide the clinician in the care of these difficult problems as reports in the literature and discussions at meetings have tended to focus on recurrent anterior glenohumeral instability, especially with regard to the choice between open and arthroscopic techniques. The purpose of the current paper was to review the evaluation and management of patients who have multidirectional instability, major loss of bone from …

The static and dynamic stabilizers of the glenohumeral joint act together to ensure joint stability throughout the wide range of normal shoulder motion. These structures are functionally altered after a traumatic anterior shoulder dislocation, often resulting in recurrent instability. The arthroscope has enhanced the surgeon’s ability to examine and repair the unstable glenohumeral joint. The rate of recurrence of instability after arthroscopic stabilization has historically been unacceptably high compared with that after open stabilization techniques. The authors offer a treatment algorithm and suggest guidelines for the use of arthroscopic techniques in the treatment of the unstable shoulder. J Am Acad Orthop Surg 1997;5:233-239

The Bristow procedure has undergone several modifications since Latarjet's original description in 1954. Throughout all the variations, the main principle remains in that the transferred bone block and muscle unit act as a mechanical buttress and sling to reinforce the weak anterior glenohumeral capsule. Several authors have reported satisfactory follow-up results with low rates of dislocation. However, multiple reports exist of complications involving hardware migration and damage to neurovascular structures. We review our previously reported follow-up on 79 shoulders after an Allman modification of the Bristow procedure at an average postoperative time of 8.6 years. The redislocation rate was 4% with average loss of external rotation of 9 degrees and internal rotation 5 degrees . Fourteen percent of shoulders required reoperation, the majority for screw removal. The likelihood of a quick return to full participation in athletics is good, except for the throwing athlete. The modified Bristow procedure provides excellent long-term stability with minimal loss of external rotation. Intraoperative radiographs are recommended to assure proper bone block placement. Patient satisfaction remains high regarding functional outcome.

In the past several years, our understanding of shoulder instability has evolved and our surgical approaches have correspondingly developed. Our contemporary approaches seek to marry the benefits of a minimally invasive, arthroscopic approach with long-term restoration of shoulder function and a low-risk of recurrence. Despite this evolution, the rate of failure after arthroscopic surgery for shoulder instability remains substantial, and new challenges in the management of failed arthroscopic stabilization surgeries have ascended, including glenohumeral bone loss. Additionally, the expectations regarding out surgical treatments have grown to not just achieve stability for the joint, but to also restore normal or near-normal kinematics and contact mechanics of the shoulder joint. In this regard, understanding the subjective and objective efficacy and complications of both our nonoperative and surgical approaches for primary and revision instability surgery is critical. In this issue, we present a number of primary research articles that address many of the current challenges in complex glenohumeral instability. These include studies evaluating the role of immobilization in external rotation on clinical outcomes and anteroposterior stability, the impact of complex, bipolar bone loss on shoulder stability, and the efficacy of remplissage or Latarjet on restoring function and stability, among many other important topics. This collection of well-designed and insightful manuscripts not only offers us novel considerations as shoulder surgeons, but also serves as a humble reminder of “what we don’t know.” Future studies must work to fill these gaps, and help us to accomplish both shoulder stability and joint preservation with normal preinjury kinematics and function.

A recent analysis of data from the American Board of Orthopaedic Surgery (ABOS) Certification Examination revealed that the use of open Bankart repair for glenohumeral dislocation is declining1. Indeed, the authors of several recent reports have suggested that arthroscopic stabilization for recurrent traumatic anterior shoulder instability with use of modern techniques yields similar recurrence rates to that of open stabilization2-4. Mohtadi et al. called this idea into question and provided evidence to the contrary in a well-powered prospective randomized trial. These authors compared arthroscopic and open stabilization in a large group of patients with recurrent traumatic anterior glenohumeral instability. A particular strength of the study was the matching of surgeons according to …

To The Editor: We read with great interest “Glenoid Rim Morphology in Recurrent Anterior Glenohumeral Instability” (2003:85:878-84), by Sugaya et al. The authors describe a valuable method to evaluate the morphology of the glenoid. As they correctly state, the contour of the inferior part of an unaffected glenoid approximates a circle, and the majority of unstable shoulders have defects in this circle. They suggest that three-dimensionally reconstructed computed tomography is more reliable than other imaging techniques in demonstrating the morphology of the glenoid, although Burkhart et al.1, in an earlier study, reported similar findings with their arthroscopic method. The authors neglect the center of the circle, as it is the bare spot; however, it is a useful point of reference in arthroscopic … Corresponding author: Hiroyuki Sugaya, MD Shoulder and Elbow Service Funabashi Orthopaedic Sports Medicine Center 1-833 Hazama, Funabashi, Chiba 2740822 Japan hsugaya{at}nifty.com

[Introduction][1] Arthroscopic capsulolabral reconstruction via the anteroinferior 5:30 portal allows secure placement of the suture anchors in the lower half of the glenoid and adequate retensioning of the inferior glenohumeral ligament. ![Figure][2] ![Figure][2] [Step 1: Examination Under Anesthesia][3] With the patient under anesthesia, and prior to surgical intervention, assess the direction of glenohumeral instability and the presence of joint hyperlaxity to confirm the repair strategy preoperatively and to determine if additional procedures such as rotator interval closure or inferior capsular plications are needed. [Step 2: Arthroscopic Evaluation and Portal Placement][4] Underestimating the anteroinferior bone loss is one of the most common failures of arthroscopic capsulolabral revision repairs. ![Figure][2] ![Figure][2] ![Figure][2] ![Figure][2] [Step 3: Mobilization of Capsulolabral Complex][5] Mobilize the capsulolabral complex down to the 6:00 position with a bent rasp to create a bleeding surface for biological healing. ![Figure][2] ![Figure][2] [Step 4: Anchor Placement][6] Place anchors at 5:30, 4:30, and 3:00, with additional anchors in the inferior half of the glenoid if more capsular material has to be shifted. ![Figure][2] ![Figure][2] [Step 5: Capsulolabral Shift and Knot Tying][7] A sufficient capsular shift of the anterior band of the inferior glenohumeral ligament at the lowest fixation point (5:30 anchor) is a key step of the procedure. ![Figure][2] ![Figure][2] ![Figure][2] [Step 6: Additional Tissue Reconstruction][8] Consider performing a rotator interval closure in patients with joint hyperlaxity or if a residual “drive through” sign with inferior instability remains after retensioning of the capsulolabral structures. [Step 7: Rehabilitation][9] Start with passive exercises and increase to active-assisted and active exercises. [Results][10] In our study of fifty-six patients treated with arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability, arthroscopic evaluation at the revision repair showed glenoid bone loss measuring up to 10% of the inferior glenoid width due to compression fracture of the glenoid rim in almost 50% of the cases and glenoid bone loss measuring 10% to 20% in about 20% of the cases. [What to Watch For][11] [Indications][12] [Contraindications][13] [Pitfalls & Challenges][14] [Introduction][1] Arthroscopic capsulolabral reconstruction via the anteroinferior 5:30 portal allows secure placement of the suture anchors in the lower half of the glenoid and adequate retensioning of the inferior glenohumeral ligament. ![Figure][2] ![Figure][2] [Step 1: Examination Under Anesthesia][3] With the patient under anesthesia, and prior to surgical intervention, assess the direction of glenohumeral instability and the presence of joint hyperlaxity to confirm the repair strategy preoperatively and to determine if additional procedures such as rotator interval closure or inferior capsular plications are needed. [Step 2: Arthroscopic Evaluation and Portal Placement][4] Underestimating the anteroinferior bone loss is one of the most common failures of arthroscopic capsulolabral revision repairs. ![Figure][2] ![Figure][2] ![Figure][2] ![Figure][2] [Step 3: Mobilization of Capsulolabral Complex][5] Mobilize the capsulolabral complex down to the 6:00 position with a bent rasp to create a bleeding surface for biological healing. ![Figure][2] ![Figure][2] [Step 4: Anchor Placement][6] Place anchors at 5:30, 4:30, and 3:00, with additional anchors in the inferior half of the glenoid if more capsular material has to be shifted. ![Figure][2] ![Figure][2] [Step 5: Capsulolabral Shift and Knot Tying][7] A sufficient capsular shift of the anterior band of the inferior glenohumeral ligament at the lowest fixation point (5:30 anchor) is a key step of the procedure. ![Figure][2] ![Figure][2] ![Figure][2] [Step 6: Additional Tissue Reconstruction][8] Consider performing a rotator interval closure in patients with joint hyperlaxity or if a residual “drive through” sign with inferior instability remains after retensioning of the capsulolabral structures. [Step 7: Rehabilitation][9] Start with passive exercises and increase to active-assisted and active exercises. [Results][10] In our study of fifty-six patients treated with arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability, arthroscopic evaluation at the revision repair showed glenoid bone loss measuring up to 10% of the inferior glenoid width due to compression fracture of the glenoid rim in almost 50% of the cases and glenoid bone loss measuring 10% to 20% in about 20% of the cases. [What to Watch For][11] [Indications][12] [Contraindications][13] [Pitfalls & Challenges][14] [1]: #sec-11 [2]: pending:yes [3]: #sec-12 [4]: #sec-13 [5]: #sec-14 [6]: #sec-15 [7]: #sec-16 [8]: #sec-17 [9]: #sec-18 [10]: #sec-19 [11]: #sec-20 [12]: #sec-21 [13]: #sec-22 [14]: #sec-23

Joseph P. Iannotti and Gerald R. Williams Jr., editors. Illustrations by Jennifer Smith. Philadelphia: Lippincott Williams and Wilkins; 1999. 1141 pages. $295.00. This book has sixty-one contributors and fourteen subsections comprising thirty-eight chapters. The subsections address the topics of rotator cuff disease, glenohumeral instability, frozen shoulder, glenohumeral joint arthritis, fractures, the acromioclavicular joint, the sternoclavicular joint, neuromuscular and scapulothoracic disorders, arthroscopy and imaging, neoplasms, infection, rehabilitation, outcome measurement, and pain management. The overall quality of this book matches the excellence expected from a major publisher. The illustrations, many of which are in color, are voluminous and of high quality. The organization of the individual chapters varies to some degree, but overall the text flows with reasonable consistency. The …

Rockwood and Matsen, along with associate editors Michael A. Wirth and Douglas T. Harryman, II, have appropriately updated the 1990 edition. This second edition consists of two volumes and twenty-eight chapters, by sixty contributors. The aesthetics and quality of the volumes are, as expected of W. B. Saunders, first-rate. The additional feature of a companion CD-ROM provides dynamic visualization of the more complex operative interventions involving the acromioclavicular joint, prosthetic replacement, and glenohumeral instability. The authors have focused on practical approaches to improving the patient's quality of life and, in the process, they have synthesized an enormous amount of information. There is an extensive bibliography; several chapters have more than 400 references. The text covers all of the pertinent issues related to the shoulder, including anatomy and biomechanics; evaluation; anatomical structures such as the scapula, clavicle, and rotator cuff; specific conditions and injuries such as fractures, arthritis, neurological problems, tumors, infections, and muscle tears; amputations; sports-related and occupational injuries; and problems in children. It concludes with a unique chapter on “Effectiveness Evaluation and the Shoulder.” The chapters are well organized. Each begins with an introductory historical review (sometimes dating to antiquity), followed by a discussion of clinical …

The authors of this book describe many of the operative approaches and techniques that have had a high percentage of success in their practices. Operative procedures for the treatment of common problems of the shoulder that are encountered in general orthopaedic practice are presented. The first chapter focuses on anatomy and biomechanics. No details of the histological features of the rotator cuff insertion or the glenoid labrum are given. Acromioplasty is discussed briefly in this chapter, although it is covered more fully later in the book. The remaining six chapters address fracture treatment, osteoarthritis of the glenohumeral joint, rotator cuff repair, glenohumeral instability, muscular disorders, and the shoulder girdle. Many of the radiographs in the section on fractures are almost impossible to visualize, although the accompanying illustrations are excellent. Subacromial decompression during hemiarthroplasty is recommended if the subacromial space is tight. The favorable reports on the use of hemiarthroplasty for the treatment of fractures …

In spite of recent advances in imaging technology, computed arthrotomography continues to be a useful imaging modality for shoulder evaluation. The spatial resolution of computed tomography (CT) and the longer clinical experience continue to provide advantages over magnetic resonance imaging (MRI). Computed arthrotomography remains a simple and reliable method for evaluation of the glenoid labrum in patients with shoulder instability.

Glenohumeral instability refers to subluxation or dislocation of the glenohumeral joint. This painful disorder is particularly common in the athletic population, and the individual with instability may present with a variety of clinical complaints. This paper addresses current theories regarding the pathophysiology of glenohumeral instability and illustrates magnetic resonance findings that can assist in diagnosis and treatment planning.

Recurrent posterior glenohumeral instability is regarded as a difficult problem to diagnose and treat. A careful history and physical examination are the most helpful tools in making this diagnosis. A positive posterior stress test, demonstrable posterior subluxation, and a sulcus sign are frequently present on examination. Special roentgenographic studies, such as the computerized arthrotomography (arthro-CT) scan, may be used in cases in which plain roentgenographs suggest bony glenoid abnormalities. When conservative therapy fails, there is no consensus on the operative treatment. Procedures that address the soft tissues, such as capsulorrhaphy and posterior labral repair, as well as those that alter the bony geometry of the joint, such as posterior bone blocks and glenoid or humeral osteotomies, have been described. Capsular laxity is the most common pathologic finding in the authors' experience, and they favor the use of a posterior-inferior capsular shift procedure to correct this problem. Augmentation of the repair with a posterior bone block is reserved for unusual cases, such as when glenoid hypoplasia is present or in certain revision situations.

Humeral head retroversion and shoulder rotation in both the frontal and scapular plane were studied in 34 patients with anterior glenohumeral instability. Twenty-two patients had traumatic anterior shoulder dislocations and another 12 patients had nontraumatic dislocations with generalized joint laxity. Patients with traumatic recurrent dislocations had a smaller than normal retroversion angle in the unstable shoulder. The angles were 26 degrees on the dominant side and 23 degrees on the nondominant side compared with 33 degrees and 29 degrees, respectively, in normal shoulders. The stable contralateral shoulder joint was clinically and roentgenographically similar to the normal shoulder. The patients with nontraumatic dislocations had increased rotation and smaller retroversion angles, irrespective of stability in the shoulder joint. The retroversion angles were 18 degrees for unstable shoulders on the dominant side and 15 degrees on the nondominant side. The retroversion angle of the stable contralateral joint in these patients was less in five of eight shoulders.

Fifteen male athletes who were skilled in throwing and who had chronic anterior instability of the shoulder (Group 1) were evaluated by dynamic intramuscular electromyography while pitching a baseball. Indwelling wire electrodes recorded the levels of activity in the biceps, middle deltoid, supraspinatus, infraspinatus, pectoralis major, subscapularis, latissimus dorsi, and serratus anterior throughout the entire pitching sequence. These signals were synchronized electronically with records of the pitch that were made using high-speed photography. The pitch was divided into five phases: wind-up, early cocking, late cocking, acceleration, and follow-through. The results were compared with previous identical studies of twelve healthy, uninjured male athletes who were skilled in throwing (Group 2). Activity increased mildly in the biceps and supraspinatus in Group 1 as compared with Group 2. Similar patterns of activity were demonstrated in the deltoid. In Group 1 the infraspinatus had increased activity during early cocking and follow-through but had decreased activity during late cocking. The pectoralis major, subscapularis, latissimus dorsi, and serratus anterior in Group 1 all were shown to have markedly decreased activity. The study revealed a difference between Groups 1 and 2 in all of the muscles of the shoulder that were tested with the exception of the deltoid. The mildly increased activity levels of the biceps and supraspinatus that were found in Group 1 may compensate for anterior laxity. The marked reduction in activity in the pectoralis major, subscapularis, and latissimus dorsi added to the anterior instability by decreasing the normal internal-rotation force that is needed during the phases of late cocking and acceleration.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1976 and 1985, we repaired avulsion of the glenohumeral ligaments in sixty-three shoulders (sixty-one patients) that had traumatic anterior glenohumeral instability. We describe the indications for operation, the operative technique, and the findings at the time of operation. We located thirty-seven patients (thirty-nine shoulders) for clinical follow-up (average, 5.49 years). One patient had recurrent anterior dislocation four years postoperatively, but no patient needed reoperation. The average range of motion was 171 degrees of forward elevation and 84 degrees of external rotation in abduction. According to the criteria of Rowe et al., 97 per cent of the results were good or excellent.

A detailed computer-assisted evaluation of eighty-nine patients whose shoulders were surgically treated for anterior instability was done. Three types of anterior instability of the shoulder were identified: Type I, subluxation without prior dislocation; Type II, recurrent dislocation with interval subluxation; and Type III, recurrent dislocation without interval subluxation. This series included fifty patients with Type-I, twenty-nine with Type-II, and ten patients with Type-III instability. Selected variables from the computer analysis of forty-five preoperative and post-operative parameters were related to the type of instability diagnosed preoperatively. The surgical procedure used in all shoulders was a modification of the Bankart procedure. Chronic glenohumeral instability is a disabling entity which can be controlled by surgical stabilization of the anterior capsule to the glenoid rim.