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Recurrent anterior instability of the shoulder: 5-year results after arthroscopic suture repair
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273
Abstracts
ARTHROSCOPIC TREATMENT OF RECURRENT ANTERIOR SHOULDER DISLOCATION. ANALYSIS OF TECHNICAL CHANGES ON CASPARI PROCEDURE M Marcacci, MD, S, Zaffagnini, MD, F, lacono, MD, A, Petitte, MD, & M. P, Ned, MD, II Orthopaedic Dept,, Rizzoli Orthopaedic Institute : Bologna -ttaly.
J. Shoulder Elbow Surg. March/April 1996 275
RECURRENT ANTERIOR INSTABILITY OF THE SHOULDER: 5-YEAR RESULTS AFTER ARTHROSCOPIC S ~ REPAIR. U.H. Bmnner, E Wiedemann, A. Trupka, P. Habermeyer, Chimrgische Klinik Innenstadt, University of Munich, Germany Artlarosenpic stabillzafian of recurrent anterior shoulder instability provides the advantages of preserving proprieeeption, preventing excessive muscle loss and a fast rehabilitation. Neverthelessthe reported recurrency rates are contradictory. Between 6/1988 and 12/1990 60 patients with recurrent anterior shoulder instability were operated on by 2 different arthroscopic transglenoidal suture techniques. The first 20 by U sutures that were knotted posteriorly and epifascially, the next 40 patients by a ,,3-point suture technique". Posteriorly mulberry knots were burried to the posterior glenoid wail. The two sutures were knotted from anteriorly to support the repositioned labroligamentous complex. 57 of the 60 patients (93%, 42 males, 15 females) were reevaluated 4,5 years postop. (mean) according to Rowe (Unit Rating Score, 100 points). For 3 patients we had a 3 months result. Patients were grouped according to the history into traumatic recurrent dislocations (A), into recurrent traumatic subluxations 03) and into atraumatic recurrent subluxations (C). All had multiple recurrencies.'In group A (n=17) 12 patients (70,5%) had an excellent or good, 2 (11,7%) a fair result and 3 (17,6%) a recurrency (2 after an adequate trauma, no reoperation, one without trauma, no success after two open revisions, Neer). In group B (n=23) 20 patients (86,9*/o) had an excellent or good, 2 (8,7%) a fair result and only one (4,3%) an atraumatic recurreucy (ongoing pain after open revision). In group C (n=17) 13 patients (76,4%) had an excellent or good, 2 (11,7%) a fair result and 2 (11,7%) a recurrency, one traumatic (stabilized by open technique) and one atraumatic (ongoing instability after open stabilization, MDI). Over all 45 patients (79%) showed an excellent or good, 6 (10,5%) a fair result and 6 (10,5%) a recurrency. Two patients with restriction of ext. rotation above 25~ were rated as complications. There were no complicationsby the transglennidal and transcutaneous drilling. The arthroscopic Bankart repair has in our hands still a higher recurrency rate than open stabilization (Bankart-Neer: 3,5%, 5 year resul0. The recnrrency rate did not increase from the 2,5 to the 5 year result. The results seem to depend on the degree (dislocation, subtuxation), and the cause (traumatic. atranmatic) of the preoperative instubility. 3 out of 5 recurrencies had a multidirectianal instability. To improve the results a better patient selection and an additianai arthroscopic capsular tightening procedure are essential.
276
CAPSULAR LAXITY AND RETROVERSION OF THE HUMERAL HEAD IN SHOULDER INSTABILITY. Gohlke F, MOiler Th, Barthel
Caspari technique is, in our opinion, one of the most effective in obtaining a superior shift of the detached ligament, but the success rate reported using this method are still controversial, Caspari had a g6% satisfactory results with a 2-6 years follow-up, but Grana reported only 56% and Wolin 73% success rate. The inhomogeneity among the~e patients can explain the differences in the outcome, but we believe that also modifications in the technique represent important variables. Purpose of this study was to compare result~ of Caspari technique with a personally modified one to evaluate the effectiveness of our technical changes, Arthroscopic treatment was performed on 71 patients with recurrent shoulder dislocations, Patient selection includes only patients with monoplanar anterior instability. Of the 71 operations, 29 were performed using original Caspari technique (follow-up 59 months) and 42 were performed after modifications made in the original technique (follow up 38 months), notably improved preparation of the capsular re-insertion zone, increase in the number of monofilament points and their anchorage directly to the bone, on the spine of the scapula. Comparison of the results obtained in these two differently treated groups was executed analyzing the number of dislocation episodes prior to the operation, as well as clinical, findings regarding, stability, movement, function and pain (Rowe scale score), contralateral shoulder laxity, resumption of sport activity and postoperative recurrence rate, Student test and correlation coefficient test were used for statistical analysis. Clinical results of Caspari treated group were excellent in 48,5%, good in 17.2%, fair in 6.8% and poor in 27.8%. In the modified technique group the results were excellent in 66.6%, good in 23.8%, fair in 4.8% and poor in 4.8%. The recurrence rate was 27% in the first group compare to 4.8% of the second one. These data were statistically significant. No correlation was found between pro-operative number of dislocation and recurrence rate as well as for contralateral shoulder laxity, No significant difference was found regarding resumption of sport activity in the two groups. Our data indicate that with accuracy in patient selection and improving the effeervness of the surgical technique with a bony fixatiori to the spirle of the scapula the recurrence rate cat1 be reduced obtaining clinical results similar to the arthrotomic technique with less morbidity.
274
ARTHROSCOPIC BANKART REPAIR: THE EFFECT OF IMMOBILIZATION ON REDISLOCATION Raymond Thai, M.D., Marc Danziger, NLD., Thomas Neviasur, M.D., Thomas B. Fleeter, M.D., 1800 Town Canter Dr., Suite 111, Restonr Virginia 22090 This study is a retrospective review of 61 patients who underwent an arthroseopic Bankart repair for anterior shoulder instability An arthroscopic transglenoid suture repair, as described by Caspari, was used in all cases. Differences in length of post-operative immobilization allowed us to divide these patients into 2 groups, forming the basis of comparison in this study. Group 1 consisted ot"34 patients who were immobilized for three weeks postoperatively and then begun on an exercise program. Follow-up averaged 30.6 months. Group 2 included 27 patients who were immobilized for six weeks, except for pendulum exercises which were allowed in the fifth and sixth week. Follow-up averaged 24.4 months. The two groups were comparable with respect to age, sex, dominant extremity, traumatic cause of initial dislocation, number of preoperative dislocations, associated findings at surgery, number of sutures used, and side of dislocation. Fourteen of the 34 patients from Group 1 redislocated (41%), while only three of the 27 from Group 2 (11%) did. Range of motion at final follow-up was comparable in both groups. We observed a decreased postoperative dislocation rate in patients immobilized for six weeks (11%) compared with a 41% redislocafion rate in those patients immobiliz~t for only three weeks alter an arthroscopic Bankart procedure. The increased time ofinmaobihzation did not adversely affect range of motion and achieved 89% good or excellent results as measured by the UCLA and Rowe rating scales.
Th, Schindfer G*, Eulert J. Department of Orthopaedics, and Department of Diagnostic Radiology* University of WOczburg, Germany Pieper et al (1985) and Kronberg et al (1989) reported that the retroversion of the humeral head is abnormal in cases of anterior instability and made the assumption that this may alter the balance of muscle forces and lead to an gradual enlargement of the anterior capsule. PURPOSE: Prospective evaluation of capsular laxity in posttraumatic anterior recurrent dislocation and the relationship to lesions found intraoperatively or in the double-contrast CT and to retroversion of the humeral head. METHODS: In 40 patients with posttraumatic anterior instability (mean age 29,5 years, male 37 - female 3) the results of radiographic examination (including the Bernageau and Kronberg projection), of double-contrast CT (including evaluation of retroversion of the humeral head measured according to Saha/Laumann), and of standardized examination under anaesthesia (according te Cofield et al. 1987) were compared to the intraoperative findings. RESULTS: Intraoperatively a Hill-Sachs lesion was present In 90 % (n=36), a bony Bankart-lesion in 52,5% (n=21), lesions of the anterior labrum in 95% (n=38) and an avulsion of the humeral insertion of the anterior capsule in 5% (n=2) of the cases. The humeral retroversion of the unstable shoulders (mean: 17 ~ was slightly reduced (significant, p<0.05) compared to the contralateral side (mean: 22~ which is in our opinion due to failures of measurements because of the presence of Hill-Sachs lesions. The retroversion angle measured by the radiographic Kronberg-projection showed a poor correlation to the angle in the CT-scan presumably due to projection failures. There was no significant correlation of the retroversion angle to the amount of capsular laxity.
273
Abstracts
ARTHROSCOPIC TREATMENT OF RECURRENT ANTERIOR SHOULDER DISLOCATION. ANALYSIS OF TECHNICAL CHANGES ON CASPARI PROCEDURE M Marcacci, MD, S, Zaffagnini, MD, F, lacono, MD, A, Petitte, MD, & M. P, Ned, MD, II Orthopaedic Dept,, Rizzoli Orthopaedic Institute : Bologna -ttaly.
J. Shoulder Elbow Surg. March/April 1996 275
RECURRENT ANTERIOR INSTABILITY OF THE SHOULDER: 5-YEAR RESULTS AFTER ARTHROSCOPIC S ~ REPAIR. U.H. Bmnner, E Wiedemann, A. Trupka, P. Habermeyer, Chimrgische Klinik Innenstadt, University of Munich, Germany Artlarosenpic stabillzafian of recurrent anterior shoulder instability provides the advantages of preserving proprieeeption, preventing excessive muscle loss and a fast rehabilitation. Neverthelessthe reported recurrency rates are contradictory. Between 6/1988 and 12/1990 60 patients with recurrent anterior shoulder instability were operated on by 2 different arthroscopic transglenoidal suture techniques. The first 20 by U sutures that were knotted posteriorly and epifascially, the next 40 patients by a ,,3-point suture technique". Posteriorly mulberry knots were burried to the posterior glenoid wail. The two sutures were knotted from anteriorly to support the repositioned labroligamentous complex. 57 of the 60 patients (93%, 42 males, 15 females) were reevaluated 4,5 years postop. (mean) according to Rowe (Unit Rating Score, 100 points). For 3 patients we had a 3 months result. Patients were grouped according to the history into traumatic recurrent dislocations (A), into recurrent traumatic subluxations 03) and into atraumatic recurrent subluxations (C). All had multiple recurrencies.'In group A (n=17) 12 patients (70,5%) had an excellent or good, 2 (11,7%) a fair result and 3 (17,6%) a recurrency (2 after an adequate trauma, no reoperation, one without trauma, no success after two open revisions, Neer). In group B (n=23) 20 patients (86,9*/o) had an excellent or good, 2 (8,7%) a fair result and only one (4,3%) an atraumatic recurreucy (ongoing pain after open revision). In group C (n=17) 13 patients (76,4%) had an excellent or good, 2 (11,7%) a fair result and 2 (11,7%) a recurrency, one traumatic (stabilized by open technique) and one atraumatic (ongoing instability after open stabilization, MDI). Over all 45 patients (79%) showed an excellent or good, 6 (10,5%) a fair result and 6 (10,5%) a recurrency. Two patients with restriction of ext. rotation above 25~ were rated as complications. There were no complicationsby the transglennidal and transcutaneous drilling. The arthroscopic Bankart repair has in our hands still a higher recurrency rate than open stabilization (Bankart-Neer: 3,5%, 5 year resul0. The recnrrency rate did not increase from the 2,5 to the 5 year result. The results seem to depend on the degree (dislocation, subtuxation), and the cause (traumatic. atranmatic) of the preoperative instubility. 3 out of 5 recurrencies had a multidirectianal instability. To improve the results a better patient selection and an additianai arthroscopic capsular tightening procedure are essential.
276
CAPSULAR LAXITY AND RETROVERSION OF THE HUMERAL HEAD IN SHOULDER INSTABILITY. Gohlke F, MOiler Th, Barthel
Caspari technique is, in our opinion, one of the most effective in obtaining a superior shift of the detached ligament, but the success rate reported using this method are still controversial, Caspari had a g6% satisfactory results with a 2-6 years follow-up, but Grana reported only 56% and Wolin 73% success rate. The inhomogeneity among the~e patients can explain the differences in the outcome, but we believe that also modifications in the technique represent important variables. Purpose of this study was to compare result~ of Caspari technique with a personally modified one to evaluate the effectiveness of our technical changes, Arthroscopic treatment was performed on 71 patients with recurrent shoulder dislocations, Patient selection includes only patients with monoplanar anterior instability. Of the 71 operations, 29 were performed using original Caspari technique (follow-up 59 months) and 42 were performed after modifications made in the original technique (follow up 38 months), notably improved preparation of the capsular re-insertion zone, increase in the number of monofilament points and their anchorage directly to the bone, on the spine of the scapula. Comparison of the results obtained in these two differently treated groups was executed analyzing the number of dislocation episodes prior to the operation, as well as clinical, findings regarding, stability, movement, function and pain (Rowe scale score), contralateral shoulder laxity, resumption of sport activity and postoperative recurrence rate, Student test and correlation coefficient test were used for statistical analysis. Clinical results of Caspari treated group were excellent in 48,5%, good in 17.2%, fair in 6.8% and poor in 27.8%. In the modified technique group the results were excellent in 66.6%, good in 23.8%, fair in 4.8% and poor in 4.8%. The recurrence rate was 27% in the first group compare to 4.8% of the second one. These data were statistically significant. No correlation was found between pro-operative number of dislocation and recurrence rate as well as for contralateral shoulder laxity, No significant difference was found regarding resumption of sport activity in the two groups. Our data indicate that with accuracy in patient selection and improving the effeervness of the surgical technique with a bony fixatiori to the spirle of the scapula the recurrence rate cat1 be reduced obtaining clinical results similar to the arthrotomic technique with less morbidity.
274
ARTHROSCOPIC BANKART REPAIR: THE EFFECT OF IMMOBILIZATION ON REDISLOCATION Raymond Thai, M.D., Marc Danziger, NLD., Thomas Neviasur, M.D., Thomas B. Fleeter, M.D., 1800 Town Canter Dr., Suite 111, Restonr Virginia 22090 This study is a retrospective review of 61 patients who underwent an arthroseopic Bankart repair for anterior shoulder instability An arthroscopic transglenoid suture repair, as described by Caspari, was used in all cases. Differences in length of post-operative immobilization allowed us to divide these patients into 2 groups, forming the basis of comparison in this study. Group 1 consisted ot"34 patients who were immobilized for three weeks postoperatively and then begun on an exercise program. Follow-up averaged 30.6 months. Group 2 included 27 patients who were immobilized for six weeks, except for pendulum exercises which were allowed in the fifth and sixth week. Follow-up averaged 24.4 months. The two groups were comparable with respect to age, sex, dominant extremity, traumatic cause of initial dislocation, number of preoperative dislocations, associated findings at surgery, number of sutures used, and side of dislocation. Fourteen of the 34 patients from Group 1 redislocated (41%), while only three of the 27 from Group 2 (11%) did. Range of motion at final follow-up was comparable in both groups. We observed a decreased postoperative dislocation rate in patients immobilized for six weeks (11%) compared with a 41% redislocafion rate in those patients immobiliz~t for only three weeks alter an arthroscopic Bankart procedure. The increased time ofinmaobihzation did not adversely affect range of motion and achieved 89% good or excellent results as measured by the UCLA and Rowe rating scales.
Th, Schindfer G*, Eulert J. Department of Orthopaedics, and Department of Diagnostic Radiology* University of WOczburg, Germany Pieper et al (1985) and Kronberg et al (1989) reported that the retroversion of the humeral head is abnormal in cases of anterior instability and made the assumption that this may alter the balance of muscle forces and lead to an gradual enlargement of the anterior capsule. PURPOSE: Prospective evaluation of capsular laxity in posttraumatic anterior recurrent dislocation and the relationship to lesions found intraoperatively or in the double-contrast CT and to retroversion of the humeral head. METHODS: In 40 patients with posttraumatic anterior instability (mean age 29,5 years, male 37 - female 3) the results of radiographic examination (including the Bernageau and Kronberg projection), of double-contrast CT (including evaluation of retroversion of the humeral head measured according to Saha/Laumann), and of standardized examination under anaesthesia (according te Cofield et al. 1987) were compared to the intraoperative findings. RESULTS: Intraoperatively a Hill-Sachs lesion was present In 90 % (n=36), a bony Bankart-lesion in 52,5% (n=21), lesions of the anterior labrum in 95% (n=38) and an avulsion of the humeral insertion of the anterior capsule in 5% (n=2) of the cases. The humeral retroversion of the unstable shoulders (mean: 17 ~ was slightly reduced (significant, p<0.05) compared to the contralateral side (mean: 22~ which is in our opinion due to failures of measurements because of the presence of Hill-Sachs lesions. The retroversion angle measured by the radiographic Kronberg-projection showed a poor correlation to the angle in the CT-scan presumably due to projection failures. There was no significant correlation of the retroversion angle to the amount of capsular laxity.