SHOULDER INSTABILITY

Ovid: Chapman’s Orthopaedic Surgery

Editors: Chapman, Michael W.
Title: Chapman’s Orthopaedic Surgery, 3rd Edition
> Table of Contents > SECTION IV – SPORTS MEDICINE > Shoulder > CHAPTER 80 – SHOULDER INSTABILITY

CHAPTER 80
SHOULDER INSTABILITY
Deryk Jones
Jon J.P. Warner
D. Jones: Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana 70012.
J. J. P. Warner: Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts 02114.
Historically, treatment of shoulder instability has
focused on constraining the joint through soft-tissue reconstruction,
which often has distorted anatomy instead of anatomically repairing the
primary lesion of an injured capsule or labrum. Foremost examples of
these reconstructive techniques include transfer of the subscapularis
(Magnuson-Stack), imbrication of the subscapularis and capsule
(Putti-Platt), and transfer of the coracoid process and conjoined
tendon (Bristow-Latarjet). As surgeons have developed a better
understanding of the functional anatomy of the shoulder, treatment of
shoulder instability has relied on anatomic restoration.
ANATOMY AND PATHOPHYSIOLOGY
Despite an articular mismatch resulting in only 25% to
30% glenohumeral contact at any one angle, stereophotogrammetric
studies show close congruency between the articular surfaces of the
glenoid cavity and the humeral head (148).
Notwithstanding a flat radiographic appearance of the glenoid, the
varying cartilage thickness on its surface allows a close
concavity–convexity match to the humeral head, which provides stability
through dynamic contraction of the rotator cuff. It has been termed the
concavity-compression mechanism of stability and is described in further detail below (88,89).
Conditions affecting this precise relationship may clinically manifest as instability (Table 80.1). Examples include congenital dysplasia of the glenoid or humeral surfaces and glenoid fractures (Fig. 80.1).
These conditions disrupt the concavity-compression effect by decreasing
the surface area of contact and disrupting the close congruent

P.2142



fit of articular surfaces (18,55,182).
Similarly, large Hill–Sachs or reverse Hill–Sachs lesions,
posterolateral or anterolateral humeral head impaction fractures
respectively, can affect this articular relationship (Fig. 80.2) (22,131,133,134).
These fractures are created by direct contact between the humeral head
and the glenoid rim during shoulder dislocations. While these lesions
are present in more than 80% of anterior dislocations and 25% of
anterior subluxations, they are rarely a contributing factor to
instability. They become biomechanically relevant to joint stability
when osteoarticular loss involves greater than 30% of the humeral head
surface.

Figure 80.1. Axial CT demonstrates a significant bony Bankart lesion with disruption of the concavity-compression mechanism.
Figure 80.2. Axial MRI with contrast demonstrates anterior capsular stripping (large curved arrows) with an associated Bankart lesion. In addition, a large Hill–Sachs lesion can be seen posteriorly (smaller straight arrows).
A fibrocartilaginous ring, the glenoid labrum, lines the
glenoid cavity and contributes to glenohumeral stability by three
mechanisms:
It acts as a “chock block” to humeral head translation (71).
It acts as a point of attachment for the glenohumeral

P.2143



ligaments and the long head of the biceps brachii (102,158).

It increases the surface area and the depth of the
glenoid cavity, improving the conforming fit of the humeral head within
the glenoid (47).
Avulsion of the glenoid labrum (Bankart lesion) has been
implicated as the primary lesion associated with traumatic anterior
shoulder dislocation (186,187).
Because variability in the anatomy of the labrum is considerable, it is
important to distinguish between true labral detachment and a variation
of normal anatomy (31,181).
As a rule, the labrum is often loosely attached to the glenoid rim
above the equator of the glenoid cavity, and in fact there may be
little or no labrum present along the anterosuperior glenoid rim. This
anatomic variant has been termed a sublabral foramen (hole) (Fig. 80.3).
Figure 80.3.
Arthroscopic view through a posterior portal demonstrates an anatomic
variant of the anterior glenoid labrum referred to as a sublabral hole.
This should not be confused with a true Bankart lesion or a superior
labrum anterior posterior (SLAP) lesion. (From Warner JJP, Warren RF.
Arthroscopic Bankart Repair Using a Cannulated Absorbable Fixation
Device. Oper Tech Orthop 1991;1:192, with permission.)
Below the equator of the glenoid, the labrum is securely
attached to the glenoid rim and is actually a fibrocartilaginous
transition zone to the glenohumeral ligaments. It functionally deepens
the glenoid fossa, thus enhancing the concavity-compression mechanism
of stability. Detachment of the glenoid labrum below the equator of the
glenoid represents a functional disruption of the origin of the
inferior glenohumeral ligament (IGHL), as well as a decrease in the
concavity of the glenoid cavity.
The glenohumeral capsuloligamentous complex is
characterized by collagenous thickenings of varying development in its
anterior portion (Fig. 80.4) (11,13). These thick bands are called the glenohumeral ligaments due to their location along the glenoid rim. Table 80.1
shows the specific functional role of each ligament and the resulting
pathology when each is injured. These ligaments and their interposed
capsule are normally lax when the shoulder is positioned in the mid
range of rotation. The rotator cuff muscles and long head of the biceps
tendon (dynamic stabilizers) create the important concavity-compression
effect (described below) that maintains stability (116,126,172).
Figure 80.4. Arthroscopic view demonstrates normal anterior capsular ligamentous anatomy as viewed through a posterior arthroscopic portal (H.H., humeral head; G, glenoid; B, biceps tendon; S.G.H.L., superior glenohumeral ligament; S.S., subscapularis; M.G.H.L., middle glenohumeral ligament; I.G.H.L.,
inferior glenohumeral ligament). (From Turkel SJ, Panio MW, Marshall
JL, Girgis FG. Stabilizing Mechanisms Preventing Anterior Dislocation
of the Glenohumeral Joint. J Bone Joint Surg [Am] 1981;63:1209, with permission.)
Table 80.1. Glenohumeral Stability

P.2144


As the arm is rotated toward its end range, the
glenohumeral ligaments function in a reciprocal fashion, acting as
checkreins to prevent excessive humeral head translation at the
extremes of motion (37,113,114 and 115,160). O’ Brien et al. (113,114)
compared the IGHL to a hammock; its anterior and posterior bands should
tighten at terminal external rotation with the arm abducted 90° (Fig. 80.5).
In addition to their action as static restraints to excessive
translation and rotation, the capsuloligamentous structures may also
have a proprioceptive role (85,173).
It has been postulated that stretch and motion receptors within the
glenohumeral capsule and ligaments relay proprioceptive feedback to the
dynamic muscle stabilizers, thus acting as an afferent feedback loop to
modulate muscle activity about this joint during active motion.
Figure 80.5. The IGHL controls glenohumeral instability in a manner analogous to a hammock. A: With the arm in 90° of abduction, the IGHL supports the humeral head inferiorly. B: With external rotation, the anterior band of the ligament prevents anterior translation of the humeral head. C:
The posterior band functions in a similar fashion with internal
rotation to prevent posterior translation of the humeral head. (From
Warner JJP, Caborn DN. Overview of Shoulder Instability. Crit Rev Phys Rehabil Med 1992;4:145, with permission.)
A clear understanding of normal glenohumeral capsular
anatomy is essential for surgeons who seek to reestablish anatomy in an
unstable shoulder (171). Procedures that repair
the soft tissues while the joint is positioned in the mid range of
motion shorten the capsuloligamentous complex. As a result, the joint
may be captured, preventing full external rotation, an outcome
associated with the development of early arthritis (59,61).
Another important characteristic of the glenohumeral
joint is the presence of negative (less than atmospheric)
intraarticular pressure. This condition results from high osmotic
pressure in the interstitial tissue, which draws water from the joint (94).
Any force that tends to displace the humeral head away from the glenoid
increases this vacuum effect resisting further humeral head
displacement. This effect is clinically relevant when the arm is
hanging at the side and the muscles of the shoulder are relaxed (19,53,82,169).
Conditions that disrupt this vacuum effect include capsular rupture,
intraarticular fracture, developmental or acquired capsular defects
(i.e., rotator interval lesion or capsular rupture), or a large,
capacious capsule (45,169).
The rotator interval has increasingly been associated with clinical instability (72).
This region of the capsule is a triangular space whose base is located
near the coracoid process and its apex near the biceps sulcus (Fig. 80.6).
The interval is bordered superiorly by the anterior margin of the
supraspinatus tendon and inferiorly by the superior border of the
subscapularis tendon. The area is completely bridged by capsule and
supplemented by the coracohumeral and the superior glenohumeral
ligaments. A deficiency

P.2145


of
these ligaments and communication of the joint with the subdeltoid
space lead to a significant sulcus sign (inferior laxity) (described
later).

Figure 80.6.
Anatomy of the rotator interval. Injury to this region is associated
with an increased sulcus sign with the arm at the side that does not
decrease with full external rotation. (From Zarins B. Bankart Repair
for Anterior Shoulder Instability. Tech Orthop 1989;3:23, with permission.)
The rotator cuff is a musculotendinous complex
consisting of the teres minor, infraspinatus, supraspinatus, and
subscapularis muscles. These muscles encircle the glenohumeral joint,
and their insertion sites are broadly intermeshed with the underlying
joint capsule (29,32,34).
These intrinsic muscles have relatively short lever arms and pass close
to the axis of rotation of the joint. As a result, they act more as
primary stabilizers than as primary movers of the glenohumeral joint.
The net effect of contraction of the rotator cuff muscles is to create
a compressive load across the glenohumeral joint. This load steers the
humeral head into the glenoid fossa, creating the concavity-compression
mechanism (Fig. 80.7) (14,17,71,88,125,135,161).
Figure 80.7. The dynamic stability provided by the rotator cuff muscles produces a concavity-compression mechanism.
Injury to the rotator cuff can result from a single
macrotrauma that exceeds the ultimate failure strength of the
tendon(s). Alternatively, injury can be the result of repetitive
submaximal loads that cumulatively disrupt the tendon fibers. Each
scenario can be associated with actual shoulder instability. In
individuals older than 40 years, the tensile properties of the rotator
cuff tendons tend to deteriorate more rapidly than those of the
glenohumeral capsule and ligaments. As a result, patients in this age
group have a high incidence of rotator cuff tears associated with a
traumatic shoulder dislocation (108,147).
Conversely, a young athlete who throws or swims may
subject the shoulder to repetitive forces that cause gradual injury to
the rotator cuff. For example, subtle degrees of shoulder subluxation
may occur with repetitive motions such as in swimming. The
capsuloligamentous tissues may stretch, and the joint may become more
lax. An overload of the rotator cuff muscles can occur. The active
(eccentric) contraction of the rotator cuff, which decelerates the
humeral head during the swimming stroke or throwing motion, has been
associated with rotator cuff injury (20).
The long head of the biceps brachii dynamically stabilizes the glenohumeral joint (73,74,75 and 76,126,174).
Contraction markedly limits anterior and superior translation of the
glenohumeral joint, increases torsional rigidity of the joint, and
decreases strain in the IGHL. Clinical experience based on arthroscopic
observations has demonstrated a correlation between shoulder
instability and the presence of the superior labral anterior posterior
(SLAP) lesion (145,172). This injury pattern represents a detachment of the origin of the long head of the biceps.
CLASSIFICATION
We use a classification system originally proposed by
the Hospital for Special Surgery. The system categorizes patients with
shoulder instability on the basis of four criteria: frequency, cause,
direction, and degree (Table 80.2) (33,142,187).
Table 80.2. Shoulder Instability Classification
The instability itself may be acute or chronic, the differentiating feature being whether the event occurred within

P.2146



the previous 24 hours. The number of recurrences (frequency of instability)
is also critical in this classification scheme, as it contributes to
the level of damage to anatomic structures. This characteristic is
extremely important when taken into consideration along with the degree
and cause of the instability. This component of the history is critical
in determining the appropriate treatment.

Etiology is subdivided into
traumatic, microtraumatic, and atraumatic groups but also includes
congenital and neuromuscular causes. The atraumatic group includes
patients who exhibit a voluntary component. In this classification,
these patients can be further subdivided into group I: voluntary instability, which is arm-position-dependent and usually posterior; and group II:
voluntary instability exhibited by an ability to selectively contract
muscles, causing a dislocation. While patients in group I can
voluntarily demonstrate their instability, they choose to avoid
dangerous arm positions. This condition subsequently affects activities
of daily living (142). Conversely, patients in
group II tend to have an underlying psychiatric problem, using their
instability as a means to control their environment (132).
The degree of instability is
also important in determining appropriate treatment options.
Dislocation refers to complete dissociation of the articular surfaces
of the humeral head and glenoid cavity. Subluxation describes increased
humeral head translation within the glenoid cavity. Initial open
procedures focused on the treatment of true glenohumeral dislocation.
Arthroscopic evaluation has heightened the awareness of subtle labral,
articular, and ligamentous damage that occurs because of unrecognized,
recurrent episodes of subluxation (7,22,24,68,112).
The direction of instability
has been a critical component of most classification systems.
Traditionally, there was an assumption that 95% of shoulder instability
was anterior (25). It has become increasingly
apparent, however, that many athletes with ligamentous laxity have
instability that is primarily posterior in nature (48,49,156,178).
These patients suffer recurrent posterior subluxation and have a
history of posterior shoulder pain rather than complaints of frank
instability. This category of patients is more prevalent than
previously recognized but should be distinguished from the rare true
posterior dislocation that results from an acute traumatic event (16,110).
Hawkins et al. (64) reported on
a series of 40 patients with 41 locked posterior shoulder dislocations.
The initial physician missed the diagnosis in the majority of cases
reviewed. In this series, the causes of posterior dislocation were
motor vehicle accidents, seizures, alcohol-related injuries, or
electroshock therapy. Recurrent anterior subluxation may also manifest
as pain rather than instability. Repetitive, high-energy, overhead
activities can cause progressive attenuation of the capsular,
ligamentous, and labral structures (2,78,159).
As these static stabilizers fail and the dynamic stabilizers weaken,
anterior subluxation occurs, leading to impingement symptoms.
Recognition of the underlying problem is critical in obtaining a
successful surgical outcome.
CLINICAL EVALUATION
HISTORY
The history can raise suspicion of shoulder instability.
A patient’s age, occupation, employment status, activity level, hand
dominance, and other medical problems are helpful in classifying the
nature of the instability. Certain circumstances, such as work-related
injuries or those with associated litigation, might affect patients’
perceptions of their disabilities as well as their expectations for
recovery and compliance with treatment (180).
Seek out specific complaints. For example, a patient may indicate that the arm “went dead” during a football tackle (158).
This symptom is likely associated with a traumatic subluxation of the
joint and the presence of a Bankart lesion. Another example is a
patient who gives a

P.2147


history
of having had a seizure and then awakening with the sensation of the
joint “out of place.” This situation suggests a posterior dislocation
as the result of unchecked internal rotation forces overcoming the
weaker external rotators of the shoulder.

If pain is a major component of a patient’s complaint,
which activities cause the pain? Question athletes as to the type of
sport, the position played, and the duration, frequency, and level of
involvement. For example, throwers, swimmers, or tennis players may
develop excessive capsular laxity as a result of subjecting their
shoulders to repetitive microtrauma (83,125).
The result is recurrent shoulder subluxation, which can create a sense
of “looseness” or “slipping” with activity. In addition, as previously
stated, secondary “nonoutlet” impingement can occur as anterior
instability decreases the subacromial space, causing pain with overhead
activities. Further, these same subluxations can create damage to the
superior labral area, creating a SLAP lesion. Posterior subluxation has
also been documented in athletes who require repetitive arm motion in
front of the body, such as offensive-line football players and
volleyball, softball, and baseball players (48,156,178). Throwing sports in particular lead to complaints of posterior
shoulder pain during the follow-through phase, which has been
associated with posterior subluxation and resultant microtrauma to the
posterior capsulolabral complex.
PHYSICAL EXAMINATION
A systematic evaluation includes observation for
abnormal motion patterns and atrophy, palpation to localize painful
areas, assessment of both active and passive range of motion,
measurement of strength of the rotator cuff muscles, neurovascular
evaluation, and finally provocative maneuvers for instability. Examine
the opposite shoulder for comparison.
In evaluating shoulder motion, carefully document any
scapulothoracic substitution for glenohumeral motion, scapular winging,
and other abnormal motion patterns. Atrophy of the spinatus muscles may
indicate a longstanding associated rotator cuff tear or injury to the
suprascapular nerve. Similarly, atrophy of the deltoid may indicate an
axillary nerve injury.
Assess patients for findings of generalized ligamentous
laxity, including the ability to hyperextend the elbows more than 10°,
apply the thumb to the forearm, hyperextend the metacarpophalangeal
joints more than 90°, or touch the palm of each hand to the floor while
keeping the knees extended (Fig. 80.8). While
there is no direct relationship between generalized ligamentous laxity
and shoulder instability, there is some association between hyperlaxity
and glenohumeral capsular development.
Figure 80.8. Systemic laxity. A: Wrist and metacarpophalangeal joint hyperextension. B: Elbow joint hyperextension. (A and B from Warner JJP. Shoulder. In: Miller MD, Cooper DE, Warner JJP, eds. Review of Sports Medicine and Arthroscopy. Philadelphia: WB Saunders, 1995:125, with permission.) C:
Knee hyperextension and thumb-to-forearm hyperflexibility. (From Gerber
C. Observations on the Classification of Instability. In: Warner JJP,
Iannotti JP, Gerber C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott–Raven Publishers, 1997:16, with permission.)
A patient with an acute, unreduced anterior dislocation holds the painful arm in slight abduction and internal rotation (2,167).
Before attempting any reduction maneuvers, perform a careful
neurovascular examination to rule out brachial plexus and, more
specifically, axillary nerve injuries (38,57,152).
The latter condition may sometimes escape detection, as decreased
sensation over the lateral deltoid is not always present with an injury
to this nerve. In older (>60 years) individuals or younger ones who
have sustained a severe trauma, be aware of the possibility of an
associated fracture of the humerus (62). Proper radiographic imaging is particularly important before attempting closed reduction in such cases.
Many methods of closed reduction apply in the case of an
acute shoulder dislocation. Perform all maneuvers as a gradual and
gentle technique with appropriate analgesia to ensure muscle
relaxation. Intravenous analgesia and intraarticular injection of a
regional anesthetic are both successful, appropriate methods of
anesthesia. A method of gentle traction in line with the arm using
countertraction is usually successful.
Pay careful attention to a patient who has an
unrecognized chronic (fixed) dislocation. The dislocation is most often
posterior, although it may be anterior, and typically occurs in
patients who are poor historians because of either alcohol use or
dementia (64). In a patient with a fixed
posterior subluxation, there is limitation of external rotation
compared with the opposite shoulder. In addition, there is flattening
of the anterior aspect of the shoulder with an associated prominence of
the coracoid process and possibly some prominence and rounding of the
posterior aspect of the shoulder. The application of excessive force in
attempting a closed reduction in such a patient risks neurovascular
injury or fracture.
Most patients who have instability are first seen by an
orthopaedic surgeon in the office setting. They may have had a
documented episode of instability or an injury with pain but no true
sense of shoulder instability. After a careful neurovascular
examination, it is important to assess active and passive range of
motion. A discrepancy between active and passive motion may indicate
either an associated rotator cuff tear or a nerve injury.
It is particularly important to identify a subscapularis
tear in the setting of shoulder instability, a condition that is
frequently missed (51,165).
Patients with such tears have passively increased external rotation
with the arm adducted at the side, as well as associated apprehension
in this position. Strength assessment is also important. Significant
external rotation weakness may indicate a rotator cuff tear.
Similarly, internal rotation weakness may be due to a
subscapularis tear. In this situation, the patient has an associated
lift-off sign (Fig. 80.9). If the patient lacks
adequate internal rotation to perform this test, perform the
belly-press maneuver instead to determine the patient’s ability to pull
the forearm in a posterior direction toward the mid abdomen while
maintaining the flexed elbow anterior

P.2148



P.2149


to
this point. If the elbow remains posterior to the anterior aspect of
the mid abdomen, there is likely a subscapularis tendon tear.

Figure 80.9. Lift-off sign. A: With the arm internally rotated, assess the patient’s ability to hold the arm off the lumbar region. B:
An inability to perform this function is clinically consistent with a
subscapularis rupture. If the patient lacks sufficient internal
rotation to perform this test, perform the belly-press maneuver. (From
Warner JJP. Shoulder. In: Miller MD, Cooper DE, Warner JJP, eds. Review of Sports Medicine and Arthroscopy. Philadelphia: WB Saunders, 1995:156, with permission.)
Various provocative maneuvers and drawer tests have been
described to assess symptomatic humeral head translation and the
direction of this movement. Neer and Foster (107)
originally described the apprehension test for anterior instability.
With the patient seated or standing, place the symptomatic shoulder
into a position of 90° of abduction and maximum external rotation. Then
move the arm so that it is posterior to the plane of the scapula, and
apply an anterior force to the humeral head. The patient’s withdrawing
from the examiner or complaining about a sense of shoulder instability
demonstrates apprehension (Fig. 80.10A).
Figure 80.10. Apprehension test. A:
In a patient with suspected anterior instability, abduct the arm 90°
and maximally externally rotate it with posterior pressure on the
humeral head. The patient should express demonstrable anxiety over a
possible dislocation.B: The relocation
maneuver is performed with the patient supine and the arm in the same
compromised position. (From Warner JJP. Shoulder. In: Miller MD, Cooper
DE, Warner JJP, eds. Review of Sports Medicine and Arthroscopy. Philadelphia: WB Saunders, 1995:128, with permission.)
The complaint of pain is not specific for instability
and may in fact be present with other conditions such as arthritis or
rotator cuff disease. Kvitne and Jobe (83)
proposed a modification of this maneuver to increase its specificity
for anterior instability. Place the patient in a supine position, and
perform the apprehension test as described above. Ask whether the
patient has a sense of instability or simply pain. Place posterior
pressure on the humerus, and ask whether this pressure relieves the
sense of apprehension or pain (Fig. 80.10B).
This “relocation maneuver” increases the specificity of the diagnosis
of instability if the patient reports decreased apprehension. If this
maneuver simply reduces pain, it is not diagnostic of instability and
may be associated with a variety of other diagnoses, including a SLAP
lesion or impingement syndrome (150).
One of us (JJPW) has found that an additional
modification to this test increases both its sensitivity and
specificity for the diagnosis of anterior shoulder subluxation. Perform
the apprehension and relocation tests as described above. If the
patient reports pain and not true apprehension, inject the subacromial
space with 10 ml of lidocaine 1% (Xylocaine). After 10 minutes, repeat
the examination. If the pain is due to rotator cuff disease, the
injection will eliminate it. If, however, the pain is due to labral
injury, it will persist after a subacromial injection (166).
Inconsistencies with the apprehension test led Gerber and Ganz (50)
to develop the anterior and posterior drawer test to assess the
shoulder for excessive translation compared with the contralateral
side. Others have found merit in this method of examination and have
developed grading scales for the degree of shoulder laxity (3,30,65).
These tests may offer some insight into the degree and direction of
instability. If one assesses laxity of the shoulder in an office
setting, it is important to determine whether translation of the
humeral head is greater on the painful side and whether this
translation causes symptoms (49). We have found
laxity assessment by drawer testing to be of limited value in the
office setting because patients tend to guard the painful shoulder.
Instead, this method is used during examination under anesthesia to
confirm the suspected degree and direction of shoulder instability.
Altchek et al. (3) and Hawkins et al. (65)
proposed a grading scale for translation of the humeral head on the
glenoid. Instability is graded on a scale of 0–3+ for all three
directions. For anterior and posterior drawer testing, a grade of 0
represents no humeral head translation, while movement of the humeral
head up to but not over the glenoid rim represents 1+ instability.
Translation of the humeral head over the glenoid rim with an associated
spontaneous reduction with relief of pressure represents

P.2150



2+ instability. Frank dislocation and locking of the humeral head over the glenoid rim is graded as 3+ instability.

When these drawer tests are performed either in the
office or in the operative setting, it is important to bear in mind
that the position of the arm determines the degree of tension in the
glenohumeral ligaments. With the arm at the side in adduction, the IGHL
is relatively lax, and anterior and posterior drawer testing may be of
limited value. In abduction, the IGHL comes underneath the humeral head
and forms a hammock that passively limits anterior, posterior, and
inferior translation (113,114).
Perform anterior drawer testing with the shoulder positioned in
abduction in the plane of the scapula. Maintain the arm in the neutral
rotation while using one hand to place an axial load along the humerus
and the other hand to apply an anterior or posterior force to the
humerus (Fig. 80.11). Often you can feel the
humeral head move back into the glenoid rather than out of the glenoid
during this maneuver. The patient may note a painful click with such a
maneuver. In our experience, this test is particularly helpful in
identifying posterior instability.
Figure 80.11.
Anterior drawer test. With the arm in abduction and neutral rotation,
apply an anterior force to the posterior aspect of the humerus to
assess anterior humeral head stability. Perform the posterior drawer
test with the arm in adduction, forward flexion, and internal rotation.
Then apply a posterior force to the arm to assess posterior stability.
(From Warner JJP. Shoulder. In: Miller MD, Cooper DE, Warner JJP, eds. Review of Sports Medicine and Arthroscopy. Philadelphia: WB Saunders, 1995:138, with permission.)
A modification of the posterior drawer test allows the
examiner to elicit posterior apprehension. Perform this modification by
placing the patient’s arm in 90° of forward flexion and adduction while
applying an axial load down the shaft of the humerus. Pain and a
palpable shift and click suggest posterior labral injury and
instability.
A modification of this test, termed the jerk test, has been described for posterior instability (12,86).
With the patient seated, load the abducted shoulder axially into the
glenoid with one hand, and with your other hand, palpate the posterior
aspect of the shoulder. Then bring the arm into horizontal adduction
anterior to the plane of the scapula; the humeral head may sublux
posteriorly. Then bring the humerus posterior to the plane of the
scapula; the humeral head may suddenly reduce into the glenoid. A
palpable shift and pain accompany a positive test.
The sulcus sign is basically an inferior drawer test (Fig. 80.12). Neer and Foster (107)
originally described it as the hallmark of inferior and
multidirectional instability (MDI). Unfortunately, a common
misconception has been that a large sulcus sign that is asymptomatic,
thus indicating inherent joint laxity, is a positive finding. The key
point is that this maneuver should be associated with pain and should
reproduce the patient’s symptoms to be clinically relevant as a finding
of inferior instability.
Figure 80.12.
Sulcus sign. Assess inferior displacement of the greater tuberosity
from the undersurface of the acromion. (From Gerber C. Observations on
the Classification of Instability. In: Warner JJP, Iannotti JP, Gerber
C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott–Raven Publishers, 1997:22, with permission.)
Perform this test with the patient seated and the arm
adducted at the side. Rotation of the shoulder is very important in
assessing the degree of inferior instability. First, with the arm in
the neutral rotation, pull the humerus inferiorly, and estimate the
amount of separation between the acromion and the humeral head. Grade
it on a 0–3+ scale (3): A separation of 1 cm is
a 1+ sulcus sign, 2 cm is a 2+ sulcus sign, and 3 cm is a 3+ sulcus
sign. Anatomically, a sulcus sign greater than 2+ indicates a capacious
capsule and specific laxity of the anterosuperior capsular region
(rotator interval).
As previously discussed, externally rotate the arm, and
repeat the sulcus sign test. If the sulcus sign remains greater than 2+
with the arm in external rotation, there is a marked deficiency of the
superior capsule, and a large rotator interval defect in the capsule is
likely. This is the result of damage to the superior and middle
glenohumeral ligaments, as well as the coracohumeral ligament. With
this information before surgical repair, you then know that surgical
reconstruction of this region with a capsular shift must be a component
of the operation (60).
Four different types of MDI patterns have been described (119):

P.2151


Type I: global instability
Type II: predominantly anterior and inferior instability
Type III: predominantly posterior and inferior instability
Type IV: anterior and posterior instability with no inferior component
The true existence of the last type has been questioned.
Since the description of superior labral pathology by Andrews et al. (5) in 1985 and of the SLAP lesion by Snyder et al. (145)
in 1990, several examination techniques have evolved to diagnose this
pathology. Andrews reported increased pain in patients during full
shoulder flexion and abduction, with noticeable catching and popping.
Snyder reported pain in patients during resisted shoulder flexion with
elbow extension and forearm supination (biceps tension test).
Another useful diagnostic test is the
compression–rotation test. With the patient supine, abduct the shoulder
90°, with the elbow flexed 90°. Apply a compression force to the
humerus to trap the torn labrum (in the same manner as McMurray’s test
for the knee is performed). O’ Brien et al. (114)
suggested a maneuver that they believed is accurate for determining
superior labral injuries. Place the patient’s shoulder in 90° of
forward flexion and then adduct it across the body. Ask the patient to
flex the arm further against resistance when the shoulder is first
internally rotated and then externally rotated. If pain occurs when the
shoulder is rotated internally but not when it is rotated externally,
the test is positive. Unfortunately, this test does not distinguish
between acromioclavicular joint disease and a superior labral tear. We
have found this test more useful than the other methods described above.

P.2152


RADIOGRAPHIC EVALUATION
The minimum radiography necessary for evaluation of an
acute dislocation or suspected subluxation is a true anteroposterior
(AP) view and an axillary view. These images will allow accurate
determination of the position of the humeral head relative to the
glenoid. A true AP radiograph is obtained by angling the x-ray beam 45°
relative to the sagittal plane of the body (Fig. 80.13). A scapular Y or transcapular view can also give useful information about the position of the humeral head (Fig. 80.14), but it is not as accurate as an axillary view (Fig. 80.15).
If a standard axillary view cannot be obtained, a Velpeau axillary view
without removing the patient’s arm from the sling will suffice (Fig. 80.16).
Figure 80.13.
A routine AP shoulder radiograph shows overlap of the anterior and the
posterior glenoid rims. A true AP radiograph demonstrates
superimposition of the anterior and the posterior glenoid rims,
producing an excellent view of the glenohumeral joint. (From Warner
JJP, Caborn DN. Overview of Shoulder Instability. Crit Rev Phys Rehabil Med 1992;4:145, with permission.)
Figure 80.14.
Transcapular or Y view of the glenohumeral joint allows assessment of
the humeral head location in relation to the glenoid cavity. (From
Warner JJP, Caborn DN. Overview of Shoulder Instability. Crit Rev Phys Rehabil Med 1992;4:145, with permission.)
Figure 80.15.
Axillary view represents the “gold standard” in radiographic assessment
of location of the humeral head relative to the glenoid cavity. (From
Warner JJP, Caborn DN. Overview of Shoulder Instability. Crit Rev Phys Rehabil Med 1992;4:145, with permission.)
Figure 80.16. Two common techniques used when a standard axillary view is difficult to obtain include the trauma axillary lateral (A) and the Velpeau axillary view (B). (From Warner JJP, Caborn DN. Overview of Shoulder Instability. Crit Rev Phys Rehabil Med 1992;4:145, with permission.)
In the office setting, a true AP view of the shoulder
with the arm in internal rotation may demonstrate a Hill–Sachs lesion.
A Stryker notch view is a special view that will also demonstrate a
Hill–Sachs lesion (Fig. 80.17) (43,121).
Figure 80.17. A: Arm position for obtaining the Stryker notch view. B:
This view can demonstrate a Hill–Sachs fracture on the posterior
humeral head surface. (From Warner JJP, Caborn DN. Overview of Shoulder
Instability. Crit Rev Phys Rehabil Med 1992;4:145, with permission.)
The West Point axillary view may prove helpful in a
patient suspected of having had an episode of instability. Take the
image with the patient prone so that the anterior glenoid is shown in
profile without an overlying acromial shadow (Fig. 80.18).
Figure 80.18. A: Positioning for the Westpoint axillary view. B:
This view allows visualization of the anteroinferior glenoid rim. (From
Warner JJP, Caborn DN. Overview of Shoulder Instability. Crit Rev Phys Rehabil Med 1992;4:145, with permission.)
Adjuvant imaging techniques are helpful when additional information about the three-dimensional relationship

P.2153



and architecture of the joint or confirmation of the presence of a
Bankart lesion is required. Computed tomography (CT) demonstrates bony
injuries or abnormalities including glenoid hypoplasia, congenital
version anomalies, acquired version abnormalities from erosion, and
glenoid rim fractures (Fig. 80.1 and Fig. 80.19). In addition, it allows measurement of the size of a humeral head defect (Hill–Sachs lesion) in cases of chronic instability (55). When combined with intraarticular dye, CT arthrography also demonstrates a Bankart lesion and articular erosion.

Figure 80.19. A: Three-dimensional CT reconstruction of a glenoid rim fracture. B: The same fracture after computerized removal of the humeral head.
Magnetic resonance imaging (MRI) with or without
gadolinium has gained great favor, although unfortunately it is often
used as a screening tool in the evaluation of patients. Its role should
instead be to confirm the presence of lesions that may need surgical
management. It is accurate in the detection of labral pathology (Fig. 80.20) (27,56).
Recent advances in MRI technology such as high-resolution fast-spin and
gradient-echo imaging make these methods particularly appealing for
detecting anterior and superior labral injuries (26).
Figure 80.20. A,B: MR arthrogram demonstrates anterior glenohumeral stripping with an associated Bankart lesion.

P.2154



P.2155


EXAMINATION UNDER ANESTHESIA
Before arthroscopy or arthrotomy is undertaken,
examination under anesthesia (EUA) can confirm or deny the preoperative
impression (30,154).
During EUA, muscle guarding is eliminated, and an accurate assessment
of joint laxity is possible. As previously described, it is essential
that laxity not be confused with instability; thus, it is important to
compare the symptomatic shoulder with the asymptomatic side.
Individuals who have had a previous dislocation will likely have a 2+
or 3+ anterior drawer test result (as described above) for the
symptomatic shoulder compared with a 1+ – 2+ finding in the
asymptomatic shoulder.
The finding of symmetric laxity, however, does not
necessarily exclude instability because a Bankart lesion may be present
without marked laxity on examination in a patient who has a history of
subluxation (149,171).
Furthermore, in very large individuals, the soft-tissue envelope of the
shoulder may be so large that accurate determination of a centimeter of
translation of the humeral head on the glenoid may not be possible.
One area where we have found EUA to be helpful is in determining capsular laxity and rotator interval lesions (45),
both of which are typically associated with MDI. If an individual is
found to have a sulcus sign of more than 2+ and if this persists when
an inferior drawer is applied with the arm in external rotation, there
will be a large rotator interval defect, as well as marked anterior and
inferior capsular laxity. In our hands, this is treated by a modified
capsular shift, along with repair of a Bankart lesion if one is found
to be present (60). Although other surgeons
have used arthroscopic techniques in the treatment of this combination
of problems, we generally treat only pure Bankart lesions with an
arthroscopic repair technique (99,136,159).
Occasionally, EUA will identify a shoulder that can be dislocated posteriorly (3+)
when anterior instability is suspected. It is usually in a patient with
congenital laxity who has had a traumatic injury. We usually treat this
condition with an open capsular shift method of repair.
ARTHROSCOPY: BASIC SETUP
Arthroscopy of the shoulder can be performed in either the seated beach-chair or the lateral decubitus position (see Chapter 77).
The lateral decubitus position allows good visualization
of the anterior and inferior glenohumeral structures by virtue of the
applied traction, but it does not allow the surgeon to easily
manipulate the shoulder through a full range of motion. Moreover, it
can limit access to the anterior glenoid with crowding of the
instrumentation and cannulas on the drapes and body. In addition, if
there is a need to convert to an open procedure, it is usually
necessary to reposition (and therefore reprepare and redrape) the
patient. As stated previously, there is a risk of transient neuropraxia
due to traction (81).
The beach-chair position, our preferred position,
provides unrestricted access to the entire shoulder and allows free
movement of the arm in all planes. In addition, visualization is
possible in a more anatomic orientation. These criteria are essential
if a diagnostic arthroscopy is to be performed that inherently requires
an assessment of the anatomy of the glenohumeral ligaments. Further, it
permits simple conversion from an arthroscopic to an open procedure. In
addition, patients tolerate the use of an interscalene block without
the need for supplemental general anesthesia, in contrast to patients
in the lateral decubitus position. Table 80.3 compares the beach-chair position with the lateral decubitus position.
Table 80.3. Advantages and Disadvantages of Lateral versus Beach-chair Arthroscopy
OPERATIVE TECHNIQUE
  • If general anesthesia is used, it is
    important to secure the endotracheal tube to the side of the mouth
    opposite the injured shoulder. After anesthesia has been obtained,
    place the patient into the seated position, and perform an EUA. There
    are special beach-chair attachments that can be fitted to the table (Fig. 80.21) (163).
    If such a device is not available, place a long beanbag beneath the
    patient. In this setting, the table is fully flexed, apex down, at the
    patient’s waist; the knees are then flexed downward approximately 45°
    with a footplate at the end of the table to prevent the patient from
    sliding down the table. Finally, the head of the table is elevated
    approximately 70° from the horizontal.
    Figure 80.21. Lateral (A) and anterior (B)
    views of the beach-chair attachment used for shoulder arthroscopy.
    (From Warner JJP. Shoulder Arthroscopy in the Beach-chair Position:
    Basic Setup. Oper Tech Orthop 1991;1:147, with permission.)
  • Then harden the beanbag, leaving the
    entire medial border of the scapula free posteriorly for sterile
    preparation and draping. Obtain this same position with the use of a
    beach-chair attachment (Fig. 80.22). Place the
    uninjured arm on a well padded arm board or a stand that is positioned
    at the appropriate height to avoid undue pressure on the neck and
    shoulder. Shave the axilla, and prepare and drape the arm from the hand
    to the medial border of the scapula posteriorly.
    Figure 80.22. Standard patient position for shoulder arthroscopy in the beach-chair position. A: The head is elevated 70° with the medial border of the scapula free and the entire shoulder free posteriorly. B:
    Anteriorly, the entire shoulder is free, with the uninjured forearm in
    a padded stand and the shoulder resting at a comfortable level. (From
    Warner JJP. Shoulder Arthroscopy in the Beach-chair Position: Basic
    Setup. Oper Tech Orthop 1991;1:147, with permission.)
  • Angle the table so that the feet are away
    from the operative side to allow better visualization of the television
    monitor positioned on the opposite side of the table from the surgeon.
    Place a padded sterile stand for instrumentation at knee level on the
    opposite side of the table. Pass the tubing and arthroscopic equipment
    underneath the arm and across the patient’s chest and then curve them
    forward over the shoulder. Use a clamp to secure the tubing in place;
    remove all instruments and tubing from beneath the arm and place them
    securely on the padded stand (Fig. 80.23).
    Figure 80.23. A: Appropriate length of the arthroscopy tubing is established by bringing the tubing under the arm and over the shoulder. B:
    Position the table and patient at an oblique angle from the monitor for
    better visualization. Note the padded Mayo stand for instrumentation.
    (From Warner JJP. Shoulder Arthroscopy in the Beach-chair Position:
    Basic Setup. Oper Tech Orthop 1991;1:147, with permission.)
  • Adding 1 ampule of epinephrine to each 3-l bag of irrigating solution limits bleeding. Commercially available

    P.2156



    P.2157



    P.2158



    P.2159



    fluid pressure pumps may be used, although we have had excellent
    visualization using simple gravity feed with elevation of two 3-l bags
    to a height of at least 7–8 ft (2 m).

PORTAL PLACEMENT AND ANATOMY
Portal placement is extremely important when an arthroscopic Bankart repair is performed.
  • Place the standard posterior portal for arthroscopy 1–2 cm inferior and medial to the posterolateral tip of the acromion (Fig. 80.24) (5,6,23,79,80,172).
    Its location can be confirmed by grasping the humeral head and applying
    an anterior drawer test. We usually place an 18-gauge spinal needle at
    this location to confirm orientation for insertion of the arthroscope.
    Figure 80.24. Posterior (A) and lateral (B) views of the lateral, posterior, and superior arthroscopic portals. A superior portal is rarely used. C:
    Insert a spinal needle into the glenohumeral joint posteriorly by
    aiming toward the coracoid process, and use it to insufflate the joint
    with normal saline. D: Insert an
    arthroscopic sheath and blunt trocar into the joint through a posterior
    incision in the same direction as the spinal needle. (From Warner JJP.
    Shoulder Arthroscopy in the Beach-chair Position: Basic Setup. Oper Tech Orthop 1991;1:147, with permission.)
  • Then insufflate the joint with sterile
    saline. This step increases hydrostatic pressure in the joint and moves
    the humeral head away from the glenoid. It decreases the likelihood of
    articular cartilage damage during introduction of the arthroscope into
    the joint. Further, reflux of saline out of an open port confirms
    proper positioning in the joint.
  • An anterosuperior portal is the primary working portal (Fig. 80.24A, Fig. 80.24C).
    Locate it by viewing with the arthroscope in the posterior portal and
    then placing an 18-gauge spinal needle into the joint just underneath
    the long head of the biceps tendon through the rotator interval. This
    portal is usually quite vertical in orientation. We make an effort to
    place it as superiorly as possible in the rotator interval to avoid
    crowding with the anteroinferior portal, which will be used for
    placement of the arthroscopic instruments (Fig. 80.25). We usually place a 6 mm cannula in this portal location.
    Figure 80.25. A: Standard anterosuperior and anteroinferior arthroscopic portals. B:
    The anterosuperior portal enters the joint just below the biceps
    tendon, while the anteroinferior portal enters the joint just above the
    subscapularis tendon. Accurate placement of each portal is performed
    with the assistance of a spinal needle and an outside-in technique.
    (From Warner JJP, Warren RF. Arthroscopic Bankart Repair Using a
    Cannulated, Absorbable Fixation Device. Oper Tech Orthop 1991;1:192, with permission.)
  • Once these two portals have been
    established, perform a review of the joint. A careful inspection begins
    with the biceps tendon and its origin and continues over the rotator
    cuff and posterior humeral head. Then inspect the glenoid rim (anterior
    and posterior) and glenohumeral ligaments (Fig. 80.26). In patients with a presumptive

    P.2160



    P.2161



    diagnosis of instability, look specifically for a Bankart lesion,
    capsular rupture, capsular laxity, a SLAP lesion, rotator cuff tear
    (partial or full), a Hill–Sachs lesion, or chondral injuries.

    Figure 80.26. A: The anterior band of the IGHL is visualized posteriorly and probed anteriorly with the arm in an adducted position. B: External rotation and abduction of the arm to 90° should increase tension in the ligament, producing a hammock-like effect. C:
    Probe analysis of the anterior labrum through the anterosuperior
    portal. (From Warner JJP. Shoulder Arthroscopy in the Beach-chair
    Position: Basic Setup. Oper Tech Orthop 1991;1:147, with permission.)
  • SLAP lesions are typically type II in nature and are amenable to repair with current arthroscopic techniques (20,44,172,184).
    In patients younger than 45 years, rotator cuff tears are typically
    partial-thickness undersurface lesions of the supraspinatus tendon and
    are treatable through gentle debridement and correction of the
    underlying instability (156). Larger tears are associated with dislocations in patients older than 40 years (109).
    Pay careful attention to the presence of a subscapularis tendon injury
    in patients older than 40. These injuries usually require formal open
    repair. Significant glenoid erosion, a large Hill–Sachs lesion, or
    frank posttraumatic arthritis signifies longstanding instability with
    associated capsular laxity or, in the worst scenario, dislocation
    arthropathy.
  • The drive-through sign is a nonspecific,
    though somewhat helpful, finding for capsular laxity, described by
    Warren and associates (118,166,178).
    This finding is positive if you can sweep the arthroscope with little
    resistance from anterior to inferior into the axillary pouch.
  • A modification of the drive-through sign that we have found more specific is termed the arthroscopic drawer test (166).
    View through the posterior portal with the patient’s shoulder abducted.
    With the arm in abduction and external rotation, apply an anterior
    drawer. If the humeral head moves over the glenoid rim when the arm is
    in this position, there is significant capsular laxity (Fig. 80.27).
    The arthroscope may then be placed through the anterosuperior cannula,
    and both anterior and posterior drawer tests can be performed (Fig. 80.28).
    Figure 80.27. Arthroscopic anterior drawer maneuver for assessing the grade of instability.
    Figure 80.28. A:
    Arthroscopic visualization can be performed anteriorly and is an
    excellent means of evaluating the anterior glenoid rim and labrum. B: View the humeral head from an anterosuperior perspective. C: Viewing through this same portal, apply an anterior drawer test (broad arrow), and assess the degree of humeral head (HH) instability. Notice the thin, lax anterior band (thin arrows) of the IGHL
    and the associated Hill–Sachs lesion (posterior humeral head). (From
    Swenson TM, Warner JJP. Arthroscopic Shoulder Stabilization: Overview
    of Indications, Technique, and Efficacy. Clin Sports Med 1995;14:841, with permission.)
  • The examination should also focus on the quality and development of the glenohumeral ligaments (Fig. 80.29).
    There is typically great variation among the three glenohumeral
    ligaments. This development has been characterized on the basis of a
    0–3+ scale (118). Zero represents absence of
    the ligament, while 1+ means that the ligament is thin and lax in
    nature or one-third the size of the biceps tendon. If the ligament is
    thick and robust in nature or one-half the size of the biceps tendon,
    it is graded as 2+, while 3+ means that the ligament is two-thirds the
    size of the biceps tendon or greater (168). We
    have found that individuals with marked laxity on drawer testing tend
    to have small or damaged glenohumeral ligaments compared with those who
    do not have marked laxity on drawer testing (Fig. 80.30) (170).
    We believe that thicker, more robust–appearing glenohumeral ligaments
    indicate a patient who is ideally suited for arthroscopic repair of a
    Bankart lesion. Optimal selection criteria for an arthroscopic versus
    an open stabilization procedure are provided in Table 80.4.
    Figure 80.30. Assess the degree of injury to the ligamentous structures, as well. A: A ruptured IGHL is visualized and probed. B: Debridement is performed for better visualization. (From Warner JJP. Arthroscopic Bankart Repair. In: Bigliani LU, ed. Shoulder Instability. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1996:47, with permission.)
    Figure 80.29.
    It is important to assess the size and quality of the IGHL. Compare its
    size to the biceps tendon, which has a consistent diameter and
    presence. A: Thin, mobile IGHL. B:
    An anterior view further demonstrates the laxity associated with this
    ligament. (From Warner JJP, Altchek DW. Arthroscopic Repairs for
    Instability. In: Warner JJP, Iannotti JP, Gerber C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott–Raven Publishers, 1997:26, with permission.)
    Table 80.4. Patient Selection Criteria for Arthroscopic versus Open Shoulder Stabilization Procedures
  • If the patient is deemed to be a suitable
    candidate for arthroscopic Bankart repair, an anteroinferior portal
    will be required for the placement of anchors and for knot-tying.
    Locate this portal with the patient’s arm adducted at the side. Place
    it approximately 1 cm inferior and lateral to the coracoid process(Fig. 80.25). With the arm is in this position, thereis little risk of injury to the musculocutaneous nerve(5,6).
  • Place a spinal needle from outside into
    the joint; its orientation should be just over the upper border of the
    subscapularis tendon. Because the arm is adducted, this tendon falls
    inferior to the equator of the glenoid, and access to the 4- to 5-o’
    clock position along the glenoid rim is possible. Remove the needle,
    and create the portal using a #11 blade. Place an 8 mm disposable
    cannula with a flow-restricting diaphragm in this portal to allow room
    for passage of the appropriate instrumentation (Fig. 80.31).
    Figure 80.31.
    This disposable cannula with a diaphragm maintains joint distention and
    contains an additional inflow–outflow portal. (From Warner JJP.
    Shoulder Arthroscopy in the Beach-chair Position: Basic Setup. Oper Tech Orthop 1991;1:147, with permission.)

P.2162



P.2163



P.2164


TREATMENT OPTIONS
As seen in the algorithm in Figure 80.32,
there are many errant courses that result in ineffective treatment. A
patient or a physician can make these errors. A successful outcome
begins with an accurate diagnosis followed by the specific treatment
required for that particular patient.
Figure 80.32.
Successful treatment requires a correct preoperative diagnosis and
performance of an appropriate procedure with excellent technique
followed by a good postoperative rehabilitation protocol. An error at
any step will result in a poor clinical outcome. (From Warner JJP.
Overview: Avoiding Pitfalls and Managing Complications and Failures of
Instability Surgery. In: Warner JJP, Iannotti JP, Gerber C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott–Raven Publishers, 1997:7, with permission.)
Nonoperative Care
Studies on the natural history of traumatic shoulder
instability demonstrate a high rate of recurrence with nonoperative
treatment (21). Rowe and Sakellarides (133)
reported a recurrence rate of 58% in 398 patients with 53% follow-up.
They noted a strong correlation between patient age and recurrence,
with an incidence of recurrence of 94% in patients younger than 20
years, 79% in patients between 20 and 40 years, and 14% in patients
older than 40 years. Subsequent studies verified this trend (62,69,103). A large Scandinavian study suggested that recurrence was less common in young males. Hovelius et al. (70)
reported on 10-year follow-up of 245 patients with 247 primary
dislocations. Recurrent dislocation requiring surgery occurred in 34%
of 99 shoulders in the 12–22-year age range, 28% of 57 shoulders in the
23–29-year age range, and 9% of 91 shoulders in the 30–40-year age
range. Recurrence rates are even higher in the pediatric age group.
Marans et al. (93) reported one or more recurrent episodes of dislocation in all of the children in their study.
Despite an initial claim by Watson-Jones (179)
in 1948 that immobilization in full internal rotation for 4 weeks
produced complete stability, others have not reported such successful
outcomes. In fact, the success of immobilization has been variable.
Rowe and Sakellarides (133) reported that immobilization for 3 weeks decreased the recurrence rate. Henry and Genung (67) reported no significant improvement with immobilization. Aronen and Regan (6b)
found a reduction in the recurrence rate to 25% if first-time
dislocations were treated with isometric, isotonic, and isokinetic
exercises (7). Burkhead and Rockwood (21)
prescribed a shoulder exercise program for patients with a traumatic or
atraumatic etiology. In the traumatic subluxation group, 16% responded
favorably to a rehabilitation program, while 87% of the atraumatic
subluxation group without psychological problems demonstrated a
good-to-excellent outcome. Hovelius et al. (70) reported that the type and duration of initial treatment had no effect on the rate of recurrence.
Thus, it is clear that the most important factors in
determining recurrence of instability after a traumatic injury are age
and activity level. The following discussion considers surgical options
in this category of patients.

P.2165


SURGICAL TECHNIQUES
DEBRIDEMENT OF LABRAL LESIONS
Detrisac and Johnson (39)
originally described five variations in labral anatomy; more recently,
however, Detrisac (personal communication) changed the categories to
two basic types. Type A labra were attached centrally and peripherally
at the inferior, posterior, and anterior regions, but superiorly they
were detached centrally and peripherally. In contrast, type B labra
were attached centrally and peripherally along the entire labrum.
Snyder et al. (146), who
performed shoulder dissections, modified this description. They
described an inferior labrum that consistently was triangular in shape
and attached centrally and peripherally. A similar shape was
demonstrated in the posterior labrum, although occasionally the
undersurface of this area was not attached. The superior region once
again showed consistent attachment peripherally, with a central portion
that was free in varying degrees. The anterior labrum was attached at
both the central and peripheral regions, appearing as a thickened band
of capsule that was clearly distinguishable on histologic and gross
assessment.
Several patterns of labral injury have been described.
Flap tears are usually found in the anterosuperior, anteroinferior, or
inferior labrum (146), associated with
subluxation or frank dislocation. Other labral tears that have been
described include bucket-handle and incomplete split tears, which have
not necessarily been associated with instability, if located superiorly
(120). Degenerative tears are labral lesions that coexist with degenerative joint disease.
Although initial reports on arthroscopic labral debridement were encouraging (4,54,122),
later reports demonstrated a clear relationship between instability and
labral pathology. In each study, despite early favorable results at 1-
and 2-year follow-up, there was significant deterioration in clinical
outcome. The authors in each article concluded that athletes whose
sports involve overhead activity should be treated as if there is some
underlying laxity or instability. Mere debridement of the labral
pathology cannot be expected to be successful.
A study of 52 patients undergoing consecutive arthroscopic labral debridement at Columbia-Presbyterian Medical

P.2166



Center further strengthened these recommendations (35).
The majority of these patients had SLAP lesions, while the remainder
had either anteroinferior or posterior labral lesions. While no patient
had a history of dislocation or clinically evident instability
preoperatively, EUA revealed instability in 70% of patients with SLAP
lesions and in all of the other patients.

At 1-year follow-up, 78% of the superior labral group
versus 30% of the anteroinferior group had excellent results from
debridement. These results deteriorated with time to 63% and 25% in
each respective group at 2-year follow-up. The authors concluded that
instability was frequently present in patients with labral pathology,
and debridement would provide only short-term relief in this patient
population. On the basis of these studies it is difficult to recommend
labral debridement for most patients.
REPAIR OF SUPERIOR LABRAL LESIONS
In 1985, Andrews et al. (5)
reported the association in athletes between throwing and injuries to
the anterosuperior glenoid labrum and the insertion of the long head of
the biceps brachii. These injuries were believed attributable to the
large deceleration forces applied by the biceps muscle at the insertion
point. Two studies further implicated the long head of the biceps in
contributing to anterior and superior shoulder stability during
abduction and external rotation (126,174). In 1990, Snyder et al. (145)
retrospectively reviewed 700 patients who underwent shoulder
arthroscopy and described four specific types of pathologic
abnormalities in this area: the SLAP lesions (Fig. 80.33). A description of each type of SLAP lesion and the recommended treatment is provided in Table 80.5.
Figure 80.33. The four types of SLAP lesions (Table 80.5).
(From Snyder SJ, Wuh HCK. Arthroscopic Evaluation and Treatment of the
Rotator Cuff Superior Labrum Anterior Posterior Lesion. Oper Tech Orthop 1991;1:212, with permission.)
Table 80.5. SLAP Lesion Types and Appropriate Treatments
Anatomic and histologic studies further characterized the superior labral area (21,31,129).
These studies demonstrated a relative avascularity at the superior and
anterosuperior regions compared with the posterior and inferior
regions, and this may be one reason for the degeneration that occurs in
this area. A retrospective review by Snyder et al. (144)
involving 2,375 arthroscopic shoulder procedures over 8 years found
SLAP lesions in 140 (6%) patients. Most lesions were classified as
either type II (55%) or type I (21%) lesions. Only 28% had isolated
superior

P.2167


labral
pathology, 22% had associated Bankart lesions, and the remainder had
associated rotator cuff pathology. Another review of 712 patients
revealed that 17% had type I lesions, while 11.8% had other significant
labral pathology (91).
The authors had difficulty classifying the remaining pathology
according to the criteria described by Snyder, but once again there was
a high association between labral lesions and subtle instability or
laxity on EUA.

SLAP LESION REPAIR
The correlation between glenohumeral instability and
superior-labral and biceps-insertion pathology has led to the
development of several arthroscopic repair techniques. In 1991, Yoneda
et al. (184) described the use of an
arthroscopic staple (Instrument Makar Inc., Okemos, MI) designed by
Lanny Johnson. The patient population consisted of 10 young athletes
(involved in overhead sports) with type II SLAP lesions. The standard
lateral decubitus position was used, and the joint was visualized
through the standard posterior portal. An anterosuperior portal was
used for instrumentation.
The surgery involved arthroscopic debridement, abrasion,
and stapling of the SLAP area. One staple (5.5 mm diameter) was used in
each case. Patients were immobilized for 2–3 weeks; range of motion was
then initiated, followed by strengthening exercises at 6 weeks. Because
of concerns over staple migration and irritation, all staples were
removed at an average of 3.9 months. On second-look arthroscopy,
complete healing had occurred in four patients, with full continuity
with the glenoid surface. The remaining repairs were deemed stable
despite incomplete healing. More important, 80% of patients were found
to have good-to-excellent results.
Reports of loosening and irritation with the arthroscopic staple have led to the development of alternative repair techniques (36,60,124).
A transglenoid approach, originally developed for Bankart lesions and
popularized by Caspari, has been applied to the SLAP lesion (24,44).
  • With the patient in the lateral decubitus
    position, use standard posterior and superior portals for visualization
    and inflow. Establish a third anterior portal with a spinal needle;
    this portal will be used for instrumentation.
  • Use a Caspari suture punch (Concept Inc.,
    Largo, FL) through the anterior portal to place four to seven 2-0
    polydioxanone (PDS) sutures from posterior to anterior along the
    labrum–biceps tendon complex. Place an additional one to two 0-PDS
    sutures into the biceps tendon, as well, to reinforce the repair.
  • Make a transglenoid drill hole (1-o’
    clock position for right shoulders or 11-o’ clock position for left
    shoulders), using a Beath needle placed through the anterior portal
    approximately 3–5 mm medial to the articular surface and exiting in the
    infraspinatus fossa posteriorly (Fig. 80.34A, Fig. 80.34B). Then pass all previously placed sutures through the glenoid neck, using the Beath needle (Fig. 80.34C). Tie the sutures through a small posterior incision over the infraspinatus fascia (Fig. 80.34D). Immobilize the patient for 1–2 weeks, and protect the shoulder in a sling for an additional 3–4 weeks. Field and Savoie (44) reported excellent results in 80% of the patients in whom they used this technique.
    Figure 80.34. Arthroscopic repair of a SLAP lesion using a transglenoid suture technique. A: Prepare the glenoid rim. B: Drill transglenoidally with a Beath needle. C:
    Pass the suture that is subsequently tied over the infraspinatus
    fascia. (From Altchek DW, Warren RF, Skyhar MJ. Shoulder Arthroscopy.
    In: Rockwood CA Jr, Matsen FA III, eds. The Shoulder. Philadelphia: WB Saunders, 1990:275, with permission.)
Some concerns have been raised about this technique, however (166),
because it requires a separate posterior incision to tie the sutures.
Tying over the infraspinatus muscle may lead to gaps at the repair site
if muscle atrophy occurs. Further, the elastic nature of PDS suture
makes it

P.2168



prone to gap 5–10 mm at the repair site (52). In addition, during transosseous pin placement, there is a risk of injury to the suprascapular nerve or one of its branches (140).

Alternative Technique
A technique designed at the Southern California Orthopedic Institute (SCOI) avoids the inherent risk of transosseous sutures (28).
The standard posterior, anterosuperior, and anteroinferior portals as
previously described are used with this technique. Wichman and Snyder (180) described the more inferior portal as the anterior mid-glenoid portal.
  • Place disposable cannulas with
    flow-restricting diaphragms into each anterior portal. For type II
    lesions, first use a shaver to debride the fibrous membrane over the
    glenoid neck. Then use a 4.0 mm ball-shaped burr to decorticate and
    create a notch beneath the SLAP region, avoiding the articular
    cartilage. SCOI recommends the use of the Revo screw system (Linvatec,
    Inc. Largo, FL), in which nonabsorbable suture is placed through the
    eyelet of the screw before implantation. Insert the Revo punch through
    the anterosuperior cannula at a 45° angle, impact it with a mallet, and
    remove it. Then place the screw with the attached braided,
    nonabsorbable suture (Fig. 80.35A, Fig. 80.35B).
    Figure 80.35. SLAP lesion repair. A: Place a suture anchor into the prepared glenoid rim, using the anterosuperior arthroscopic portal. B: Firmly seat the anchor in the bone. C:
    Pass one limb of the suture through the anteroinferior portal. (From
    Cheng JC, Karzel RP. Superior Labrum Anterior Posterior Lesions of the
    Shoulder: Operative Techniques of Management. Oper Tech Sports Med 1997;5:249, with permission.)
  • Apply tension to the suture through the
    cannula to assess the stability of the anchor. Then use a hook or
    grasper to retrieve one limb of the suture through the anteroinferior
    cannula (Fig. 80.35C). Place a crescent-shaped
    suture passer through the anterosuperior portal, and use it to pass a
    Shuttle Relay (Linvatec, Inc., Largo, FL) through the anterior superior
    labrum–biceps complex

    P.2169



    (Fig. 80.36A). The Shuttle Relay contains a central loop through which suture can be placed and then pulled back through the tissue.

    Figure 80.36. SLAP lesion repair. A:
    Place a cannulated hook and Shuttle Relay through the SLAP lesion. Then
    expose the latter externally through the anteroinferior portal. Pass
    the suture through the eyelet portion of the Shuttle Relay. B: Pull the suture in a retrograde fashion through the SLAP lesion and the anterosuperior cannula. C: Repeat the process for the other limb. D:
    Tie the suture arthroscopically, creating a horizontal configuration.
    (From Cheng JC, Karzel RP. Superior Labrum Anterior Posterior Lesions
    of the Shoulder: Operative Techniques of Management. Oper Tech Sports Med 1997;5:249, with permission.)
  • Pass the Shuttle Relay through the
    anteroinferior portal with a grasper, and expose the loop externally.
    Pass the limb of nonabsorbable suture in the anteroinferior portal
    through the loop of the relay. Then pass the suture through the tissue
    by applying tension on the other end of the Shuttle Relay still exposed
    through the anterosuperior portal (Fig. 80.36B).
    Thus, the relay and attached suture are pulled back through the tissue
    and out the anterosuperior cannula in a retrograde fashion.
  • P.2170


  • Repeat the process for the other limb of
    the suture, creating a horizontal mattress repair. Place a probe
    through the anteroinferior portal to reduce the entire complex, and use
    an arthroscopic knot pusher to tie the suture in place (Fig. 80.36C, Fig. 80.36D).
  • An alternative to the Shuttle Relay is a suture-transport system (Smith and Nephew, Andover, MA) (Fig. 80.37). These instruments contain a sharp tip that is passed through the anterosuperior portal and directly through the tissue (Fig. 80.38A).
    The surgeon deploys two small metal arms and grasps one limb of the
    suture, pulling it back through the tissue and out the cannula (Fig. 80.38B). The process is repeated, and the sutures are tied in horizontal fashion.
    Figure 80.37.
    Suture-transport system (Acufex). (From Cheng JC, Karzel RP. Superior
    Labrum Anterior Posterior Lesions of the Shoulder: Operative Techniques
    of Management. Oper Tech Sports Med 1997;5:249, with permission.)
    Figure 80.38. SLAP lesion repair. A: Pass the transport system through the labral tissue. B:
    Deploy the central arms, and grasp the suture; then pass the suture
    back through the tissue, and tie it for an effective repair. (From
    Cheng JC, Karzel RP. Superior Labrum Anterior Posterior Lesions of the
    Shoulder: Operative Techniques of Management. Oper Tech Sports Med 1997;5:249, with permission.)
  • In type IV lesions, for tears involving
    less than 30% of the torn biceps tendon, perform debridement and
    complete repair as for type II lesions. With greater involvement,
    perform a primary biceps tenodesis in elderly patients or a suture
    repair of the biceps tendon and labrum in younger patients.
    Good-to-excellent results with this technique have been reported in 74%
    of patients after long-term follow-up (153).
The numerous suture anchors on the market have different advantages and disadvantages (Fig. 80.39).
Many surgeons prefer to use metal anchors for postoperative
radiographic visualization in the event that an anchor dislodges from
the bone, which is a potential risk with this technique. If an anchor
loosens, the device must be removed because an intraarticular loose
body could lead to cartilage damage. In addition, there are potentially
grave complications from migration of a foreign object to the lung,
subclavian artery, or spinal canal (90,96,98,111,138).
Figure 80.39. Some suture anchors currently on the market. A: Arthrotek Harpoon Suture Anchor, Warsaw, IN. B: Acufex Suretac II, Andover, MA. C: Innovasive Devices Roc, Marlborough, MA. D: Acufex Tag Wedge, Andover, MA. E: Linvatec Bio-Anchor, Largo, FL. F: Linvatec Mini-Revo, Largo, FL. G: Linvatec Revo, Largo, FL. H: Mitek Stealth, Westwood, MA. I: Mitek G-II Anchor, Westwood, MA. J: Zimmer Statak. K: Acufex Tag Rd II, Andover, MA. L: Arthrex Fastak, Naples, FL. (From Elrod B. Arthroscopic Reconstruction of Traumatic Anterior Instability. Oper Tech Sports Med 1997;5:215, with permission.)
With this concern in mind, absorbable anchors have been
developed. However, because they degrade, they raise concerns about the
stability of the repair. Studies have focused on initial pullout
strengths and degradation of the entire anchor (8,9,97). As most absorbable materi-als lose their strength in 4–6 weeks, there are also concerns

P.2171



over the degradation at the eyelet (20).
This technique also requires secure intraarticular knot-tying with a
certain level of experience before actual use in the operating room.

Warren and colleagues developed the Suretac device
(Smith and Nephew, Andover, MA) to overcome some of the problems
inherent in suture anchors (151,177).
This implant is an absorbable, cannulated device composed of a
synthetic copolymer (polyglyconate). The tack contains ribs for
increased pullout strength (3.2 mm shaft diameter). It has a wide, flat
head (6.5 mm diameter) to adequately hold tissues, and undergoes
hydrolysis, thereby preventing a significant inflammatory response (Fig. 80.40).
The rapid, 4-week bioabsorption profile prevents the possibility of
loose fragments, as might occur with slower absorption profiles, but is
considered long enough for adequate tissue healing. In most
descriptions of procedures employing this implant, the beach-chair
position has been used (117,172).
Figure 80.40. Suretac implants.
Authors’ Preferred Method
True complete superior labral detachments are a
challenge to repair, but they are much more easily repaired through an
arthroscopic than through an open approach because the overlying
acromion makes exposure of the superior glenoid difficult through a
deltopectoral approach. Furthermore, the diagnosis of a SLAP lesion is
essentially an arthroscopic diagnosis.
For 6 years, one of us (JJPW) has used an arthroscopic technique that employs the Suretac device (172).
In the past 2 years, a suture method has been developed. Both methods
have proven efficacious. Theoretically, the suture method gives
stronger immediate repair without any worry about deterioration of the
strength of repair due to resorption of the polyglyconate anchor, as
with the Suretac device.
  • Perform both techniques with the patient
    in a beach-chair position. Use an anterosuperior portal with a 6 mm
    cannula with a flow-restricting diaphragm entering the joint just
    underneath the biceps tendon. Use an accessory anterolateral or
    transcuff portal, as well (Fig. 80.41).
    Figure 80.41.
    SLAP lesion repair. The superior portal provides direct access to the
    superior labral area, but the surrounding soft tissues prevent adequate
    visualization and manipulation of lesion. There is also an increased
    possibility of drill slippage with resultant articular cartilage
    damage. Use of the lateral portal provides equal access and avoids
    these problems. (From Warner JJ, Kann S, Marks P. Arthroscopic Repair
    of Combined Bankart and Superior Labral Detachment Anterior and
    Posterior Lesions: Technique and Preliminary Results. Arthroscopy 1994;10:383, with permission.)
  • Place an 18-gauge spinal needle through
    the rotator cuff from just lateral to the acromion to identify this
    latter portal. Position the needle so that the most direct angle to the
    superior labrum is possible. Then withdraw the spinal needle and use a
    #11 blade to make a portal through the rotator cuff while visualizing
    from within the joint. Insert another 6 mm cannula into the joint

    P.2172


    through
    the rotator cuff. The defect made in the cuff with this approach has
    not led to any significant clinical problems postoperatively.

  • Using the anterosuperior portal, clear the superior glenoid rim of soft tissue, using a motorized shaver (Fig. 80.42), and decorticate the juxtaarticular margin with a burr (Fig. 80.43).
    Figure 80.42.
    SLAP lesion repair. Arthroscopic debridement of the superior and
    anterior labral areas can be performed through the anterosuperior
    portal. (From Warner JJ, Kann S, Marks P. Arthroscopic Repair of
    Combined Bankart and Superior Labral Detachment Anterior and Posterior
    Lesions: Technique and Preliminary Results. Arthroscopy 1994;10:383, with permission.)
    Figure 80.43. SLAP lesion repair. The lateral portal provides direct access to the superior aspect of the glenoid for preparation (A) for and placement (B)
    of the Suretac device. (From Warner JJ, Kann S, Marks P. Arthroscopic
    Repair of Combined Bankart and Superior Labral Detachment Anterior and
    Posterior Lesions: Technique and Preliminary Results. Arthroscopy 1994;10:383, with permission.)
  • Repair the SLAP lesion through the
    transcuff portal, using either one Suretac implant placed through the
    labrum–biceps tendon complex or two suture anchors placed just anterior
    and posterior to the biceps origin. When using the Suretac implant,
    place a cannulated drill with protruding guidewire (3 mm) through the
    transcuff portal (Fig. 80.44). The wire, which is locked in position, pierces the tissue and is used to bring the complex toward the prepared glenoid neck.
    Figure 80.44. Arthroscopic view of a type II SLAP lesion. An anterosuperior portal allows manipulation of the biceps (Bi) and preparation of the glenoid (G),
    while the lateral portal allows placement of the guidewire and drill.
    (From Warner JJ, Kann S, Marks P. Arthroscopic Repair of Combined
    Bankart and Superior Labral Detachment Anterior and Posterior Lesions:
    Technique and Preliminary Results. Arthroscopy 1994;10:383, with permission.)
  • Advance the drill to a depth of one
    external mark (approximately 1–2 cm), and unlock the wire from the bit.
    Tap at its free end to release it from the drill, and remove the drill.
    The wire should remain in place, piercing the tissue. Place the tack
    over the wire, and tamp it into place with a cannulated pusher.
Usually, one Suretac implant is placed (Fig. 80.45).
Technical errors encountered with the Suretac device will be discussed
later in the chapter. Clinical and cadaveric experience have
demonstrated that the accessory anterolateral portal (localized with a
spinal needle) can provide reliable access to the superior glenoid
region (Fig. 80.46).
Figure 80.45.
Arthroscopic stabilization of a type II SLAP lesion with a Suretac
implant. (From Warner JJ, Kann S, Marks P. Arthroscopic Repair of
Combined Bankart and Superior Labral Detachment Anterior and Posterior
Lesions: Technique and Preliminary Results. Arthroscopy 1994;10:383, with permission.)
Figure 80.46.
This cadaveric dissection demonstrates the direct localization of the
superior glenoid and SLAP repair from a lateral direction. (From Warner
JJ, Kann S, Marks P. Arthroscopic Repair of Combined Bankart and
Superior Labral Detachment Anterior and Posterior Lesions: Technique
and Preliminary Results. Arthroscopy 1994;10:383, with permission.)
Protect patients in a sling and swathe for 4 weeks.
Initiate gentle passive range-of-motion exercises in a supervised
setting 1 week postoperatively. Advise patients to avoid external
rotation past neutral and forceful abduction greater than 60° for 4
weeks. With this technique,

P.2173



P.2174


86%
satisfactory results were obtained at 2-year follow-up. Twelve of 13
athletes were able to return to full overhead function (117).

Alternatively, suture anchors can be used to repair these lesions.
  • Use the anterosuperior portal for glenoid
    preparation and the transcuff portal for implant placement. Assess and
    prepare the area beneath the labrum–biceps tendon complex as described
    previously (Fig. 80.47A, Fig. 80.47B).
    Place suture anchors anterior and posterior to the complex. We have had
    experience with the Tag Rd II (Smith and Nephew, Andover, MA) and the
    ROC (Innovasive Devices, Inc., Marlborough, MA) suture anchor systems.
    As stated previously, there are many suture anchors on the market, each
    with its own advantages and disadvantages.
    Figure 80.47. Slap lesion repair. A: Prepare the superior labral region through the lateral portal, using a shaver. B: Use an arthroscopic burr to create a bleeding surface. C: Place the arthroscopic drill through the lateral portal. D: Implant a suture anchor after drilling has been performed.
  • Regardless of the system used, drill the glenoid neck at a 45° angle from the articular surface through the transcuff portal (Fig. 80.47C). Remove the drill, and then tap the preloaded (braided, nonabsorbable material) suture anchor into place (Fig. 80.47D).
    Apply firm tension on the suture to assess fixation. Use either a
    Shuttle Relay or a suture-transport system to pass one limb of the
    suture through the biceps tendon, as previously described, using the
    anterosuperior portal (Fig. 80.48A).
    Figure 80.48. Slap lesion repair. A:
    One arthroscopic knot has been tied anteriorly. Use a suture-transport
    system to pass an additional suture through the posterior portion of
    the SLAP lesion, using the lateral portal.
  • Using arthroscopic knot-tying technique,
    fix the biceps anchor to the glenoid rim with a simple (not horizontal
    mattress) suture configuration (Fig. 80.48B).
    Assess the repair for stability at this point, and, if deemed
    necessary, place another suture anchor either anterior or posterior to
    the initial suture anchor for additional fixation.
  • Use the same postoperative protocol as for the Suretac repair.
Preliminary results with this technique have been
satisfying, although longer follow-up will be required to determine its
true clinical efficacy.
ARTHROSCOPIC BANKART REPAIR
Many of the arthroscopic techniques for SLAP lesion
repairs were adapted from techniques for arthroscopic repair of Bankart
lesions. Arthroscopic shoulder stabilization was initially attempted
with an arthroscopic staple (79).
Unfortunately, this technique was associated with a high recurrence
rate and an unacceptably high rate of complications related to the
implant (Table 80.6). Complications included
breakage and migration of the staple, as well as articular and
neurovascular injuries from the staple. This technique has largely been
abandoned.
Table 80.6. Published Complications and Instability Recurrence Rates of the Arthroscopic Staple Technique
Subsequently, Caspari and Morgan developed a
transosseous suture repair technique that avoided the pitfalls of a
juxtaarticular staple (24a,104,136). This method was based on the open technique developed by Reider and Ingles (166).
In a manner similar to that previously described for SLAP lesion
repairs, a Caspari suture punch is used to place PDS sutures through
the IGHL. These sutures are then loaded onto a special pin with a hole
at one end (Beath pin) and passed through a drill hole made at the
anterior glenoid rim so that it exits out of the infraspinatus fossa (Fig. 80.34). These sutures are then separated into two limbs and tied over the infraspinatus fascia.
In the hands of the surgeons who developed this method
of repair, results have been good to excellent over intermediate
follow-up (157). Unfortunately, others have
been unable to duplicate the success of these surgeons, and with longer
follow-up, recurrence rates have beenreported in the 20% to 40% range (Table 80.7) (58,127,140,162,165).
Table 80.7. Published Instability Recurrence Rates of the Arthroscopic Suture Technique
As discussed previously, there are technical problems
associated with this technique, such as placement of the drill hole too
medially so that the Bankart lesion is not repaired, as well as
suprascapular nerve injury from posterior exit of the pin. Finally, the
need for an additional posterior incision has made this approach less
desirable.
One of the first attempts to develop a reliable all intraarticular

P.2175



P.2176



P.2177



technique was made by Maki (92).
He proposed drilling across the glenoid in a manner similar to the
technique described above; however, a large suture (Mulberry knot) was
tied in the PDS suture so that when it was pulled back it locked on the
posterior cortex of the scapula. Internal knots were then tied over the
anterior capsule and labrum with a special knot pusher and special
knot-tying techniques. Current approaches to arthroscopic Bankart
repair involve the use of suture anchors and internal knots or
absorbable transfixing implants (42,127,183).

Regardless of which implant is used, arthroscopic
methods of repair are continuing to evolve, along with an appreciation
of more specific indications for their use. There are clear-cut
advantages and disadvantages to arthroscopic stabilization procedures (Table 80.8).
Appropriate patient selection is based on a detailed history and
physical examination, imaging studies when indicated, and a careful EUA
and arthroscopic inspection. In addition, other specific factors seem
to be associated with a good result (Table 80.4).
Table 80.8. Arthroscopic Bankart Repair
While some surgeons are exploring the role of
arthroscopic capsulorrhaphy and thermal capsular shrinkage for patients
with capsular laxity, we feel that the optimal patient for repair is
one who has a discrete Bankart lesion with robust capsuloligamentous
structures without significant capsular injury. In addition, it is
preferable if there is no significant glenoid erosion or a bony Bankart
lesion. While a small Hill–Sachs lesion is not a contraindication to
arthroscopic repair, we believe that a large Hill–Sachs lesion is
associated with recurrent episodes of dislocation and generally
indicates significant capsular laxity. With these criteria, short-term
follow-up studies have demonstrated a significant reduction to
approximately 7% to 10% in postoperative failure rates

P.2178



(recurrences) after arthroscopic stabilization procedures (84,175,176).

Authors’ Preferred Method
  • Perform arthroscopy with the patient in the beach-chair position.
  • Use three portals for the arthroscopic Bankart repair: the standard posterior, anterosuperior, and anteroinferior portals (Fig. 80.49A).
    Accurate portal placement is essential for proper technical execution
    of the procedure. The anterosuperior and anteroinferior portals must
    diverge so that intraarticular instrument crowding is not a problem.
    Figure 80.49. Arthroscopic Bankart repair. A: Use anterosuperior and anteroinferior portals for a standard repair. B:
    Use a spinal needle to localize the correct position for portal
    placement. The location should allow access to the 4- and 5-o’clock
    positions along the glenoid rim. This method is referred to as the
    outside-in technique. (From Warner JJ, Warren RF. Arthroscopic Bankart
    Repair Using a Cannulated, Absorbable Fixation Device. Oper Tech Orthop 1991;1:192, with permission.)
  • As previously discussed, place the
    anterosuperior portal just anterior and lateral to the
    acromioclavicular joint, so that a 6 mm cannula enters the joint
    vertically just beneath the biceps tendon. Locate the anteroinferior
    portal 1 cm inferior and lateral to the coracoid process, entering the
    joint just over the subscapularis tendon. Use a spinal needle before
    incising the skin to ensure access to the appropriate region along the
    anteroinferior glenoid neck (Fig. 80.49B). It
    should correspond to the 4- and 5-o’ clock positions for the right
    shoulder and to the 7- and 8-o’ clock positions for the left shoulder.
    If this inferior portal is not placed correctly, there will be a
    tendency for the drill to slip either medially or inferiorly when you
    attempt fixation. Insert a large, 8 mm cannula through this portal to
    allow placement of the appropriate instruments.
  • As with SLAP lesions, adequately prepare
    the glenoid neck to ensure healing of soft tissue to bone, including
    the inferior glenoid rim, which usually requires enlargement of the
    Bankart lesion (Fig. 80.50A). Gain access to
    this region through the anteroinferior portal; use a motorized shaver
    and burr to create a bony trough along the anterior glenoid neck that
    prevents drill slippage during subsequent portions of the procedure (Fig. 80.50B, Fig. 80.50C and Fig. 80.50D).
    Figure 80.50. Arthroscopic Bankart repair. A:
    The standard arthroscopic portals are depicted. Place an arthroscopic
    rasp through the anterosuperior portal to prepare the glenoid rim.
    (From Warner JJ, Warren RF. Arthroscopic Bankart Repair Using a
    Cannulated, Absorbable Fixation Device. Oper Tech Orthop Surg 1991;1:192, with permission.) B: An arthroscopic burr has been placed through the anterosuperior portal. C: This cadaveric dissection demonstrates glenoid preparation with the burr. D:
    Glenoid preparation has been performed up to the 5-o’clock position.
    (From Warner JJ, Miller MD, Marks P. Arthroscopic Bankart Repair with
    the Suretac Device. Part II. Experimental Observations. Arthroscopy 1995;11:14, with permission.)
  • Use a 30° arthroscope placed through the posterior and anterosuperior portals to assess the preparation (Fig. 80.51).

    P.2179



    Alternatively, place a 70° arthroscope through the posterior portal to gain a bird’s-eye view of the anterior glenoid region.

    Figure 80.51. Arthroscopic view through the anterosuperior portal demonstrates displacement of the anterior band of the IGHL with a probe. The anterior glenoid rim has been decorticated before arthroscopic repair (arrows). (From Warner JJP, Altchek DW. Arthroscopic Repairs for Instability. In: Warner JJP, Iannotti JP, Gerber C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott–Raven Publishers, 1997:34, with permission.)
  • In chronic instability, the detached capsulolabral complex may adhere by scar medially along the scapula. Neviaser (109) termed this an anterior labral periosteal sleeve avulsion
    (ALPSA) injury. It is essential to mobilize this tissue so that it can
    be reattached at its anatomic site adjacent to the articular margin of
    the glenoid. Use a hooked-tip electrocautery device and a knife–rasp to
    subperiosteally elevate the scarred capsulolabral tissue (Fig. 80.52A).
    Figure 80.52. Arthroscopic Bankart repair. A: Place an arthroscopic instrument through the anterosuperior portal and grasp the anterior band of the IGHL (H.H., humeral head; G., glenoid). B: Pull the IGHL in a posterosuperior direction, using an arthroscopic grasper. C: This cadaveric dissection demonstrates a persistent Bankart lesion after inadequate mobilization of the IGHL. (arrows). D:
    Appropriate superior shift of the anterior band of the IGHL avoids this
    problem by bringing the soft tissues firmly against the anteroinferior
    glenoid rim. (From Warner JJ, Miller MD, Marks P. Arthroscopic Bankart
    Repair with the Suretac Device. Part II. Experimental Observations. Arthroscopy 1995;11:14, with permission.)
  • Place an arthroscopic grasper through the
    anterosuperior portal, and use it to pull the tissue into the
    appropriate position before repair with the Suretac implant (Fig. 80.52B, Fig. 80.52C and Fig. 80.52D). Place this device, using the same technique described previously for SLAP lesion repairs.
  • Postoperatively, protect patients in a
    sling and swathe for 4 weeks. Allow them to shower, but they should
    avoid external rotation; advise them to maintain the arm internally
    rotated when it is out of the sling. Allow elbow motion, as well as
    activities of daily living, which generally involve limited forward
    flexion. After 4 weeks, allow active-assisted stretching and
    strengthening exercises. Allow swimming and throwing at 4 months and
    contact sports at 6 months.
Using many of the principals developed for the Suretac
device, we recently increased our use of suture anchors along the
anterior glenohumeral rim in patients with labral pathology and
associated capsular laxity or stretch.
  • With the patient in the beach-chair
    position, create posterior, anterosuperior, and anteroinferior portals
    as previously described. Once again, it is important to maintain
    adequate distance between the two anterior portals to avoid instrument
    crowding. A spinal needle is helpful in localizing the more inferior
    portal (Fig. 80.53A). The anteroinferior portal
    contains a large, 8.0 mm cannula to allow placement of the drill and
    suture hook during the procedure.
    Figure 80.53. Arthroscopic Bankart repair. A: Use a spinal needle to localize the appropriate portal location. B: Use arthroscopic electrocautery to mobilize the anterior band of the IGHL and prepare the anterior glenoid rim. C: Use an arthroscopic burr to create a bleeding surface to promote postoperative healing.
  • Prepare the glenoid rim through the same anterior portals, making sure to effectively mobilize the anterior

    P.2180



    P.2181



    capsulolabral tissue (Fig. 80.53B).
    As previously described, create a trough with the burr to prevent the
    drill from slipping and possibly damaging the articular cartilage (Fig. 80.53C).

  • This suture anchor system requires
    predrilling before anchor placement. Drilling is performed through the
    anteroinferior portal. The system contains a drill guide, which
    maintains appropriate orientation and drill hole location. Remove the
    drill and keep the guide in place. Tap the suture anchor loaded with
    braided suture into place (Fig. 80.54A). Apply tension to the suture ends to test the fixation.
    Figure 80.54. Arthroscopic Bankart repair. A:
    Impact a suture anchor loaded with a nonabsorbable, braided suture into
    the anterior glenoid rim through the anteroinferior portal. B:
    Use a cannulated hook to pass the Shuttle Relay through the IGHL, and
    then pull it through the anterosuperior portal, using an arthroscopic
    grasper. C: Use the Shuttle Relay to pass
    the suture in the anterosuperior portal through the IGHL, which is then
    tied arthroscopically with half-hitch knots. D: Alternatively, use a suture-transport system to pass the suture through the soft tissue.
  • Perform the remaining portion of the
    procedure, using a suture hook and Shuttle Relay system or a
    suture-transport system as previously mentioned. If the Shuttle Relay
    is to be used, pass one limb of the suture through the anterosuperior
    portal with a grasper. Pass a suture hook loaded with a Shuttle Relay
    through the anteroinferior capsule and IGHL. Take care to avoid tearing
    the tissue while grasping enough tissue to adequately reduce joint
    volume. If using the Shuttle Relay, advance it through the suture hook
    and pull it through the anterosuperior cannula with a grasper (Fig. 80.54B). Remove the suture hook while maintaining tension on the

    P.2182



    Shuttle Relay; then load the eyelet of the Shuttle Relay with the
    previously passed suture, and pull this suture in a retrograde fashion
    back through the tissue and the anteroinferior cannula.

  • Leave the second limb of suture free,
    rather than passing it through the tissue. This technique pulls the
    tissue to the glenoid rim, and bunches it together to recreate the
    “chock block” effect of the labrum. Then tie the suture with an
    arthroscopic knot pusher (Fig. 80.54C). In the
    case illustrated, a half-hitch technique was used to secure the tissue,
    essentially tying the suture with alternating half-knots. There are
    other knot-tying techniques (i.e., Tennessee slider) that allow
    immediate locking of the stitch by pulling the post. These knots have
    the benefit of being lower profile.
  • Alternatively, if using a
    suture-transport system, pass the device through the anteroinferior
    portal and tissue. Grasp one limb of the suture still in the
    anteroinferior portal, and pull the device and suture in retrograde
    fashion back through the tissue and cannula (Fig. 80.54D). Then use an arthroscopic knot pusher, and tie the nonabsorbable suture.

P.2183



P.2184


Table 80.9. Suretac Technical Errors
 
Problem Solution
Bending of wire during drill placement and glenoid drilling Allow only 2 to 3 mm of wire exposure, wire locked in place
Improper drill or wire placement:  
   Above the equator of the glenoid (Fig. 80.55) Appropriate portal localization with spinal needle
   Slips medially and inferiorly Preparation of deep bony trough along glenoid rim
   Captures too little tissue +/- tissue of poor quality (Fig. 80.56) Appropriate tissue mobilization and good patient selection (robust ligament)
Guidewire extraction during drill removal Maintenance of wire placement:Unlock wire Tap in further before drill removal Remove drill with counterpressure
Head of Suretac buttonholes through tissue (Fig. 80.57) Gentle impaction
Removal of Suretac causes bleeding If occurs:Leave implant in place Debride head Place second, adjacent Suretac
Drill too deeply (exiting posterior cortex of scapula) Drill depth of one external mark, which corresponds the length of the Suretac implant
Breakage or bending of Suretac during placement (Fig. 80.58A) Adequate drilling (depth) before placement
Suretac may fall into axillary pouch (Fig. 80.58B) Accessory posterior portal for retrieval (Fig. 80.58E)
Table 80.10. Suture Anchor Technical Errors
Figure 80.55. Arthroscopic Bankart repair. A: The Suretac implant has been placed too far medially (arrow) in this cadaveric specimen. B: This coronal dissection demonstrates a medially placed implant. Arrows
demonstrate the correct location for implant placement and a persistent
capsulolabral separation that results from medial Suretac placement.
(From Warner JJ, Miller MD, Marks P. Arthroscopic Bankart Repair with
the Suretac Device. Part II. Experimental Observations. Arthroscopy 1995;11:14, with permission.)
Figure 80.56. Arthroscopic Bankart repair. A: Arthroscopic view demonstrates a rupture in the anterior band of the IGHL while the arm is in the neutral position. B:
With the arm in abduction, the degree of damage is further
demonstrated. Incompetent or damaged ligamentous tissues prohibit
adequate arthroscopic shoulder stabilization. (From Warner JJP.
Arthroscopic Bankart Repair. In: Bigliani LU, ed. Shoulder Instability. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1996:47, with permission.)
Figure 80.57. Arthroscopic Bankart repair. A: Arthroscopic view through the anterosuperior portal demonstrates a Suretac implant that has buttonholed (arrows) through the anterior band of the IGHL. B: Viewing through the posterior portal demonstrates limited soft tissue under the head (arrows)
of the device. (From Warner JJP, Altchek DW. Arthroscopic Repairs for
Instability. In: Warner JJP, Iannotti JP, Gerber C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott–Raven Publishers, 1997:39, with permission.)
Figure 80.58. Arthroscopic Bankart repair. A:
Arthroscopic view through the anterosuperior portal demonstrates a bent
guidewire and associated implant breakage during attempted repair of a
posterior Bankart lesion. B: The Suretac has fallen into the axillary pouch. C: The implant is retrieved from the axillary pouch with the use of an accessory posterior portal (HH,
humeral head). (From Warner JJP, Altchek DW. Arthroscopic Repairs for
Instability. In: Warner JJP, Iannotti JP, Gerber C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott–Raven Publishers, 1997:40, with permission.)
Maintain patients in a sling and swathe for 4 weeks.
Allow bathing and elbow–wrist range of motion at 1 week, but external
rotation past neutral should be avoided. Allow passive and
active-assisted range-of-motion exercises and pulley exercises at 4
weeks. Initiate elastic band rotator cuff strengthening exercises at 2
months and weight training at 4 months. Allow noncontact sports at 4
months and contact sports at 6–9 months, depending on the level of
contact.
ARTHROSCOPIC CAPSULAR SHIFT
Since Neer and Foster’s (107) original description of MDI, many open techniques have been developed to stabilize patients with the condition (3,10,78,171).
While results with these methods have been good, they have not been on
par with the results after treatment of traumatic unidirectional
anterior instability; return to overhead athletic activities has been
less certain. Moreover, there is a perception that perioperative
morbidity might be improved with a “less invasive” arthroscopic
technique. For this reason, several surgeons have attempted to develop
arthroscopic methods of capsulorrhaphy to treat patients with MDI.
While some surgeons have reported on their initial experience with
these methods (Eugene Wolf and Steven Snyder, personal communications),
little has been reported in the peer-reviewed literature.
Duncan and Savoie (41) described an arthroscopic inferior capsular shift in 1993. The technique involved dividing

P.2185



the anterior and inferior capsule with an end-cutting shaver. This
division allowed the inferior capsule to be advanced superiorly.
Sutures were tied with a transglenoid suture technique. This initial
report was a preliminary study of 10 patients who were all found to
have a “satisfactory” shoulder according to the Neer and Foster
criteria. An average Rowe score of 90 was reported, as well.
Modifications of this transglenoid suture capsulorrhaphy have been
developed to address posterior instability (100).

Wichman and Snyder (180)
described a technique of capsular plication in a select population with
MDI and no associated labral pathology. All patients underwent a
prolonged course of rehabilitation before surgical intervention, which
allowed serial examinations. Over the weeks, the physicians’ knowledge
of the patient and the underlying disorder increased. Thus, patients
with voluntary instability of a psychological nature could be
identified.
  • This technique is performed in the
    lateral decubitus position, using the standard posterior and
    anterosuperior portals as described previously. In addition, an
    anterior mid-glenoid portal is used corresponding to an area
    approximately 3 cm distal and 2 cm lateral to the anterosuperior
    portal. This portal is made through an outside-in technique and enters
    the joint just over the subscapularis tendon in a manner similar to the
    anteroinferior portal previously described.
  • Place a large (8.4 mm) cannula into this
    portal to provide access for large suture hooks. For anterior
    plication, place the arthroscope posteriorly, and abrade the synovium
    along the anterior and inferior capsule with a rasp or 4.5 mm
    arthroscopic shaver (Fig. 80.59A).

    P.2186



    P.2187



    P.2188



    This abrasion creates bleeding, which will subsequently promote healing.

    Figure 80.59. Arthroscopic capsular shift. A: Use an arthroscopic rasp to prepare the anterior capsule through the anteroinferior portal. B: Pass a suture hook through the inferior capsule. C:
    The hook allows passage of the Shuttle Relay through the inferior
    capsule and labrum, and the relay is then passed through the
    anterosuperior portal using an arthroscopic grasper. D:
    Use the Shuttle Relay to pass the suture in a retrograde fashion
    through the tissue. (From Wichman MT, Snyder SJ. Arthroscopic Capsular
    Plication for Multidirectional Instability of the Shoulder. Oper Tech Sports Med 1997;5:238, with permission.)
  • Pass a 90° suture hook with a loaded
    Shuttle Relay through the anteroinferior cannula and create a pinch
    stitch by taking anteroinferior capsule and advancing it superiorly and
    medially to the anteroinferior labrum (Fig. 80.59B). A 1-cm-thick fold is produced between the capsule and labrum.
  • Deliver the Shuttle Relay through the end of the hook, and pull it through the anterosuperior portal with a grasper (Fig. 80.59C).
    Lead the eyelet of the Shuttle Relay with a braided, nonabsorbable
    suture, and pull it in a retrograde fashion through the labrum and
    capsule and out the anteroinferior portal (Fig. 80.59D). Repeat this process slightly more superiorly to create a horizontal mattress stitch (Fig. 80.60A).
    Figure 80.60. Arthroscopic capsular shift. A: Repeat the process for the second limb of the suture to create an effective horizontal stitch. B: The process can be repeated anteriorly, inferiorly, and posteriorly for the patient with MDI. C:
    The goal is to decrease the capsular volume and recreate the “chock
    block” effect of the labrum. (From Wichman MT, Snyder SJ. Arthroscopic
    Capsular Plication for Multidirectional Instability of the Shoulder. Oper Tech Sports Med 1997;5:238, with permission.)
  • Use an arthroscopic knot pusher to close the fold, with the knot away from the articular surface. Other sutures

    P.2189



    can be placed in this fashion in other regions of the joint, where necessary (Fig. 80.60B, Fig. 80.60C).

  • If posterior plication is anticipated, it
    is recommended that the posterior portal be created slightly more
    superiorly. Of course, hook and suture placement would be performed
    with the arthroscope through the anterosuperior portal in this case.
With this technique, external rotation was preserved to
within 10° of the preoperative level in 92% of patients at a minimum
2-year follow-up. An assessment of postoperative function using the
American Shoulder and Elbow Society instrument revealed an improvement
from a preoperative score of 63 to a postoperative score of 86.2 The
average Rowe score postoperatively was 79.6. Five patients’s conditions
were rated unsatisfactory, with 19 patients having satisfactory
ratings, according to Neer’s criteria. The authors noted a
disproportionately high number of workers’ compensation cases in the
unsatisfactory group. Interestingly, three patients underwent
second-look arthroscopy (two for unrelated procedures) that revealed
significant capsule formation at the site of previous plication and no
adverse synovial reaction to the suture.
LASER OR THERMAL CAPSULAR SHRINKAGE
The use of heat to treat shoulder instability dates back
to 460 BC when Hippocrates inserted a hot iron into the axilla,
contracting the inferior aspect of the joint. This same concept has
gained recent popularity, but laser and radiofrequency energy sources
are used to produce the heat. The triple-helix structure of collagen
unwinds at 65°C, undergoing a conformational change from a crystalline,
extended state to a randomly coiled, contracted state (denatured) and
producing shrinkage in capsular tissues (106). Current literature has focused on laser technology as a source of the thermal energy. Hayashi et al. (66) demonstrated a dose-dependent effect of nonablative laser energy on capsular tissue properties.
The Holmium:yttrium-aluminum-garnet (Ho:YAG) laser has received considerable attention (1,141).
Laser energy at low power—less than 10 watts (1.0 joule per pulse at 10
hertz)—is recommended for laser-assisted capsular shrinkage. There are
several disadvantages to the use of laser energy. First, lasers are
very expensive and require a certain level of expertise and appropriate
certification for use. Further, lasers produce significant power that
can be difficult to control.
Radiofrequency thermal stimulation has been used as an
alternative energy source that avoids some of the problems inherent in
laser energy. Such devices are less expensive and are relatively easier
to use. The ElectroThermal Arthroscopy system (ORATEC Interventions,
Inc., Menlo Park, CA) integrates a thermocouple into the arthroscopic
handpiece, creating a monopolar system. The current applied to the
tissue at the dull probe tip is minimally invasive while still
accomplishing collagen denaturation (S.P. Arnoczky, personal
communication). This system contrasts with the vapor system from Mitek
Surgical Products, Inc. (Westwood, MA), which represents a bipolar
system without a thermocouple. Both products are radiofrequency systems.
These instruments have been applied over the past
several years as an experimental treatment method. Their obvious appeal
is that they can be used effectively in an outpatient setting. The
procedure does not require a great deal of time or the use of sutures
or implants. Unfortunately, while anecdotal reports concerning these
procedures are appearing, there is currently no peer-reviewed
literature available regarding the effectiveness of this technique.
Nevertheless, thermal capsular shrinkage remains a possible alternative
treatment. Its efficacy will need to be substantiated over the next
5–10 years with well controlled follow-up studies to assess whether
there is a gradual restretching of the tissues with increased use.
OPEN SURGICAL TECHNIQUES
The indications for open versus arthroscopic shoulder stabilization remain a controversial topic (164). As outlined in Table 80.4,
the criteria for arthroscopic shoulder stabilization are becoming more
clearly defined. As surgeons continue to improve their ability to
arthroscopically shift the glenohumeral ligaments and repair labral
lesions and as new technologies are developed, the number of patients
who are candidates for open surgical procedures will decrease.
Certainly, the presence of a large Hill–Sachs lesion or a bony Bankart
lesion on radiographic examination is an indication for an open
surgical approach. Likewise, patients without a significant Bankart
lesion by MRI or CT may not be optimal candidates for an arthroscopic
Bankart procedure. Similarly, findings consistent with significant
capsular laxity or stretch, such as an atraumatic history or MDI
findings on physical examination, should direct the surgeon toward open
treatment options. Significant capsular damage, rotator interval
lesions, or rotator cuff tears are also currently better repaired with
open surgical techniques.
Open Anterior Shoulder Stabilization Procedures
Many open procedures have been developed and popularized
to treat anterior glenohumeral instability. TheMagnuson-Stack and
Putti-Platt procedures attempted to realign and tighten the
subscapularis tendon (158,179).
The anterior capsule was also tightened by the latter technique. The du
Toit staple capsulorrhaphy attempted to reattach the capsule and
glenoid (15,143). The Bristow

P.2190



and other bone block procedures attempted to replace the injured anterior labrum and glenoid (10).

These procedures and their modifications achieved
reasonable success rates in decreasing recurrent instability. Long-term
follow-up studies continued to reveal low recurrence rates, but
techniques that used metal staples or screws revealed high rates of
hardware-related problems. Zuckerman and Matsen (188)
retrospectively reviewed 37 patients who had previously been treated
with a modified Bristow procedure, a staple capsulorrhaphy, or a
modified Magnuson-Stack procedure. The hardware migrated or loosened in
24 shoulders and broke in three patients. Thirty-four patients required
a second operation to remove the hardware. At reoperation, 41%
demonstrated significant injury to the articular surface. Other studies
have reported similar rates of hardware-related complications (59,185).
Further, because of failure to correct the underlying anatomic problem,
many patients had significant loss of external rotation or frank
internal rotation contractures and subsequent glenohumeral arthritis (61).
In an attempt to avoid the use of hardware and correct
the presumed anatomic abnormality, Rowe and colleagues popularized the
Bankart procedure for anterior unidirectional instability (130,131,133,134).
  • This technique uses a standard
    deltopectoral approach. Classically, the subscapularis tendon is
    incised vertically at its lateral insertion and sharply dissected
    medially from the anterior capsule (Fig. 80.61A).
    Several alternatives for subscapularis dissection have been developed
    that purportedly gave equal exposure of the anterior capsule (Fig. 80.61B, Fig. 80.61C) (77,96).
    Figure 80.61. Bankart procedure for anterior unidirectional instability. A: Perform a standard lateral subscapularis dissection 1 cm from its insertion onto the lesser tuberosity. B: An L-shaped dissection avoids the anterior circumflex humeral vessels but prevents complete access to the inferior capsule. C:
    Alternatively, the subscapularis muscle can be horizontally split,
    which avoids the need for later repair of the tendon. (From Zarins B.
    Bankart Repair for Anterior Shoulder Instability. Tech Orthop 1989;3:23, with permission.)
  • Make a vertical capsulotomy approximately 0.5 cm lateral to the glenoid rim with the arm in complete external rotation (Fig. 80.62).
    Figure 80.62.
    Bankart procedure for anterior unidirectional instability. A medially
    based capsulotomy can be converted to a T-shaped capsulotomy that
    allows improved mobilization of the inferior axillary pouch in patients
    with increased anteroinferior instability. (From Zarins B. Bankart
    Repair for Anterior Shoulder Instability. Tech Orthop 1989;3:23, with permission.)
  • With complete muscle relaxation, insert a
    humeral head retractor and inspect the glenoid for evidence of a
    Bankart lesion. If a Bankart lesion is present, repair the lateral
    capsular flap to the glenoid neck.
  • Prepare this area with a curet to expose bleeding bone,

    P.2191



    and drill three holes; one at the 2-o’ clock, one at the 4-o’ clock,
    and one at the 6-o’ clock positions for right shoulders (10-, 8-, and
    6-o’ clock positions for left shoulders) as demonstrated in Figure 80.63.

    Figure 80.63.
    Bankart procedure for anterior unidirectional instability. Make drill
    holes along the glenoid rim at the 1-, 3-, and 5-o’clock positions for
    right shoulders. (From Zarins B. Bankart Repair for Anterior Shoulder
    Instability. Tech Orthop 1989;3:23, with permission.)
  • Pass sutures through the holes and the lateral capsular flap with a Mayo needle (Fig. 80.64A).
    Tie the flap down to the glenoid rim, and pass these same sutures
    through the small medial capsular flap, reinforcing the repair (Fig. 80.65).
    Figure 80.64. Bankart procedure for anterior unidirectional instability. A: Pass the suture through drill holes in the glenoid rim. B:
    Alternatively, if there is no significant Bankart lesion, the suture
    can be placed directly through the anterior labrum. (From Zarins B.
    Bankart Repair for Anterior Shoulder Instability. Tech Orthop 1989;3:23, with permission.)
    Figure 80.65.
    Bankart procedure for anterior unidirectional instability. Pull the
    inferior capsular flap superiorly to the glenoid rim first. Arm
    position is critical during this portion of the procedure and
    determines final postoperative motion. Increasing abduction and
    external rotation will improve final postoperative motion. (From Zarins
    B. Bankart Repair for Anterior Shoulder Instability. Tech Orthop 1989;3:23, with permission.)
  • If no Bankart lesion is found on inspection, merely place sutures through the labrum rather than drill holes (Fig. 80.64B).
  • With the production of multiple suture
    anchors, many surgeons have modified the procedure, using these
    implants along the glenoid rim (87). Despite
    reports of good success with these devices, there remains a risk of
    technical failure and resultant instability or articular cartilage
    damage.
Rowe et al. (131,134)
reported good-to-excellent results in 96.5% of patients, with a 3.5%
recurrence rate, using this procedure. A loss of terminal external
rotation, however, was noted in many patients. Further, only 33% of
throwing athletes with involvement of the dominant arm were able to
return to their original level of competition. Rosenberg et al. (128) demonstrated a

P.2192



statistical relationship between late degenerative changes and
restriction of external rotation in 90° of arm abduction. These reports
led others to modify the operative techniques to address these
problems. In addition, the increased association between repeated
subluxations or dislocations and subsequent capsuloligamentous injury
has shifted attention toward correction of the associated capsular
laxity.

The T-plasty modification of the Bankart procedure was
developed to treat underlying anteroinferior capsular laxity with an
associated Bankart lesion (3).
  • Expose the anterior capsule as previously
    described. In addition to the vertical capsulotomy at the glenoid
    margin, create a transverse limb at the mid portion of the capsule (Fig. 80.62).
  • If a Bankart lesion is visualized,
    prepare the glenoid neck as previously described. If there is no
    lesion, pass sutures through the labrum rather than through drill holes.
  • Position the arm in 40° of external
    rotation and 45° of abduction. Then pull the inferior flap superiorly
    and medially to the upper rim to allow 40° external rotation (Fig. 80.66),
    reduce the inferior redundancy, and simultaneously correct for a
    Bankart lesion, if present. Pull the superior flap inferiorly and
    medially to reinforce the inferior flap (Fig. 80.67).
    Figure 80.66.
    T-plasty modification of the Bankart procedure. Pull the superior
    capsular flap inferiorly with the arm in slight abduction and external
    rotation. (From Zarins B. Bankart Repair for Anterior Shoulder
    Instability. Tech Orthop 1989;3:23, with permission.)
    Figure 80.67.
    T-plasty modification of the Bankart procedure. Pull the medial flap
    over the lateral flap to supplement the repair. (From Zarins B. Bankart
    Repair for Anterior Shoulder Instability. Tech Orthop 1989;3:23, with permission.)

P.2193


Altchek et al. (3) reported on
their experience with this procedure involving 42 shoulders in 40
athletes. Postoperatively, 20 shoulders had external rotation in
adduction that was symmetric to the opposite side. The remaining22
shoulders, however, demonstrated a loss of 5° to 25° external rotation
(average, 10°). Despite 95% excellent results with this procedure,
throwing athletes in this study continued to report a decrease in
maximum ball speed on throwing.
Jobe et al. (78) performed a
similar operation but used a horizontal split in the subscapularis
muscle to expose the anterior capsule. This method avoids the risk of
postoperative subscapularis tendon disruption (59).
Intraoperatively, they made sure no tension was present along the
suture line until 90° of abduction and 45° of external rotation was
reached. Patients were then splinted in 90° of abduction, 45° of
external rotation, and 30° of forward flexion. With this technique,
they reported excellent results in 68% of a group of overhand athletes.
Despite these efforts, six patients had a loss of 10° to 20° external
rotation. An assessment of the 12 skilled pitchers in this study
revealed that 50% returned to their former level of competition for at
least one season.
As becomes apparent from these studies, it is difficult
to obtain full terminal rotation postoperatively with this repair
technique; further, full external rotation is necessary for high-level
pitchers to obtain peak throwing velocity. In Neer and Foster’s (107)
classic article on MDI, the inferior capsular shift was introduced.
Like the modified Bankart procedures described above, this technique
involved a T-shaped capsulotomy, but the vertical cut was made
laterally along the humeral neck and a horizontal cut was made between
the middle glenohumeral ligament (MGHL) and the IGHL. If a rotator
interval defect was noted, it was repaired and then the same horizontal
cut created.
This operation was designed for patients with
involuntary inferior and multidirectional instability. If a patient had
an associated Bankart lesion, however, it was repaired with the use of
an inside-out suture technique at the glenoid rim. A shallow trough was
made laterally along the humeral neck. Neer and Foster recommended
holding the arm in 10° external rotation while suturing the inferior
flap to the stump of the subscapularis tendon and to the remaining cuff
of capsule along the humeral neck. The superior flap containing the
MGHL was then sutured over the inferior flap to reinforce the repair.
The tension on the inferior flap was selected to reduce the inferior
and posterior capsular laxity. The lateral capsulotomy, as opposed to
the medial approach, has a greater ability to reduce capsular volume
because the capsular circumference is largest laterally.
Bigliani et al. (10) reported on
a series of inferior capsular shift procedures performed in 68
shoulders in 63 athletic individuals. On the basis of Neer and Foster’s
experience and the concept that anterior instability in the athlete
represents a spectrum of pathology, they performed an inferior capsular
shift in all cases. The inferior capsule was mobilized and shifted on
the basis of the degree of inferior laxity demonstrated by EUA in each
individual. Initially, the shoulders were repaired with the arm in 20°
of abduction and 10° of external rotation. However, as it was noticed
that only 50% of the overhead athletes involved in throwing had
excellent results, abduction and external rotation were increased by
10° at the time of repair. Despite modifications in technique and
postoperative mobilization, only 5 of 10 overhead athletes returned to
their same level of competitiveness. Only two of six varsity or
professional overhead athletes were able to return to the same level of
sporting activity.
Authors’ Preferred Method
We prefer a selective capsular shift. This technique is
based on the clinical observation that a spectrum of labral and
capsuloligamentous pathology exists, as well as on experimental
observations concerning the role of the glenohumeral ligaments (171).
As alluded to previously, patients with traumatic
instability may have a Bankart lesion, while others may have capsular
injury without labral pathology. It is generally believed that some
capsuloligamentous damage is created with each episode of instability.
As a result, it becomes difficult to categorize patients purely on the
basis of history or physical examination. An operative repair should be
able to address all intraarticular pathology adequately.
In addition, cadaver studies demonstrate that the
superior glenohumeral ligament and the MGHL function as a static
barrier to anteroinferior humeral head translation with the arm in
adduction and external rotation (37,160).
Similar studies demonstrate that the IGHL serves as a static restraint
to translation with progressive increases in abduction and external
rotation (113,114 and 115).
As a result, in the technique that follows, each capsular flap is
sutured with the arm in the position that maintains greatest tension on
ligamentous structures being repaired, contributing, it is hoped, to
overall postoperative motion.
Examination under anesthesia is performed as described
previously, and the degree of capsular laxity is used to determine the
amount the inferior capsule that should be mobilized.
  • Place the patient in a semisitting
    position resting on a long bean bag. Contour the bag along the medial
    scapular border, allowing the injured shoulder and arm to hang over the
    edge of the table. First, mold and solidify the bag, and then pull the
    entire construct over the edge of the table. A McConnell Shoulder
    Holder (McConnell, Inc., Greenville, TX) allows proper positioning of
    the arm. Use a standard deltopectoral approach, with the incision
    maintained low in the axillary fold for better cosmesis. Place a
    self-retaining retractor into the interval.

    P.2194


    Make
    a small transverse incision, if needed, in the conjoined tendon just
    distal to the coracoid tip to increase medial exposure. Maintain manual
    retraction along the conjoined tendon to avoid a neuropraxic injury to
    the musculocutaneous nerve. Resect the coracoacromial ligament to
    better expose the superior capsule and evaluate the rotator interval.

  • Isolate the anterior circumflex humeral
    vessels, and suture-ligate them at the inferior aspect of the
    subscapularis muscle. Use needle-tip electrocautery to dissect the
    subscapularis muscle from lateral to medial off the anterior capsule in
    the coronal plane. Palpate the axillary nerve; then visualize and
    isolate it with a vessel loop to avoid injuring it during surgery.
  • If no significant rotator interval lesion
    is noted, create a T-shaped capsulotomy with the horizontal cut between
    the MGHL and the IGHL, ending at the equator of the glenoid. Make the
    vertical component of the capsulotomy just medial to the lateral
    insertion of the capsule into the humeral neck. At this point, consider
    the degree of capsular laxity demonstrated during the EUA. The position
    of the vertical capsulotomy may range from 6 o’ clock to 8 o’ clock
    along the humeral neck, depending on the degree of inferior laxity. If
    there is significant inferior laxity, choose the latter position. Carry
    the vertical component up to the supraspinatus tendon superiorly. With
    maximal muscle relaxation, place a humeral head retractor into the
    joint, and visualize the anterior labral region.
If a Bankart lesion exists, further mobilize it from the
scapular neck, and place a three-prong retractor medially along the
scapular neck for exposure. Then decorticate the glenoid surface, using
a small osteotome. Place suture anchors (Acufex Microsurgical, Inc.,
Mansfield, MA) loaded with a #1 nonabsorbable suture into the 2-, 4-,
and 6-o’ clock positions for right shoulders or corresponding positions
for left shoulders. Then place sutures through the capsule from the
inside-out, and tie them over the capsule in a horizontal mattress
fashion to repair the Bankart lesion (Fig. 80.68).
Take care to repair the capsule without any shortening in a medial
direction. No shifting of the capsule is performed at this point, as an
anatomic repair of the Bankart lesion is the goal.
Figure 80.68. Open selective capsular shift. A:
After a lateral capsulotomy, mobilize the capsule laterally from its
scarred position along the glenoid rim. Place a suture anchor along the
rim, and pull each limb of the suture through the capsule. B:
Typically, three suture anchors are placed and tied in horizontal
fashion. An additional horizontal capsulotomy creates superior and
inferior flaps. (From Warner JJP, Johnson D, Miller MD, Caborn DN.
Technique for Selecting Capsular Tightness in Repair of Anteroinferior
Shoulder Instability. J Shoulder Elbow Surg 1995;352, with permission.)
  • Remove the humeral head retractor, and
    place the shoulder into 60° to 80° of abduction, 45° to 60° of external
    rotation, and 10° of forward flexion. Pull the inferior capsular flap
    superiorly and laterally, and suture it to the cuff of capsular tissue
    at the humeral neck (Fig. 80.69A). Adjust
    abduction and external rotation on the basis of the individual’s needs.
    Thus, if the operation involves the dominant arm of a throwing athlete,
    position the arm in 80° of abduction and 60° of external rotation. Use
    lower degrees if treatment involves a nondominant arm or an athlete
    involved in a sport with limited overhead activity.
    Figure 80.69. Open selective capsular shift. A:
    Tie the inferior flap to the superolateral capsular tissue with the arm
    in 40° of abduction and between 45° and 80° of external rotation. The
    amount of rotation depends on the postoperative expectations of the
    patient. B: Tie the superior flap to the
    inferolateral tissue with the arm in neutral to 10° of abduction and
    45° to 60° of external rotation. (From Warner JJP, Johnson D, Miller
    MD, Caborn DN. Technique for Selecting Capsular Tightness in Repair of
    Anteroinferior Shoulder Instability. J Shoulder Elbow Surg 1995;352, with permission.)
Following the repair of the inferior flap, reposition
the arm in 0° of adduction and 45° of external rotation. The superior
capsular flap is then sutured inferiorly and laterally over the other
flap (Fig. 80.69B). Place sutures, which were previously placed through the inferior flap,

P.2195



through the superior flap to create a pants-over-vest closure.

Incorporate significant rotator interval defects, which
are associated with increased inferior laxity in adduction, into the
capsulotomy. This method is in contrast to repairing the defect as Neer
and Foster recommend. The rotator interval becomes part of the
horizontal cut to create an upside-down L-shaped capsulotomy (Fig. 80.70A, Fig. 80.70B).
Suture the inferior capsular flap as previously described, but apply
tension to the remaining superior capsule by repairing the horizontal
portion of the inferior flap over the superior flap with the arm in 0°
of adduction and 45° of external rotation (Fig. 80.70C, Fig. 80.70D).
Figure 80.70. Open selective capsular shift. A:
A rotator interval lesion is demonstrated in associated with increased
inferior laxity in neutral abduction that does not stabilize with
increasing external rotation. B: Incorporate this capsular defect, if present, into the capsulotomy, creating an inverted L-shaped capsulotomy. C: Mobilize the tissue superiorly, and tie it to the lateral capsular tissue with the arm in abduction and external rotation. D:
Subsequently, repair the rotator interval lesion with the arm in
neutral abduction and external rotation. (From Warner JJP, Johnson D,
Miller MD, Caborn DN. Technique for Selecting Capsular Tightness in
Repair of Anteroinferior Shoulder Instability. J Shoulder Elbow Surg 1995;352, with permission.)
On completion of the repair, 90° of abduction should be
possible in the scapular plane. Further, in this position, 60° of
external rotation should be possible before tension is noted along the
suture lines. With the arm in 0° of adduction, external rotation to 45°
should be possible with minimal tension along the repair. Typically, an
intraoperative drawer test is performed, and with the arm in 45° of
abduction and neutral rotation, anterior and posterior drawer tests
should not be greater than 1+. The shoulder should further stabilize
with increased abduction and external rotation, with the drawer tests
decreasing to zero. The inferior drawer test should be 0–1+ with the
arm at the side. If so, the subscapularis tendon is repaired
anatomically.
Postoperatively, immobilize the arm in a sling and
swathe for 3–4 weeks, allowing the patient to perform limited abduction
for axillary care and dressing. During this period, allow the patient
to flex and extend the elbow. Then remove the sling and institute
unlimited active-assisted range-of-motion exercises, as well as
isometric strengthening for external rotation, flexion, extension, and
abduction of the arm. Caution the patient to avoid internal rotation
for 6 weeks to prevent stress on the subscapularis repair.
At 6 weeks, allow isotonic strengthening exercises using
elastic bands, and at 4 months allow the patient to swim, throw a ball,
or hit gentle ground strokes in tennis. At 6 months, release the
patient to more forceful throwing or swinging. Do not allow the patient
to return to contact sports until 8 months after the operative
procedure.
Open Posterior Shoulder Stabilization Procedures
The incidence of true posterior dislocations is rare.
Yet there is increasing evidence that a higher prevalence of posterior
subluxation exists, especially in overhead athletes, than previously
recognized (50,123,156).
Operative procedures that have treated posterior instability have been
less successful than anterior procedures at preventing recurrent
instability.
Nonoperative Treatment
Because of the lower success rates with posterior
procedures, it is important in primary and revision cases to attempt an
adequate course of nonoperative management. Focus rehabilitation on
strengthening the dynamic muscle stabilizers to correct for the
deficient posterior static stabilizers. Specifically, exercises should
focus on strengthening the rotator cuff and deltoid and scapular
muscles. Further, the patient and the therapist should be educated to
avoid forward flexion, adduction, and internal rotation, as these
positions place increased stress on the posterior structures. If this
process fails to alleviate symptoms or episodes of instability, it is
important to focus on patient goals, as the outcome of surgical
treatment may be unsatisfactory to the patient.
Operative Techniques
Initial attempts at posterior stabilization procedures used either the Nicola procedure or the posterior Bankart procedure (40,95,101,102,137). These initial reports involved limited numbers of patients with mixed results. Boyd and Sisk (16) used a posterior

P.2196



capsulorrhaphy and posterior transfer of the long head of the biceps
brachii in nine shoulders and reported no recurrences. Mowery et al. (105)
reported on the use of a posterior bone block in five patients with
recurrent posterior dislocations. Four of the five cases were rated as
excellent at a minimum 2.5-year follow-up. However, closer evaluation
revealed that one patient underwent screw removal, and one of the bone
grafts was deemed osteoporotic at 3 years. Further, in the fifth case
that was rated as good, the patient required a manipulation under
anesthesia for limited motion and subsequently suffered from anterior
instability.

These initial posterior procedures were performed on individuals with a history of dislocation. As noted by Hawkins et al. (63),
the uncommon nature of posterior instability and confusion in the
literature in differentiating subluxations from dislocations led to a
poor understanding of this entity. In the same article, they
retrospectively reviewed 50 shoulders in 35 patients treated for
recurrent posterior instability. Only 11 patients had had a primary
traumatic event before the onset of instability. Forty-one of the
affected shoulders demonstrated voluntary, positional instability that
affected activities of daily living. Thirteen of 26 shoulders that
underwent surgical reconstruction (17 posterior
glenoid osteotomies, six reverse Putti-Platt procedures, and three
biceps tendon transfers) developed recurrent instability. The authors
also noted that the posterior glenoid osteotomy was associated with
osteoarthritis.
In 1989, Fronek et al. (48)
presented a series of 24 patients with posterior subluxation who were
divided into two groups. Members of the first group, who had less

P.2197


severe
symptoms, were treated with physical therapy and had a 63% success
rate. Group II consisted of individuals who either failed physical
therapy or had more severe symptoms. They were treated with a posterior
capsulorrhaphy with or without a posterior bone block. In this group,
91% suffered no additional episodes of instability. However, 70% of the
athletes in both groups participated in sports at a diminished level.

Tibone and Ting (155) reported
on their experience using a posterior staple capsulorrhaphy technique.
Twenty athletes were treated for recurrent posterior subluxation, with
eight of them also suffering from concomitant anterior instability. In
this series, six patients suffered from recurrent posterior
instability, while an additional three patients had moderate to severe
pain. Significant complications that were a direct result of the
procedure developed in five patients. They concluded that this
technique was not an acceptable treatment option for posterior
instability.
In 1993, Tibone and Bradley (156)
reported on their experience using a posterior suture capsulorrhaphy
technique that avoided the complications associated with staples or
bone blocks.
  • This technique, which was very similar to that described by Fronek et al. (48),
    used a posterior saber incision starting at the acromion and
    terminating in the posterior axillary fold. Split the deltoid muscle in
    line with its fibers approximately 2–3 cm medial to the posterolateral
    corner of the acromion for 5–6 cm, with care to avoid injury to the
    axillary nerve, which enters the muscle distal to the teres minor
    muscle.
  • Develop the interval between the
    infraspinatus and teres minor muscles, and expose the underlying
    capsule. Make a T-shaped capsulotomy with the horizontal component at
    the glenoid rim.
  • Transfer the inferior flap superiorly and
    medially. Secure it to the glenoid rim with #1 nonabsorbable suture
    placed through the labrum, if it is intact.
  • If there is significant labral pathology,
    expose the glenoid rim, and prepare it as previously described for
    anterior repairs. Suture the capsular flap through bone holes, or
    secure it with suture anchors. Once again, the superior flap is sutured
    over the inferior flap to reinforce the repair. Position the arm in
    neutral rotation during the repair.
In these operations, there was no need to augment the
repair with infraspinatus advancement or bone blocks. Researchers
reported a 40% failure rate in 40 athletes who were followed
adequately, attributing the failures to ligamentous laxity or
unrecognized MDI. Importantly, they also noted worsening results as the
athletes’ competitive level increased and concluded that high-level
athletes should be informed preoperatively of a possible poor outcome.
In 1994, Tibone and coworkers described a modification of this technique (139).
A cadaveric and clinical investigation was undertaken to study an
infraspinatus muscle-splitting approach to the posterior capsule.
Dissection of 20 cadavers revealed that the suprascapular nerve entered
the infraspinous fossa at the spinoglenoid notch as a single trunk, 22
mm medial to the glenoid rim. The infraspinatus muscle was bipennate in
all specimens, with the tendinous interval an average of 14 mm inferior
to the scapular spine. Limiting dissection in this interval to 1.5 cm
medial to the posterior glenoid rim prevented damage to any
suprascapular nerve branches. The researchers performed this approach
in four patients and reported excellent exposure of the posterior
capsule, labrum, and glenoid, thus avoiding tendon detachment.
Electrodiagnostic testing revealed no significant denervation in these
patients.
Neer and Foster (107) introduced
a posterior capsular shift procedure in their classic article on the
treatment of MDI. This technique has many features that are similar to
their previously described anterior capsular shift.
  • Make a 10 cm incision either horizontally
    at the level of the scapular spine or vertically just medial to the
    posterolateral corner of the acromion. The latter incision creates a
    more cosmetic postoperative scar.
  • Detach the deltoid from the posterolateral aspect of the acromion and from the lateral 9.0 cm of the scapular spine.
  • Split the deltoid muscle for
    approximately 3.0 cm inferiorly, exposing the infraspinatus muscle and
    tendon. This muscle–tendon unit is split obliquely, creating a
    superficial tendinous flap later used to reinforce the capsule.
    Mobilize the remaining infraspinatus muscle medially to expose the
    underlying capsule.
  • Make a T-shaped capsulotomy with the
    horizontal component created laterally along the humeral neck. The
    authors noted that the arm should be progressively internally rotated
    during mobilization of the inferior capsular flap to protect the
    axillary nerve.
  • Then place a humeral head retractor into
    the joint and visualize the labrum; if there is labral pathology
    extending beyond the inferior glenoid rim into the anterior aspect of
    the joint, a separate anterior incision is recommended to address the
    Bankart lesion. Posterior labral pathology is incorporated into the
    capsular shift as previously described for the anterior procedure. Once
    again, this is performed before advancement of the flaps.
  • Position the arm in slight extension and
    external rotation during capsular reattachment. Then pull the superior
    flap inferiorly and laterally, and suture it to a shallow bony trough
    created at the humeral neck. Next, pull the inferior flap superiorly
    and laterally, and repair it over the superior flap. The superficial
    portion of the infraspinatus tendon is used to augment the posterior

    P.2198


    capsular
    repair. The deep portion of the infraspinatus muscle is then repaired
    to its origin to prevent postoperative weakness. Carefully reattach the
    deltoid muscle.

Postoperatively, keep patients in a plastic splint that
extends from the wrist to the mid-arm level and around the waist. Keep
the arm in neutral flexion and extension and 10° of external rotation
for 6 weeks. Begin isometric deltoid and rotator cuff exercises at 8
weeks, and add progressive resistive exercises at 12 weeks. Using this
technique in 25 shoulders, Bigliani et al. (11) reported good-to-excellent results in 88%. This assessment was based on stability, pain, range of motion, and activity level.
Author’s Preferred Method
After adequate general anesthesia has been obtained,
place the patient into the lateral decubitus position with the injured
side up. Place an axillary roll, and pad all potential pressure points
on the downside. Inflate the bean bag, and contour it anteriorly and
posteriorly. Prepare and drape the injured arm and hemithorax in
sterile fashion. Apply a McConnell Shoulder Holder to the table
opposite the surgeon, and use it to maintain appropriate arm position
during the operation.
  • Create a vertical incision in line with
    the posterior axillary fold, and carry it over the posterior acromial
    edge. Employ sharp dissection through the subcutaneous tissue down to
    the deltoid fascia. Raise subcutaneous flaps medially and laterally.
  • Palpate the glenohumeral joint, and split the deltoid muscle in line with its fibers at this level (Fig. 80.71).
    If necessary, further elevate the deltoid subperiosteally off the
    acromion to the posterolateral corner of the acromion. This latter step
    is usually required for large, muscular patients.
    Figure 80.71.
    Open posterior shoulder stabilization procedure. Make a standard split
    in the posterior deltoid muscle in line with the muscular fibers at the
    level of the glenohumeral joint. In muscular patients, decreased
    visualization may require periosteal elevation of the deltoid muscle
    from the scapular spine. (From Rowe CR, Yee LB. A Posterior Approach to
    the Shoulder. J Bone Joint Surg [Am] 1944;26:580, with permission.)
  • Insert a self-retaining shoulder
    retractor, and adequately mobilize the subdeltoid plane to expose the
    underlying infraspinatus fascia (Fig. 80.72).
    Then externally rotate the arm, and split the infraspinatus at the
    equator of the glenoid in line with its fibers. Carefully, develop the
    plane between this muscle and the underlying capsule (Fig. 80.73).
    Take care with this step, as there are frequently adhesions, as well as
    a thin redundant capsule. If further visualization of the capsule along
    the humeral neck is required, a portion of the infraspinatus tendon
    insertion may have to be released. Maintain a cuff of tissue in this
    case to permit an anatomic repair later in the procedure.
    Figure 80.72.
    Open posterior shoulder stabilization procedure. Develop the interval
    between the two heads of the infraspinatus muscle, which exposes the
    underlying capsule. Alternatively, the glenohumeral joint can be
    palpated, and the infraspinatus muscle can be split at this level.
    (From Rowe CR, Yee LB. A Posterior Approach to the Shoulder. J Bone Joint Surg [Am] 1944;26:580, with permission.)
    Figure 80.73.
    Open posterior shoulder stabilization procedure. Make a medially based
    T-shaped capsulotomy. (From Rowe CR, Yee LB. A Posterior Approach to
    the Shoulder. J Bone Joint Surg [Am] 1944;26:580, with permission.)
  • Place long, thin manual retractors along
    the infraspinatus muscle to aid in visualization at this point in the
    procedure. Carefully, create a vertical capsulotomy just off the
    glenoid margin to dissect inferiorly and allow adequate correction of
    the capsular laxity later in the procedure. Make a horizontal cut at
    the equator of the glenoid to create a T-type capsulotomy (Fig. 80.74).
    If there has been concomitant avulsion of the capsule from the humeral
    insertion site, incorporate it into the procedure to create an H-type
    capsulotomy.
    Figure 80.74.
    Open posterior shoulder stabilization procedure. Raise capsular flaps
    to allow exploration of the posterior labrum. If a true posterior
    Bankart lesion is present, repair it, using either a suture anchor
    technique or transsosseus drill holes. (From Rowe CR, Yee LB. A
    Posterior Approach to the Shoulder. J Bone Joint Surg [Am] 1944;26:580, with permission.)
  • Place a spiked retractor medially along
    the scapula to allow adequate visualization of the posterior labrum. If
    a posterior Bankart lesion exists, repair it at this point. Prepare the
    glenoid rim with a motorized burr and rasp to create a bleeding
    surface. Place double-loaded (#1 nonabsorbable) suture anchors at the
    2- and 4-o’ clock positions for left shoulders and at the 10- and 8-o’
    clock

    P.2199


    positions
    for right shoulders. Then repair the capsulolabral tissue with these
    sutures placed in standard horizontal mattress fashion. Retain the
    suture and attached needles for lateral closure of the capsulotomy. If
    no Bankart lesion exists, maintain this area intact, and place sutures
    directly through the labral tissue during later repair of the capsule.

  • Then mobilize the inferior capsular flap in a superior and medial direction for a T-type capsulotomy (Fig. 80.75)
    to reestablish tension in the IGHL. Use the previously placed
    nonabsorbable sutures to secure the capsule to the glenoid surface.
    Pull the superior flap inferiorly and medially to supplement the thin
    capsular tissue. Suture this flap to the glenoid surface, using the
    previously placed nonabsorbable sutures, as well as to the underlying
    capsule (Fig. 80.76).
    Figure 80.75.
    Open posterior shoulder stabilization procedure. Tie the inferior
    capsular flap to the superomedial capsular tissue first to correct the
    posteroinferior laxity. (From Rowe CR, Yee LB. A Posterior Approach to
    the Shoulder. J Bone Joint Surg [Am] 1944;26:580, with permission.)
    Figure 80.76.
    Open posterior shoulder stabilization procedure. Repair the superior
    capsular flap to the inferomedial glenoid rim to supplement the repair.
    (From Rowe CR, Yee LB. A Posterior Approach to the Shoulder. J Bone Joint Surg [Am] 1944;26:580, with permission.)
  • If a lateral capsular avulsion exists and
    an H-type capsulotomy has been created, also place suture anchors along
    the humeral neck. Repair the medial capsulolabral tissue as previously
    described, without significantly shifting the capsule. Once again,
    mobilize the inferior capsular flap superiorly and laterally to
    reestablish tension along the IGHL. Pull the superior flap inferiorly
    as above to supplement the repair.
  • Repair the infraspinatus muscle
    anatomically to its insertion if it was released previously. Also
    repair the horizontal split in a side-to-side fashion. If the deltoid
    muscle was subperiosteally dissected from the acromion,

    P.2200



    reestablish the origin through transosseous drill holes. Complete the repair with nonabsorbable sutures.

Place the patient into a prefabricated gunslinger brace,
with immobilization for 6 weeks. Then initiate active-assisted and
active range-of-motion exercise. Allow light muscle-strengthening
exercises (Theraband, Hygenic Corp., Malaysia) 3 months postoperatively
but no heavy contact sports or significant labor until 6 months after
the operative procedure.
REFERENCES
Each reference is categorized according to the following
scheme: *, classic article; #, review article; !, basic research
article; and +, clinical results/outcome study.
+ 1. Abelow SP. Laser Capsulorrhaphy for Multidirectional Instability of the Shoulder. Oper Tech Sports Med 1997;5:244.
2. Allen AA, Warner JJ. Shoulder Instability in the Athlete. Orthop Clin North Am 1995;26:487.
+ 3. Altchek
DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty Modification of the Bankart
Procedure for Multidirectional Instability of the Anterior and Inferior
Types. J Bone Joint Surg [Am] 1991;73:105.
+ 4. Altchek DW, Warren RF, Wickiewicz TL, Ortiz G. Arthroscopic Labral Debridement: A Three-year Follow-up Study. Am J Sports Med 1992;20:702.
+ 5. Andrews JR, Carson WG Jr, McLeod WD. Glenoid Labrum Tears Related to the Long Head of the Biceps. Am J Sports Med 1985;13:337.
6. Andrews
JR, Heckman MM, Guerra JJ. Diagnostic Arthroscopy of the Shoulder. In:
Mcginty JB, Caspari RB, Jackson RW, Poehling GG, eds. Diagnostic Arthroscopy of the Shoulder. Philadelphia: Lippincott–Raven Publishers, 1996:647.

P.2201


+ 6a. Arciero
RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart Repair versus
Nonoperative Treatment for Acute, Initial Anterior Shoulder
Dislocations. Am J Sports Med 1994;22:589.
+ 6b. Aronen JG, Regan K. Decrasing the Incidence of Recurrence of First Time Anterior Shoulder Dislocations with Rehabilitation. Am J Sports Med1984;12:283.
+ 7. Baker CL, Uribe JW, Whitman C. Arthroscopic Evaluation of Acute Initial Anterior Shoulder Dislocations. Am J Sports Med 1990;18:25.
! 8. Barber
FA, Feder SM, Burkhart SS, Ahrens J. The Relationship of Suture Anchor
Failure and Bone Density to Proximal Humerus Location: A Cadaveric
Study. Arthroscopy 1997;13:340.
! 9. Barber FA, Herbert MA, Click JN. Internal Fixation Strength of Suture Anchors—Update 1997. Arthroscopy 1997;13:355.
+ 9a. Benedetto KP, Glotzer W. Arthroscopic Bankart Procedure by Suture Technique: Indications, Technique, and Results. Arthroscopy 1992;8:111.
+ 10. Bigliani
LU, Kurzweil PR, Schwartzbach CC, et al. Inferior Capsular Shift
Procedure for Anterior-inferior Shoulder Instability in Athletes. Am J Sports Med 1994;22:578.
! 11. Bigliani LU, Pollock RG, Soslowsky LJ, et al. Tensile Properties of the Inferior Glenohumeral Ligament. J Orthop Res 1992;10:187.
! 12. Blasier
RB, Soslowsky LJ, Malicky DM, Palmer ML. Posterior Glenohumeral
Subluxation: Active and Passive Stabilization in a Biomechanical Model.
J Bone Joint Surg [Am] 1997;79:433.
! 13. Boardman ND, Debski RE, Warner JJ, et al. Tensile Properties of the Superior Glenohumeral and Coracohumeral Ligaments. J Shoulder Elbow Surg 1996;5:249.
! 14. Bowen MK, Deng XH, Warner JJ, et al. The Effect of Joint Compression on Stability of the Glenohumeral Joint. Trans Orthop Res Soc 1992;17:289.
+ 15. Boyd HB, Hunt HL. Recurrent Dislocation of the Shoulder: The Staple Capsulorrhaphy. J Bone Joint Surg [Am] 1965;47:1514.
+ 16. Boyd HB, Sisk TD. Recurrent Posterior Dislocation of the Shoulder. J Bone Joint Surg [Am] 1972;54:779.
! 17. Bradley JP, Tibone JE. Electromyographic Analysis of Muscle Action about the Shoulder. Clin Sports Med 1991;10:789.
+ 18. Brewer
BJ, Wubben RC, Carrera GF. Excessive Retroversion of the Glenoid
Cavity: A Cause of Non-traumatic Posterior Instability of the Shoulder.
J Bone Joint Surg [Am] 1986;68:724. [Erratum: J Bone Joint Surg [Am] 1986;68:1128.]
! 19. Browne AO, Hoffmeyer P, An KN, Morrey BF. The Influence of Atmospheric Pressure on Shoulder Instability. Orthop Trans 1990;14:259.
+ 19a. Burger RS, Shengel D, Bonatus T, Lewis J. Arthroscopic Staple Capsulorrhaphy for Recurrent Shoulder Instability. Orthop Trans1990;14:596.
+ 20. Burkhart
SS, Fox DL. Case Report: Arthroscopic Repair of a Type IV SLAP
Lesion—The Red-on-White Lesion as a Component of Anterior Instability. Arthroscopy 1993;9:488.
+ 21. Burkhead WZ Jr, Rockwood CA Jr. Treatment of Instability of the Shoulder with an Exercise Program. J Bone Joint Surg [Am] 1992;74:890.
+ 22. Calandra JJ, Baker CL, Uribe J. The Incidence of Hill-Sachs Lesions in Initial Anterior Shoulder Dislocations. Arthroscopy 1989;5:254.
23. Caspari RB. Anatomy and Portals for Arthroscopic Surgery of the Shoulder. In: Mcginty JB, ed. Arthroscopic Surgery of the Shoulder Update: Techniques in Orthopaedics. Rockville, MD: Aspen Systems, 1985;15.
+ 24. Caspari RB, Geissler WB. Arthroscopic Manifestations of Shoulder Subluxation and Dislocation. Clin Orthop 1993;291:54.
24a. Caspari RB, Savoie FH. Arthroscopic Reconstruction of the Shoulder; The Bankart Repair. In: Mcginty J, ed. Operative Arthroscopy. New York: Raven Press, 1991:50.
* 25. Cave EF, Rowe CR. Capsular Repair for Recurrent Dislocation of the Shoulder: Pathologic Findings and Operative Technique. Surg Clin North Am 1947;27:1289.
+ 26. Chandnani
VP, Gagliardi JA, Murnane TG, et al. Glenohumeral Ligaments and
Shoulder Capsular Mechanism: Evaluation with MR Arthrography. Radiology 1995;196:27.
+ 27. Chandnani
VP, Yeager TD, DeBerardino T, et al. Glenoid Labral Tears: Prospective
Evaluation with MRI Imaging, MR Arthrography, and CT Arthrography. AJR 1993;161:1229.
28. Cheng JC, Karzel RP. Superior Labrum Anterior Posterior Lesions of the Shoulder: Operative Techniques of Management. Oper Tech Sports Med 1997;5:249.
+ 29. Clark J, Sidles JA, Matsen FA. The Relationship of the Glenohumeral Joint Capsule to the Rotator Cuff. Clin Orthop 1990;254:29.
+ 30. Cofield RH, Nessler JP, Weinstabl R. Diagnosis of Shoulder Instability by Examination under Anesthesia. Clin Orthop 1993;291:45.
! 31. Cooper DE, Arnoczky SP, O’ Brien SJ, et al. Anatomy, Histology, and Vascularity of the Glenoid Labrum: An Anatomical Study. J Bone Joint Surg [Am] 1992;74:46.
! 32. Cooper DE, O’ Brien SJ, Warren RF. Supporting Layers of the Glenohumeral Joint: An Anatomic Study. Clin Orthop 1993;289:144.
33. Cooper DE, Warner JJ, Warren RF. Complications of Shoulder Instability in the Competitive Athlete. In: Bigliani LU, ed. Complications of Shoulder Surgery. Baltimore: Williams & Wilkins, 1993:247.
! 34. Cooper DE, Warner JJ, Warren RF. The Structure and Function of the Coracohumeral Ligament: An Anatomic and Microscopic Study. J Shoulder Elbow Surg 1993;2:70.
+ 35. Cordasco FA, Steinmann S, Flatow EL, Bigliani LU. Arthroscopic Treatment of Glenoid Labral Tears. Am J Sports Med 1993;21:425.
+ 36. Coughlin L, Rubinovich M, Johansson J, et al. Arthroscopic Staple Capsulorrhaphy for Anterior Shoulder Instability. Am J Sports Med 1992;20:253.
! 37. Curl LA, Warren RF. Glenohumeral Joint Stability: Selective Cutting Studies on the Static Capsular Restraints. Clin Orthop 1996;330:54.

P.2202


+ 38. de
Laat EA, Visser CP, Coene LN, et al. Nerve Lesions in Primary Shoulder
Dislocations and Humeral Neck Fractures: A Prospective Clinical and EMG
Study. J Bone Joint Surg Br 1994;76:381.
39. Detrisac DA, Johnson LL. Arthroscopic Shoulder Anatomy: Pathologic and Surgical Implications. Thorofare, NJ: Slack Publications, 1986:21.
+ 40. Dimon JH. Posterior Dislocation and Posterior Fracture Dislocation of the Shoulder: A Report of 25 Cases. South Med J 1967;60:661.
+ 41. Duncan
R, Savoie FH. Arthroscopic Inferior Capsular Shift for Multidirectional
Instability of the Shoulder: A Preliminary Report. Arthroscopy 1993;9:24.
42. Elrod BF. Arthroscopic Reconstruction of Traumatic Anterior Instability. Oper Tech Sports Med 1997;5:215.
+ 43. Engebretsen L, Craig EV. Radiologic Features of Shoulder Instability. Clin Orthop 1993;291:29.
+ 44. Field LD, Savoie FH. Arthroscopic Suture Repair of Superior Labral Detachment Lesions of the Shoulder. Am J Sports Med 1993;21:783.
+ 45. Field LD, Warren RF, O’ Brien SJ, et al. Isolated Closure of Rotator Interval Defects for Shoulder Instability. Am J Sports Med 1995;23:557.
! 46. Flatow
EL, Ateshian GA, Soslowsky LJ, et al. Computer Simulation of
Glenohumeral and Patellofemoral Subluxation: Estimating Pathological
Articular Contact. Clin Orthop 1994;306:28.
! 47. Flatow
EL, Soslowsky LJ, Ateshian GA, et al. Shoulder Joint Anatomy and the
Effect of Subluxations and Size Mismatch on Patterns of Glenohumeral
Contact. Orthop Trans 1991;15:803.
+ 47a. Foster CR. Arthroscopic Shoulder Reconstruction for Instability. Orthop Trans1994;18:192.
+ 48. Fronek J, Warren RF, Bowen M. Posterior Subluxation of the Glenohumeral Joint. J Bone Joint Surg [Am] 1989;71:205.
+ 48a. Geiger DF, Hurley JA, Tovey JA, Rao JP. Results of Arthroscopic versus Open Bankart Suture Repair. Orthop Trans 1993;17:973.
49. Gerber C. Observations on the Classification of Instability. In: Warner JJP, Iannotti JP, Gerber C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott–Raven Publishers, 1997:9.
+ 50. Gerber
C, Ganz R. Clinical Assessment of Instability of the Shoulder: With
Special Reference to Anterior and Posterior Drawer Tests. J Bone Joint Surg Br 1984;66:551.
+ 51. Gerber C, Kuechle DK. Isolated Rupture of the Tendon of the Subscapularis Muscle: Clinical Features of Sixteen Cases. J Bone Joint Surg Br 1991;73:389.
! 52. Gerber C, Schneeberger AG, Beck M, Schlegel U. Mechanical Strength of Repairs of the Rotator Cuff. J Bone Joint Surg Br 1994;76:371.
! 53. Gibb TD, Sidles JA, Harryman DT, et al. The Effect of Capsular Venting on Glenohumeral Laxity. Clin Orthop 1991;268:120.
+ 54. Glasgow
SG, Bruce RA, Yacobucci GN, Torg JS. Arthroscopic Resection of Glenoid
Labral Tears in the Athlete: A Report of 29 Cases. Arthroscopy 1992;8:48.
+ 54a. Goldberg
BJ, Nirschl RP, McConnell JP, Pettrone FA. Arthroscopic Transglenoid
Suture Capsulolabral Repairs: Preliminary Results. Am J Sports Med 1993;21:656.
+ 55. Goss TP. Fractures of the Glenoid Cavity. J Bone Joint Surg [Am] 1992;74:299.
+ 55a. Grana WA, Buckley PD, Yates CK. Arthroscopic Bankart Suture Repair. Am J Sports Med 1993;21:348.
+ 56. Green MR, Christensen KP. Magnetic Resonance Imaging of the Glenoid Labrum in Anterior Shoulder Instability. Am J Sports Med 1994;22:493.
+ 57. Groh
GI, Rockwood CA Jr. The Terrible Triad: Anterior Dislocation of the
Shoulder Associated with Rupture of the Rotator Cuff and Injury to the
Brachial Plexus. J Shoulder Elbow Surg 1995;4:51.
+ 58. Gross MR. Arthroscopic Shoulder Capsulorrhaphy: Does it Work? Am J Sports Med 1989;17:495.
+ 59. Hawkins RH, Hawkins RJ. Failed Anterior Reconstruction for Shoulder Instability. J Bone Joint Surg Br 1985;67:709.
+ 60. Hawkins RJ. Arthroscopic Staple Repair for Shoulder Instability: A Retrospective Study of Fifty Patients. Arthroscopy 1989;5:122.
+ 61. Hawkins RJ, Angelo RL. Glenohumeral Osteoarthrosis: A Late Complication of the Putti-Platt Repair. J Bone Joint Surg [Am] 1990;72:1193.
+ 62. Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ. Anterior Dislocation of the Shoulder in the Older Patient. Clin Orthop 1986;206:192.
+ 63. Hawkins RJ, Koppert G, Johnston G. Recurrent Posterior Instability (Subluxation) of the Shoulder. J Bone Joint Surg [Am] 1984;66:169.
+ 64. Hawkins RJ, Neer CS, Pianta RM, Mendoza FX. Locked Posterior Dislocation of the Shoulder. J Bone Joint Surg [Am] 1987;69:9.
+ 65. Hawkins RJ, Schutte JP, Janda DH, Huckell GH. Translation of the Glenohumeral Joint with the Patient under Anesthesia. J Shoulder Elbow Surg 1996;5:286.
! 66. Hayashi K, Thabit G, Vailas AC, et al. The Effect of Nonablative Laser Energy on Joint Capsular Properties: An in Vitro Histologic and Biochemical Study Using a Rabbit Model. Am J Sports Med 1996;24:640.
+ 67. Henry JH, Genung JA. Natural History of Glenohumeral Dislocation—Revisited. Am J Sports Med 1982;10:135.
+ 68. Hintermann B, Gachter A. Arthroscopic Findings after Shoulder Dislocation. Am J Sports Med 1995;23:545.
+ 69. Hovelius L. Anterior Dislocation of the Shoulder in Teen-agers and Young Adults: Five-year Prognosis. J Bone Joint Surg [Am] 1987;69:393.
+ 70. Hovelius
L, Augustini BG, Fredin H, et al. Primary Anterior Dislocation of the
Shoulder in Young Patients: A Ten-year Prospective Study. J Bone Joint Surg [Am] 1996;78:1677.
! 71. Howell SM, Galinat BJ. The Glenoid-labral Socket: A Constrained Articular Surface. Clin Orthop 1989;243:122.

P.2203


+ 72. Itoi
E, Berglund LJ, Grabowski JJ, et al. Superior-inferior Stability of the
Shoulder: Role of the Coracohumeral Ligament and the Rotator Interval
Capsule. Mayo Clin Proc 1998;73:508.
! 73. Itoi E, Hsu HC, An KN. Biomechanical Investigation of the Glenohumeral Joint. J Shoulder Elbow Surg 1996;5:407.
! 74. Itoi E, Kuechle DK, Newman SR, et al. Stabilising Function of the Biceps in Stable and Unstable Shoulders. J Bone Joint Surg Br 1993;75:546. [Erratum: J Bone Joint Surg Br 1994;76:170.]
! 75. Itoi E, Motzkin NE, Morrey BF. The Stabilizing Function of the Long Head of the Biceps with the Arm in a Hanging Position. J Shoulder Elbow Surg 1994;3(suppl.)32.
! 76. Itoi E, Newman SR, Kuechle DK, et al. Dynamic Anterior Stabilisers of the Shoulder with the Arm in Abduction. J Bone Joint Surg Br 1994;76:834.
77. Jobe FW. Unstable Shoulders in the Athlete. Instr Course Lect 1985;34:228.
+ 78. Jobe
FW, Giangarra CE, Kvitne RS, Glousman RE. Anterior Capsulolabral
Reconstruction of the Shoulder in Athletes in Overhand Sports. Am J Sports Med 1991;19:428.
79. Johnson LL. Diagnostic and Surgical Arthroscopy of the Shoulder. St. Louis, MO: Mosby, 1993:304.
+ 80. Johnson LL. The Shoulder Joint: An Arthroscopist’s Perspective of Anatomy and Pathology. Clin Orthop 1987;223:113.
+ 81. Klein AH, France JC, Mutschler TA, Fu FH. Measurement of Brachial Plexus Strain in Arthroscopy of the Shoulder. Arthroscopy 1987;3:45.
! 82. Kumar VP, Balasubramaniam P. The Role of Atmospheric Pressure in Stabilising the Shoulder: An Experimental Study. J Bone Joint Surg Br 1985;67:719.
+ 83. Kvitne RS, Jobe FW. The Diagnosis and Treatment of Anterior Instability in the Throwing Athlete. Clin Orthop 1993;291:107.
+ 83a. Landsiedl F. Arthroscopic Therapy of Recurrent Anterior Luxation of the Shoulder by Capsular Repair. Arthroscopy 1992;8:296.
+ 83b. Lane JG, Sachs RA, Riehl B. Arthroscopic Staple Capsulorrhaphy: A Long-term Follow-up. Arthroscopy 1993;9:190.
+ 84. Laurencin
CT, Stephens S, Warren RF, Altchek DW. Arthroscopic Bankart Repair
Using a Degradable Tack: A Follow-up Study Using Optimized Indications.
Clin Orthop 1996;332:132.
+ 85. Lephart S, Warner JJ, et al. Proprioception of the Shoulder Joint in Healthy, Unstable and Surgically Repaired Shoulders. J Shoulder Elbow Surg 1994;3:371.
+ 86. Lerat
JL, Chotel F, Besse JL, et al. Dynamic Anterior Jerk of the Shoulder: A
New Clinical Test for Shoulder Instability: Preliminary Study. Rev Chir Orthop Reparatrice Appar Mot 1994;80:461.
+ 87. Levine WN, Richmond JC, Donaldson WR. Use of the Suture Anchor in Open Bankart Reconstruction: A Follow-up Report. Am J Sports Med 1994;22:723.
+ 88. Lippitt S, Matsen F. Mechanisms of Glenohumeral Joint Stability. Clin Orthop 1993;291:20.
! 89. Lippitt S, Vanderhooft E. Glenohumeral Stability from Concavity-Compression: A Quantitative Analysis. J Shoulder Elbow Surg 1993;2:27.
+ 90. Lyons FA, Rockwood CA Jr. Migration of Pins Used in Operations on the Shoulder. J Bone Joint Surg [Am] 1990;72:1262.
+ 91. Maffet MW, Gartsman GM, Moseley B. Superior Labrum–Biceps Tendon Complex Lesions of the Shoulder. Am J Sports Med 1995;23:93.
+ 92. Maki NJ. Arthroscopic Stabilization: Suture Technique. Oper Tech Orthop 1991;1:180.
+ 93. Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The Fate of Traumatic Anterior Dislocation of the Shoulder in Children. J Bone Joint Surg [Am] 1992;74:1242.
94. Matsen F, Thomas S, Rockwood C Jr., Wirth M. Glenohumeral Instability. In: Rockwood C Jr., Matsen F, eds. The Shoulder. Philadelphia: WB Saunders, 1990:637.
+ 94a. Matthews LS, Vetter WL, Oweida SJ, et al. Arthroscopic Staple Capsulorrhaphy for Recurrent Anterior Shoulder Instability. Arthroscopy1988;4:106.
+ 95. May H. Nicola Operation for Posterior Subacromial Dislocation of the Humerus. J Bone Joint Surg [Am] 1943;25:78.
+ 96. Mazat R. Migration of a Kirschner Wire from the Shoulder Region into the Lung: Report of Two Cases. J Bone Joint Surg [Am] 1943;25:477.
+ 97. McEleney ET, Donovan MJ, Shea KP, Nowak MD. Initial Failure Strength of Open and Arthroscopic Bankart Repairs. Arthroscopy 1995;11:426.
+ 98. McGaughan JS, Miller PR. Migration of Steinman Pin from Shoulder to Lung. JAMA 1969;207:1917.
99. McIntyre LF, Caspari RB, Savoie FH. The Arthroscopic Treatment of Anterior and Multidirectional Shoulder Instability. Instr Course Lect 1996;45:47.
+ 100. McIntyre
LF, Caspari RB, Savoie FH. The Arthroscopic Treatment of Posterior
Shoulder Instability: Two-year Results of a Multiple Suture Technique. Arthroscopy 1997;13:426.
101. McLaughlin HL. Posterior Dislocation of the Shoulder. J Bone Joint Surg [Am] 1962;44:1477.
+ 102. McLaughlin HL. Recurrent Anterior Dislocation of the Shoulder I. Morbid Anatomy. Am J Surg 1960;99:628.
# 103. Micheli LJ. Sports Injuries in Children and Adolescents: Questions and Controversies. Clin Sports Med 1995;14:727.
+ 103a. Morgan CD. Arthroscopic Transglenoid Bankart Suture Repair. Oper Tech Orthop 1991;1:171.
+ 104. Morgan CD, Bodenstab AB. Arthroscopic Bankart Suture Repair: Technique and Early Results. Arthroscopy 1987;3:111.
+ 105. Mowery CA, Garfin SR, Booth RE, Rothman RH. Recurrent Posterior Dislocation of the Shoulder: Treatment Using a Bone Block. J Bone Joint Surg [Am] 1985;67:777.
! 106. Naseef
GS, Foster TE, Trauner K, et al. The Thermal Properties of Bovine Joint
Capsule: The Basic Science of Laser- and Radiofrequency-induced
Capsular Shrinkage. Am J Sports Med 1997;25:670.

P.2204


* 107. Neer
CS 2d, Foster CR. Inferior Capsular Shift for Involuntary Inferior and
Multidirectional Instability of the Shoulder: A Preliminary Report. J Bone Joint Surg [Am] 1980;62:897.
* 108. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior Dislocation of the Shoulder and Rotator Cuff Rupture. Clin Orthop 1993;291:103.
* 109. Neviaser TJ. The Anterior Labroligamentous Periosteal Sleeve Avulsion Lesion: A Cause of Anterior Instability of the Shoulder. Arthroscopy 1993;9:17.
+ 110. Nobel W. Posterior Traumatic Dislocation of the Shoulder. J Bone Joint Surg [Am] 1962;44:523.
+ 111. Norell H, Loehr JF. Migration of a Threaded Steinmann Pin from an Acromioclavicular Joint into the Spinal Canal: A Case Report. J Bone Joint Surg [Am] 1965;47:1024.
+ 112. Norlin R. Intraarticular Pathology in Acute, First-time Anterior Shoulder Dislocation: An Arthroscopic Study. Arthroscopy 1993;9:546.
! 113. O’
Brien SJ, Neves MC, Arnoczky SP, et al. The Anatomy and Histology of
the Inferior Glenohumeral Ligament Complex of the Shoulder. Am J Sports Med 1990;18:449.
! 114. O’
Brien SJ, Schwartz RS, Warren RF, Torzilli PA. Capsular Restraints to
Anterior-posterior Motion of the Abducted Shoulder: A Biomechanical
Study. J Shoulder Elbow Surg 1995;4:298.
! 115. O’
Connell PW, Nuber GW, Mileski RA, Lautenschlager E. The Contribution of
the Glenohumeral Ligaments to Anterior Stability of the Shoulder Joint.
Am J Sports Med 1990;18:579.
! 116. Pagnani
MJ, Deng XH, Warren RF, et al. Role of the Long Head of the Biceps
Brachii in Glenohumeral Stability: A Biomechanical Study in Cadavera. J Shoulder Elbow Surg 1996;5:255.
+ 117. Pagnani
MJ, Speer KP, Altchek DW, et al. Arthroscopic Fixation of Superior
Labral Lesions Using a Biodegradable Implant: A Preliminary Report. Arthroscopy 1995;11:194.
+ 118. Pagnani MJ, Warren RF. Arthroscopic Shoulder Stabilization. Oper Tech Sports Med 1993;1:276.
+ 119. Pagnani MJ, Warren RF. MDI: Medial T-plasty and Selective Capsular Repair. Sports Med Arthrosc Rev 1993;1:249.
+ 120. Pappas AM, Goss TP, Kleinman PK. Symptomatic Shoulder Instability Due to Lesions of the Glenoid Labrum. Am J Sports Med 1983;11:279.
+ 121. Pavlov H, Warren RF, Weiss CB Jr, Dines DM. The Roentgenographic Evaluation of Anterior Shoulder Instability. Clin Orthop 1985;194:153.
+ 122. Payne LZ, Jokl P. The Results of Arthroscopic Debridement of Glenoid Labral Tears Based on Tear Location. Arthroscopy 1993;9:560.
+ 123. Pollock RG, Bigliani LU. Recurrent Posterior Shoulder Instability: Diagnosis and Treatment. Clin Orthop 1993;291:85.
+ 123a. Rao
JP, Tovey JE, Zoppi A, et al. Comparison of Arthroscopic Capsulorrhaphy
for Anterior Shoulder Instability: Stapling versus Suturing. Orthop Trans1994;17:972.
+ 124. Resch H, Gosler K, Thoeni H, Sperner G. Arthroscopic Repair of Superior Glenoid Labral Detachment (the SLAP Lesion). J Shoulder Elbow Surg 1993;2:147.
+ 125. Richardson AB, Jobe FW, Collins HR. The Shoulder in Competitive Swimming. Am J Sports Med 1980;8:159.
! 126. Rodosky
MW, Harner CD, Fu FH. The Role of the Long Head of the Biceps Muscle
and Superior Glenoid Labrum in Anterior Stability of the Shoulder. Am J Sports Med 1994;22:121.
+ 127. Rose DJ. Arthroscopic Suture Capsulorrhaphy for Anterior Shoulder Instability. Orthop Trans 1990;14:597.
+ 128. Rosenberg
BN, Richmond JC, Levine WN. Long-term Follow-up of Bankart
Reconstruction: Incidence of Late Degenerative Glenohumeral Arthrosis. Am J Sports Med 1995;23:538.
! 129. Rouse LM, Burkhead WZ, Neer CS. Vascularity of the Glenoid Labrum. Orthop Trans 1990;14:595.
+ 130. Rowe CR. The Bankart Procedure: Improvements and Options. Surg Rounds Orthop 1990;Feb:15.
* 131. Rowe CR, Patel D, Southmayd WW. The Bankart Procedure: A Long-term End-result Study. J Bone Joint Surg [Am] 1978;60:1.
* 132. Rowe
CR, Pierce DS, Clark JG. Voluntary Dislocation of the Shoulder: A
Preliminary Report on a Clinical, Electromyographic, and Psychiatric
Study of Twenty-six Patients. J Bone Joint Surg [Am] 1973;55:445.
* 133. Rowe CR, Sakellarides HT. Factors Related to Recurrences of Anterior Dislocation of the Shoulder. Clin Orthop 1961;20:40.
+ 134. Rowe
CR, Zarins B, Ciullo JV. Recurrent Anterior Dislocation of the Shoulder
after Surgical Repair: Apparent Causes of Failure and Treatment. J Bone Joint Surg [Am] 1984;66:159.
+ 135. Saha AK. Dynamic Stability of the Glenohumeral Joint. Acta Orthop Scand 1971;42:491.
+ 136. Savoie
FH, Miller CD, Field LD. Arthroscopic Reconstruction of Traumatic
Anterior Instability of the Shoulder: The Caspari Technique. Arthroscopy 1997;13:201.
+ 137. Scott DJ Jr. Treatment of Recurrent Posterior Dislocations of the Shoulder by Glenoplasty: Report of Three Cases. J Bone Joint Surg [Am] 1967;49:471.
+ 138. Sethi GK, Scott SM. Subclavian Artery Laceration Due to Migration of a Hagie Pin. Surgery 1965;80:644.
! 139. Shaffer
BS, Conway J, Jobe FW, et al. Infraspinatus Muscle-splitting Incision
in Posterior Shoulder Surgery: An Anatomic and Electromyographic Study.
Am J Sports Med 1994;22:113.
+ 140. Shea KP, Lovallo JL. Scapulothoracic Penetration of a Beath Pin: An Unusual Complication of Arthroscopic Bankart Suture Repair. Arthroscopy 1991;7:115.
! 141. Sheilds
CL. Soft Tissue Shortening with the Ho:YAG Laser: Experimental Model,
Structural Effects, and Histological and Ultrastructural Analysis.
Presented at the Second Annual Meeting of the Orthopaedic Laser Society
of North America and International Musculoskeletal Laser Society, South
Lake, Tahoe, CA, December, 1995.

P.2205


+ 142. Silliman JF, Hawkins RJ. Classification and Physical Diagnosis of Instability of the Shoulder. Clin Orthop 1993;291:7.
+ 143. Sisk TD, Boyd HB. Management of Recurrent Anterior Dislocation of the Shoulder: Du Toit-type or Staple Capsulorrhaphy. Clin Orthop 1974;103:150.
+ 143a. Small NC. Complications of Arthroscopy: The Knee and Other Joints. Arthroscopy 1986;2:253.
+ 144. Snyder SJ, Banas MP, Karzel RP. An Analysis of 140 Injuries to the Superior Glenoid Labrum. J Shoulder Elbow Surg 1995;4:243.
* 145. Snyder SJ, Karzel RP, Del Pizzo W, et al. SLAP Lesions of the Shoulder. Arthroscopy 1990;6:274.
146. Snyder SJ, Rames RD, Wolbert E. Labral Lesions. In: Mcginty JB, ed. Operative Arthroscopy. New York: Raven Press, 1991;491.
+ 147. Sonnabend
DH. Treatment of Primary Anterior Shoulder Dislocation in Patients
Older than 40 Years of Age: Conservative versus Operative. Clin Orthop 1994;304:74.
! 148. Soslowsky LJ, Flatow EL, Bigliani LU, Mow VC. Articular Geometry of the Glenohumeral Joint. Clin Orthop 1992;285:181.
! 149. Speer KP, Deng X, Torzilli PA, et al. Strategies for an Anterior Capsular Shift of the Shoulder: A Biomechanical Comparison. Am J Sports Med 1995;23:264.
+ 150. Speer KP, Hannafin JA, Altchek DW, Warren RF. An Evaluation of the Shoulder Relocation Test. Am J Sports Med 1994;22:177.
+ 151. Speer KP, Warren RF. Arthroscopic Shoulder Stabilization: A Role for Biodegradable Materials. Clin Orthop 1993;291:67.
+ 152. Spinner M. Injuries to the Major Branches of Peripheral Nerves in the Forearm. Philadephia: WB Saunders, 1978.
+ 153. Stetson
WB, Snyder SJ, Karzel RP, et al. Long-term Clinical Follow-up of
Isolated SLAP Lesions of the Shoulder. Presented at the Annual Meeting
of the American Academy of Orthopaedic Surgeons, San Francisco, CA,
February, 1997.
+ 154. Thomas
SC, Matsen FA. An Approach to the Repair of Avulsion of the
Glenohumeral Ligaments in the Management of Traumatic Anterior
Glenohumeral Instability. J Bone Joint Surg [Am] 1989;71:506.
+ 155. Tibone J, Ting A. Capsulorrhaphy with a Staple for Recurrent Posterior Subluxation of the Shoulder. J Bone Joint Surg [Am] 1990;72:999.
+ 156. Tibone JE, Bradley JP. The Treatment of Posterior Subluxation in Athletes. Clin Orthop 1993;291:124.
+ 157. Torchia
ME, Caspari RB, Asselmeier MA, et al. Arthroscopic Transglenoid
Multiple Suture Repair: 2- to 8-Year Results in 150 Shoulders. Arthroscopy 1997;13:609.
+ 158. Townley CO. The Capsular Mechanism in Recurrent Dislocation of the Shoulder. J Bone Joint Surg [Am] 1950;32:370.
+ 159. Treacy SH, Field LD, Savoie FH. Rotator Interval Capsule Closure: An Arthroscopic Technique. Arthroscopy 1997;13:103.
! 160. Turkel SJ, Panio MW, Marshall JL, Girgis FG. Stabilizing Mechanisms Preventing Anterior Dislocation of the Glenohumeral Joint. J Bone Joint Surg [Am] 1981;63:1208.
! 161. Vanderhooft
E, Lippitt S, Matsen FA. Glenohumeral Stability from Concavity
Compression: A Quantitative Analysis. Presented at the Annual Meeting
of the American Shoulder and Elbow Surgeons, Washington, DC, April,
1992.
+ 162. Walch
G, Boileau P, Levigne C, et al. Arthroscopic Stabilization for
Recurrent Anterior Shoulder Dislocation: Results of 59 Cases. Arthroscopy 1995;11:173.
+ 163. Warner JJ. Shoulder Arthroscopy in the Beach-chair Position: Basic Setup. Oper Tech Orthop 1991;1:147.
+ 164. Warner JJ. Treatment Options for Anterior Instability: Open versus Arthroscopic. Oper Tech Orthop 1995;5:233.
+ 165. Warner JJ, Allen AA, Gerber C. Diagnosis and Management of Subscapularis Tendon Tears. Oper Tech Orthop 1994;9:116.
166. Warner JJ, Altchek DW. Arthroscopic Repairs for Instability. In: Warner JJP, Iannotti JP, Gerber C, eds. Complex and Revision Problems in Shoulder Surgery. Philadelphia: Lippincott–Raven Publishers, 1997:19.
167. Warner JJ, Caborn DN. Overview of Shoulder Instability. Crit Rev Phys Rehabil Med 1992;4:145.
! 168. Warner JJ, Caborn DN, Berger R, et al. Dynamic Capsuloligamentous Anatomy of the Glenohumeral Joint. J Shoulder Elbow Surg 1993;2:115.
! 169. Warner JJ, Deng XH, Warren RF, et al. Superior-inferior Translation in the Intact and Vented Glenohumeral Joint. J Shoulder Elbow Surg 1993;2:99.
+ 170. Warner JJ, Janetta-Alpers C, Miller MD. Correlation of Glenohumeral Laxity with Arthroscopic Ligament Anatomy. J Shoulder Elbow Surg 1994;4[Suppl]:532.
+ 171. Warner
JJ, Johnson D, Miller M, Caborn DN. Technique for Selecting Capsular
Tightness in Repair of Anterior-inferior Shoulder Instability. J Shoulder Elbow Surg 1995;4:352.
+ 172. Warner
JJ, Kann S, Marks P. Arthroscopic Repair of Combined Bankart and
Superior Labral Detachment Anterior and Posterior Lesions: Technique
and Preliminary Results. Arthroscopy 1994;10:383.
+ 173. Warner JJ, Lephart S, Fu FH. Role of Proprioception in Pathoetiology of Shoulder Instability. Clin Orthop 1996;330:35.
+ 174. Warner JJ, McMahon PJ. The Role of the Long Head of the Biceps Brachii in Superior Stability of the Glenohumeral Joint. J Bone Joint Surg [Am] 1995;77:366.
! 175. Warner JJ, Miller MD, Marks P. Arthroscopic Bankart Repair with the Suretac Device. Part II. Experimental Observations. Arthroscopy 1995;11:14.
+ 176. Warner JJ, Miller MD, Marks P, Fu FH. Arthroscopic Bankart Repair with the Suretac Device. Part I. Clinical Observations. Arthroscopy 1995;11:2.
+ 177. Warner JJ, Warren RF. Arthroscopic Bankart Repair Using a Cannulated, Absorbable Fixation Device. Oper Tech Orthop 1991;1:192.
178. Warren RF. Subluxation of the Shoulder in Athletes. Clin Sports Med 1983;2:339.
* 179. Watson-Jones R. Recurrent Dislocation of the Shoulder. J Bone Joint Surg Br 1948;50:6.

P.2206


+ 179a. Weber SC. A Prospective Evaluation Comparing Arthroscopic and Open Treatment of Recurrent Anterior Glenohumeral Dislocation. Orthop Trans 1991;15:763.
+ 179b. Wheeler
JH, Ryan JB, Arciero RA, Molinari RN. Arthroscopic versus Nonoperative
Treatment of Acute Shoulder Dislocations in Young Athletes. Arthroscopy 1989;5:213.
+ 180. Wichman MT, Snyder SJ. Arthroscopic Capsular Plication for Multidirectional Instability of the Shoulder. Oper Tech Sports Med 1997;5:238.
+ 180a. Wiley MA. Arthroscopy for Shoulder Instability and a Technique for Arthroscopic Repair. Arthroscopy 1988;4:25.
+ 181. Williams
MM, Snyder SJ, Buford D Jr. The Buford Complex—the “Cord-like” Middle
Glenohumeral Ligament and Absent Anterosuperior Labrum Complex: A
Normal Anatomic Capsulolabral Variant. Arthroscopy 1994;10:241.
+ 181a. Wilson FD, Adams G, Hile LE, et al. Arthroscopic Treatment of Recurrent Dislocating Shoulder. Orthop Trans 1993;14:979.
+ 182. Wirth MA, Lyons FR, Rockwood CA Jr. Hypoplasia of the Glenoid: A Review of Sixteen Patients. J Bone Joint Surg [Am] 1993;75:1175.
+ 183. Wolf EM, Wilk RM, Richmond JL. Arthroscopic Bankart Repair Using Suture Anchors. Oper Tech Orthop 1991;1:187.
+ 183a. Wolin PM. Arthroscopic Glenoid Labrum Suture Repair. Orthop Trans1990;14:597.
+ 184. Yoneda M, Hirooka A, Saito S, et al. Arthroscopic Stapling for Detached Superior Glenoid Labrum. J Bone Joint Surg Br 1991;73:746.
+ 185. Young DC, Rockwood CA Jr. Complications of a Failed Bristow Procedure and Their Management. J Bone Joint Surg [Am] 1991;73:969.
186. Zarins B. Bankart Repair for Anterior Shoulder Instability. Tech Orthop 1989;3:23.
+ 187. Zarins B, McMahon MS, Rowe CR. Diagnosis and Treatment of Traumatic Anterior Instability of the Shoulder. Clin Orthop 1993;291:75.
+ 188. Zuckerman JD, Matsen FA. Complications about the Glenohumeral Joint Related to the Use of Screws and Staples. J Bone Joint Surg [Am] 1984;66:175.

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More