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This radiograph shows static superior subluxation. The acromiohumeral distance is less than 7 mm, indicating that there is a supraspinatus and infraspinatus tendon tear.
Source publication
Shoulder instabilities have been classified according to the etiology, the direction of instability, or on combinations thereof. The current authors describe a classification system, which distinguishes between static instabilities, dynamic instabilities, and voluntary dislocation. Static instabilities are defined by the absence of classic symptoms...
Context in source publication
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OBJETIVO: Avaliar a prevalência das lesões associadas à instabilidade anterior traumática do ombro e a relação entre o número de episódios e o tempo do início dos sintomas com a prevalência destas lesões.MÉTODO: Foram selecionados 57 pacientes com instabilidade anterior traumática do ombro, entre 18 e 40 anos, com mais de um episódio de luxação do...
Experimental work has shown that dislocation of the shoulder may involve disruption of the capsule from its lateral humeral attachment. We report two patients with recurrent dislocation due to this injury. Lateral repair gave good results. It is suggested that this injury be considered and looked for when glenoid labral injury is minimal or absent.
An Irreducible dislocation of the shoulder is an uncommon event. When it does occur, blocks to reduction can include bone, labrum, rotator cuff musculature or tendon. Patients older than 40 at the time of initial dislocation are at increased risk of sustaining a concomitant rotator cuff tear. We present a case of an irreducible anterior shoulder di...
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Irreducible shoulder dislocation is an uncommon event. When it does occur, blocks to reduction can include bone, labrum, rotator cuff musculature, or tendon. Concomitant rotator cuff tear at the time of initial dislocation is not an exclusive complication of anterior shoulder dislocation in the older population. Indeed, rotator cuff tear should not...
Citations
... It is worthwhile noting that Thomas and Matsen's description of the AMBRI group of patients was a conceptual one at the time and not based on published data (9). Gerber and Nyffeler (10) in 2002 were one of the first to include a multidirectional hyperlax subgroup in anterior instability explicitly. Thereafter, in 2010, Kuhn (11) published a new classification system for shoulder instability, termed as the FEDS (frequency, etiology, direction, and severity) classification and intentionally left out MDI in the classification. ...
Purpose
A variety of instabilities are grouped under multidirectional instability (MDI) of the shoulder. This makes understanding its diagnostic process, presentation and treatment difficult due to lack of evidence-based consensus. This review aims to propose a novel classification for subtypes of MDI.
Methods
A systematic search was performed on PubMed Medline and Embase. A combination of the following 'MeSH' and 'non-MesH' search terms were used: (1) Glenohumeral joint[tiab] OR Glenohumeral[tiab] OR Shoulder[tiab] OR Shoulder joint[tiab] OR Shoulder[MeSH] OR Shoulder joint[MeSH], (2) Multidirectional[tiab], (3) Instability[tiab] OR Joint instability[MeSH]. Sixty-eight publications which met our criteria were included.
Results
There was a high degree of heterogeneity in the definition of MDI. Thirty-one studies (46%) included a trauma etiology in the definition, while 23 studies (34%) did not. Twenty-five studies (37%) excluded patients with labral or bony injuries. Only 15 (22%) studies defined MDI as a global instability (instability in all directions), while 28 (41%) studies considered MDI to be instability in two directions, of which one had to include the inferior direction. Six (9%) studies included the presence of global ligamentous laxity as part of the definition. To improve scientific accuracy, the authors propose a novel AB classification which considers traumatic etiology and the presence of hyperlaxity when subdividing MDI.
Conclusion
MDI is defined as symptomatic instability of the shoulder joint in two or more directions. A comprehensive classification system that considers predisposing trauma and the presence of hyperlaxity can provide a more precise assessment of the various existing subtypes of MDI.
Level of Evidence
III
... Baseline examination included general and shoulder-instability-specific anamnesis (mechanism/trauma leading to shoulder dislocation, time since first dislocation, and previous treatment). Clinical examination included assessment of range of motion (ROM), shoulder instability (apprehension test, joint laxity) with determination of the type of shoulder instability according to Gerber [6] (B2 or B3) and shoulder outcome measurement with subjective and objective clinical shoulder scores in terms of the Subjective Shoulder Value (SSV) [7], Constant-Murley Score (CS) [8], Rowe Score (RS) [9], Walch-Duplay Score (WDS) [10], and Western Ontario Shoulder Instability Index (WOSI) [11,12]. Preoperative imaging included a computed tomography (CT) scan with 3D reconstruction and measuring of the glenoid defect (Pico method) [13,14]. ...
All-suture or soft-anchors (SA) represent a new generation of suture anchor technology with a completely suture-based system. This study’s objective was to assess Juggerknot® SA, for arthroscopic Bankart repair in recurrent shoulder instability (RSI), and to compare it to a commonly performed knotless anchor (KA) technique (Pushlock®). In a prospective cohort study, 30 consecutive patients scheduled for reconstruction of the capsulolabral complex without substantial glenoid bone loss were included and operated on using the SA technique. A historical control group was operated on using the KA technique for the same indication. Clinical examinations were performed preoperatively and 12 and 24 months postoperatively. RSI and WOSI at 24 months were the co-primary endpoints, evaluated with logistic and linear regression. A total of 5 out of 30 (16.7%) patients suffered from RSI in the SA group, one out of 31 (3.2%) in the KA group (adjusted odds ratio = 10.12, 95% CI: 0.89–115.35), and 13.3% in the SA group and 3.2% in the KAgroup had a revision. The median WOSI in the SA group was lower than in the KA group (81% vs. 95%) (adjusted regression coefficient = 10.12, 95% CI: 0.89–115.35). Arthroscopic capsulolabral repair for RSI using either the SA or KA technique led to satisfying clinical outcomes. However, there is a tendency for higher RSI and lower WOSI following the SA technique.
... In addition to terminology and diagnosis inconsistencies, a universal classification system for shoulder instability is currently lacking. Several methods to classify shoulder instability have been proposed in the literature, such as the Rockwood (Rockwood Jr, 1979), Thomas and Matsen (i.e., TUBS and AMBRI) (Thomas & Matsen 3rd, 1989) Stanmore (i.e., Polar type I, II, III and sub-types), (Lewis et al., 2004) or, Gerber classifications, (Gerber & Nyffeler, 2002) which are mostly based on expert opinion and lack validity and reliability (Kuhn et al., 2011). Based on the most common features used to characterize shoulder instability in the literature, a new classification system namely FEDS, which stands for Frequency (solitary, occasional [2-5 per year], or frequent [>5 per year]), Etiology (traumatic or atraumatic), Direction (anterior, inferior, or posterior) and Severity (dislocation or subluxation), was developed. ...
Objective
The aim of this study is to review the implementation of the Frequency, Etiology, Direction, and Severity (FEDS) classification for shoulder instability by the physical therapy scientific community since its publication in 2011.
Methods
A systematic search was conducted on January 10, 2024 in the MEDLINE, EMBASE, SPORTDiscus, Scopus, Web of Science, Cochrane, and SciELO databases, as well as Google Scholar. Studies investigating physical therapy interventions in people with shoulder instability, and reporting selection criteria for shoulder instability were considered eligible. A narrative synthesis was conducted.
Results
Twenty-six studies were included. None reported using the FEDS classification as eligibility criteria for shoulder instability. Only 42% of the studies provided data of all four criteria of the FEDS classification. The most reported criterion was direction (92%), followed by etiology (85%), severity (65%), and frequency (58%). The most common reported descriptor for profiling shoulder instability was “dislocation” (83.3%), followed by “first-time” (66.7%), “anterior” (62.5%), and “traumatic” (59.1%). Regarding other instability classifications, only one study (4%) used the Thomas & Matsen classification, and two (8%) the Stanmore classification.
Conclusions
The FEDS classification system has not been embraced enough by the physical therapy scientific community since its publication in 2011.
... Preoperative CT scans were analyzed with Horos Project v4.0.0 (Horos Project, Brooklyn, NY, USA) software by a single shoulder fellowship-trained surgeon per described methods. Glenoids were assessed with the use of two-dimensional CT (2D-CT) with multiplanar reconstruction, with evaluation based on 6 parameters: circle area, 17,23 eroded area, 17,23 erosion edge length, 9,10 anteriorposterior width, 9,10 width of anterior glenoid bone loss (d), and diameter of best fit circle (D). 14 The percentage of anterior glenoid bone loss was assessed using both the "Pico" method (as described by Baudi et al 2 ) and the Sugaya et al method. ...
... Preoperative CT scans were analyzed with Horos Project v4.0.0 (Horos Project, Brooklyn, NY, USA) software by a single shoulder fellowship-trained surgeon per described methods. Glenoids were assessed with the use of two-dimensional CT (2D-CT) with multiplanar reconstruction, with evaluation based on 6 parameters: circle area, 17,23 eroded area, 17,23 erosion edge length, 9,10 anteriorposterior width, 9,10 width of anterior glenoid bone loss (d), and diameter of best fit circle (D). 14 The percentage of anterior glenoid bone loss was assessed using both the "Pico" method (as described by Baudi et al 2 ) and the Sugaya et al method. ...
Background
The glenoid track concept identifies patients with “off-track” (engaging) Hill-Sachs lesions (HSLs) as poor candidates for arthroscopic Bankart repair (ABR) due to the high risk of shoulder instability recurrence.
Purpose
To retrospectively calculate the glenoid track index, using preoperative computed tomography (CT) scans, in a cohort of patients with failed ABR. We hypothesized that all patients with a failed ABR would have engaging (“off-track”) HSLs on preoperative CT scan.
Type of Study
CT scan study.
Methods
Preoperative CT scan of 45 patients, seen in our facility for failed ABR, was used to retrospectively calculate the glenoid track index. The risk of recurrence was also calculated for each patient using Instability Severity Index Score (ISI-Score) and Glenoid Track Instability Management Score (GTIMS). There were 37 failed isolated ABRs and 8 associated HS remplissage. The mean t age at surgery was 24 years (range, 15-52) and instability recurred at a mean of 29 months postoperative (range, 3-167).
Results
Preoperative CT scan imaging identified “off-track” bony lesions in 85% of patients (38/45) and “on-track” lesions in 15% (7/45). No significant differences were noted between the 2 groups (off-track vs. on-track) regarding patient age, hyperlaxity, sports participation, size of HS lesion, or ISI-Score. The mean glenoid bone loss was 15.7% (range, 4-36%) with mean HS width was greater than 20 mm in 66% of CT scans. The preoperative ISI-Score was predictive of failures (>3 points in all patients) with no difference between on-track and off-track patients (6.3 ± 1.7 vs. 6.6 ± 1.7, P = .453). By contrast, the GTIMS did not predict failures as there was a significant difference between GTIMS for on-track and off-track patients (2.1 ± 1.3 vs. 6.6 ± 1.7).
Conclusions
The glenoid track concept alone is insufficient to predict Bankart failures: in the present series of failed ABR, 15% of shoulders had “on-track” (non-engaging) lesions on preoperative CT scan. In patients, with “on-track” bony lesions, the ISI-Score is a useful predictive tool to detect patients at risk of failure, while the GTIMS is not.
... Numerous linear-based measurements have also been described (28)(29)(30)(31). Griffith et al. described the "Griffith Index", which involves drawing a line from the supraglenoid tubercle to the infraglenoid tubercle on the uninjured side (line B), followed by a perpendicular line spanning the widest portion of the glenoid (line A). ...
Studies have shown that glenoid- and humeral-sided bone loss may be present in up to 73–93% of individuals with recurrent anterior shoulder instability. As such, bone loss must be addressed appropriately, as the amount of bone loss drives surgical decision making and influences outcomes. Methods to describe and measure bone loss have changed over time. Originally, glenoid and humeral bone loss were viewed separately. However, the concepts of bipolar bone loss, the glenoid track (GT), and “on/off-track” lesions arose, highlighting the interplay between the two entities in contributing to recurrent instability. Classically, “off-track” lesions have been described as those Hill-Sachs interval (HSI) greater than the GT, and have been shown to result in higher rates of re-instability when addressed nonoperatively or with Bankart repair alone. More recently, further attention has been given to “on-track” lesions (HSI < GT). The new concept of “distance to dislocation” (DTD) has gained popularity. DTD is calculated as the difference between the GT and HSI, and literature evaluating DTD suggests that not all “on-track” lesions should be treated in the same manner. The purpose of this concept review article is twofold: (I) describe glenoid, humeral, and bipolar bone loss in the setting of anterior shoulder instability; and (II) elaborate on the new concept of “DTD” and its use in guidance of management.
... persons/year, the glenohumeral joint has the highest dislocation rate of all joints [1,2]. Antero-inferior shoulder dislocation is the most common, occurring in 95% of all glenohumeral instabilities [3]. In the case of traumatic anterior shoulder dislocations, bony defects of the glenoid are reported in 5% to 56% of cases [4,5], whereas bony defects of the humerus, including Hill-Sachs lesions, are documented in 71% [6,7]. ...
Background: We assessed intraarticular injuries in patients after primary anterior traumatic shoulder dislocation by comparing magnetic resonance arthrography (MRA) results with concomitant arthroscopic findings. Methods: All patients with primary traumatic shoulder dislocation who underwent arthroscopic surgery between 2001 and 2020 with preoperative MRA were included in this study. MRA was retrospectively compared with arthroscopic findings. Postoperative shoulder function was prospectively assessed using the Disabilities of Arm, Shoulder and Hand score (quick DASH), the Oxford Shoulder Score (OSS), the Subjective Shoulder Value (SSV), as well as the rate of return to sports. Results: A total of 74 patients were included in this study. A Hill–Sachs lesion was consistently found in the corresponding shoulders on MRA and arthroscopy in 35 cases (p = 0.007), a Bankart lesion in 37 shoulders (p = 0.004), and a superior labrum from anterior to posterior (SLAP) lesion in 55 cases (p = 0.581). Of all cases, 32 patients were available for a clinical and functional follow-up evaluation. A positive correlation was found between the level of sport practiced and the Oxford Shoulder Score (redislocation subset) (p = 0.032) and between the age at the time of surgery and the follow-up SSV (p = 0.036). Conversely, a negative correlation was observed between the age at the time of surgery and the Oxford Instability Score (redislocation subset) (p = 0.038). Conclusions: The results of this study show a good correlation between MRA and arthroscopy. Therefore, MRA is a valid tool for the detection of soft tissue pathologies after primary anterior traumatic shoulder dislocation and can aid in presurgical planning.
... 35,37 Significant glenoid bone loss, greater than 25% of anteroinferior glenoid bone attenuation, should be addressed through bony augmentation. 17,21,35,37 Several common grafts exist for the bony reconstruction of the glenoid: coracoid, iliac crest, distal tibia, and distal clavicle. 28,38,51,52 The Latarjet procedure is considered to be the most common method to address the bone loss of the glenoid, as it predictably restores stability and has favorable clinical and biomechanical outcomes. ...
Background
Glenohumeral dislocations often lead to glenoid bone loss and recurrent instability, warranting bony augmentation. While numerous biomechanical studies have investigated fixation methods to secure a graft to the glenoid, a review of available constructs has yet to be performed.
Purpose
To synthesize the literature and compare the biomechanics of screw and suture button constructs for anterior glenoid bony augmentation.
Study Design
Systematic review.
Methods
A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. There were 2 independent reviewers who performed a literature search using the PubMed, Embase, and Google Scholar databases of studies published between 1950 and 2020. Studies were included that compared the biomechanical outcomes of fixation for the treatment of anterior shoulder instability with glenoid bone loss.
Results
Overall, 13 of the 363 studies screened met the inclusion criteria. The included studies measured the biomechanical strength of screws or suture buttons on a cadaveric or synthetic Latarjet construct. Screws and suture buttons were biomechanically similar, as both constructs exhibited comparable loads at failure and final displacement. Screw type (diameter, threading, or composition) did not significantly affect construct strength, and double-screw fixation was superior to single-screw fixation. Additionally, 2 screws augmented with a small plate had a higher load at failure than screws that were not augmented. Unicortical double-screw fixation was inferior to bicortical double-screw fixation, although construct strength did not significantly decrease if 1 of these screws was unicortical. Further, 2 screws inserted at 15° off axis experienced significantly higher graft displacement and lower ultimate failure loads than those inserted at 0° parallel to the glenoid.
Conclusion
Suture buttons provided comparable strength to screws and offer an effective alternative to reduce screw-related complications. Augmentation with a small plate may clinically enhance construct strength and decrease complications through the dispersion of force loads over a greater surface area. Differences in screw type did not appear to alter construct strength, provided that screws were placed parallel to the articular surface and were bicortical.
... [5][6][7][8] Traumatic instability is frequently combined with a posterior labrum lesion, a posterior bony Bankart, an erosion of the glenoid rim, or a reverse Hill-Sachs lesion. 9 Atraumatic instability is often associated with hyperlaxity, multidirectional instability, and glenoid dysplasia without any bone lesion. 10 Conservative treatment had led to an 80% success rate in treating the involuntary form of posterior instability, even in the presence of hyperlaxity. ...
Technique Video
Video 1
This surgery is performed with the patient in the beach-chair position. Both the shoulder and iliac crest are draped. A tricortical bone graft is harvested in the desired dimensions and prepared using a specific guide. Two bone tunnels of 3.0 mm diameter with a separating distance of 8 mm are created. Using 4 portals (A, P, AL, and PL), a diagnostic and therapeutic arthroscopy is performed. The posterior portal is lower than the classical soft point. The camera is changed from the anterior portal to the posterior portal. The posterior labrum and capsule is detached from the 9 to the 6 o’clock position. Lasso loop stitches are passed for posterior labral repair. The posterior wall is then debrided and flattened using a burr. The camera is moved to the PL portal. The guide blade is introduced into the joint through the extended posterior portal and is blocked anteriorly and posteriorly. Two tunnels are performed, with an oblique direction from down to up, using a cannulated 3.0 mm drill bit through the glenoid guide. The strands of the 2 cortical buttons are shuttled through both bone tunnels from anterior and are then passed through the respective superior and inferior holes of the iliac crest bone graft. Two cortical buttons are fixated on the strands, which are used to pass the bone graft intra-articularly through the space between the infraspinatus and teres minor muscles by pulling on the alternating strands exiting through the anterior portal. The implants are then tightened with a suture tensioner from the anterior portal. An additional capsulolabral repair can be performed.
... M ultidirectional instability (MDI) is relatively rare, accounting for approximately 2% to 10% of all cases of shoulder instability. 1 Although definitions have historically varied, 1 MDI according to Neer 2 is defined as symptomatic instability in !2 directions, one of which is inferior. Although often closely associated, MDI must be differentiated from unidirectional anteroinferior instability with multidirectional hyperlaxity, 3 which has a prevalence of 13% in first-time dislocators. 4 MDI can occur spontaneously and atraumatically or as the result of multiple traumatic events in patients with normal capsular laxity or in the setting of minor traumatic events leading to a decompensation of glenohumeral stability in patients with constitutional or acquired shoulder hyperlaxity. ...
... 4 MDI can occur spontaneously and atraumatically or as the result of multiple traumatic events in patients with normal capsular laxity or in the setting of minor traumatic events leading to a decompensation of glenohumeral stability in patients with constitutional or acquired shoulder hyperlaxity. 3,5 Frequently, labral tears are also present. 6,7 A concomitant lesion to the SLAP complex in the setting of MDI adds to the complexity of the injury, as the long head of the biceps (LHBT) can act as a stabilizing structure by contributing to the concavity compression centering the humeral head in the glenoid and resisting torsional forces in abduction and external rotation. ...
In the management of multidirectional type of shoulder instability (MDI), arthroscopic surgical stabilization is a preferred treatment option after failed conservative therapy regimens because of the ability to easily access all aspects of the capsule with one surgical procedure. As arthroscopic techniques have evolved, factors critical to postoperative success have been elucidated. Currently, optimal arthroscopic treatment of MDI involves circumferentially restoring labral integrity, a tailored, patient-specific surgical reduction of capsular volume, and adequately managing potential lesions of the biceps anchor. The purpose of this article and accompanying video is to present our technique for arthroscopic circumferential labral repair and pancapsular shift using knotless all-suture anchors in the setting of MDI with a concurrent type II SLAP lesion.
... [30] Using this method, the width-to-length (W/L) ratio and glenoid defect length, when expressed as functions of glenoid diameter, were most predictive of glenoid bone loss and recurrent instability, respectively. [30,33] Further, validation against an arthroscopic "gold standard" showed a sensitivity and specificity of detecting glenoid bone loss with CT as 93% and 78%, respectively [19]. ...
... A number of other variations exist, all utilizing a variation of the circle of best fit for the injured glenoid. Individually, these various methods have been shown to be reproducible, though in small sample sizes with low levels of evidence [24][25][26]33]. ...
Purpose
The extent of glenohumeral bone loss seen in anterior shoulder dislocations plays a major role in guiding surgical management of these patients. The need for accurate and reliable preoperative assessment of bone loss on imaging studies is therefore of paramount importance to orthopedic surgeons. This article will focus on the tools that are available to clinicians for quantifying glenoid bone loss with a focus on emerging trends and research in order to describe current practices.
Recent findings
Recent evidence supports the use of 3D CT as the most optimal method for quantifying bone loss on the glenoid and humerus. New trends in the use of 3D and ZTE MRI represent exciting alternatives to CT imaging, although they are not widely used and require further investigation. Contemporary thinking surrounding the glenoid track concept and the symbiotic relationship between glenoid and humeral bone loss on shoulder stability has transformed our understanding of these lesions and has inspired a new focus of study for radiologists and orthopedist alike.
Summary
Although a number of different advanced imaging modalities are utilized to detect and quantify glenohumeral bone loss in practice, the current literature supports 3D CT imaging to provide the most reliable and accurate assessments. The emergence of the glenoid track concept for glenoid and humeral head bone loss has inspired a new area of study for researchers that presents exciting opportunities for the development of a deeper understanding of glenohumeral instability in the future. Ultimately, however, the heterogeneity of literature, which speaks to the diverse practices that exist across the world, limits any firm conclusions from being drawn.
