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ORIGINAL ARTICLE
Year : 2015  |  Volume : 15  |  Issue : 1  |  Page : 56-61

Arthroscopic evaluation and management of instability of shoulder joint


1 Department of Orthopedics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
2 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India

Date of Web Publication19-Jan-2015

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan 713 102, West Bengal
India
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DOI: 10.4103/1319-6308.149541

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  Abstract 

Background: Shoulder joint instability results in great disability and it is possible to get good results of treatment in selected patients in whom intraarticular pathologies are diagnosed and treated appropriately. Aims: To investigate the pathology of unstable shoulder joint and study the effect of arthroscopic stabilization for the management of traumatic anterior glenohumeral instability and success rate of all arthroscopic Bankart repair. Materials and Methods: This prospective study was conducted in a tertiary care hospital of West Bengal in a time span of 1 year, after getting the approval of the Institutional Ethical Committee and informed consent of the patients. Patients aged between 20 and 40 years with post-traumatic recurrent anterior dislocation of the shoulder were included. Patients were operated arthroscopically and followed up. Results were analyzed per the assessment criteria of Rowe scale. Results: Ten percent had fair and 90% had poor Rowe score during preoperative period. Bankart lesion was present in 16 patients out of 20 patients in whom we performed arthroscopic Bankart repair with suture anchors. At last follow up, 13 patients were able to work above shoulder level normally; two patients had mild limitation of work. One patient had moderate type of restriction of activities. This patient had a history of trauma 3 months after operation. Conclusions: Overall 93.75% patients had excellent to good result in the present study. Based on this short series and minimum follow-up we recommended, this method of management for shoulder instability due to Bankart lesion.

  Abstract in Arabic 

تقييم ومعالجة عدم استقرار مفصل الكتف

خلفية: عدم استقرار مفصل الكتف قد يؤدي إلى إعاقة كبيرة، إلاّ أن معاجته قد تؤدي إلى نتائج جيدة في بعض المرضى الذين يتم تشخيصهم ومعالجتهم بطريقة مناسبة.

أهداف الدراسة: دراسة الحالة المرضية لعدم استقرار مفصل الكتف و تأثير المناظير في تثبيت عدم الاستقرار الرضخي العضدي الحقاني و النسبة الكلية لنجاح منظار بانكارت في العلاج.

منهج الدراسة و عينتها: أجريت هذه الدراسة في مستشف تعليمي للرعاية الصحية في غربي البتغال على مدى عام، و بعد أخذ الموافقة من جمعية أخلاقيات المهنة وموافقة المرضي. و تراوحت أعمار المرضى بين 20 و 40 سنة كانوا يعانون خلعا قي الكتف. تمت معاجة المرضى بالمنظار و متابعتهم. و تم تحليل النتائج وفقا لمعيير التقييم على نطاق روو.

النتائج: كانت نسبة 10% من المرضى نتائجهم مرضية و90% كانت نتائجهم أقل من ذلك في مرحلة ما قبل العملية. وقد ظهر أثر جرح منظار بانكارت على 16% من المرضى من أصل عشرين، أظهروا تحسنا مع منظار بانكارت مع تثبيت بالخياطة. وفي متابعة المرضى الأخيرة ، اسنطاع 13 من المرضى العمل فوق مستوى الكتف بطريقة عادية، و بينما ظهر عند اثنين من المرضى ضعف محدود في الحركة. و ظهرت عند مريض واحد إعاقة حركية معتدلة ، وكان هذا المريض قد تعرض لرضخ قبل ثلاثة أشهر بعد العملية.

الاستنتاجات: أظهرت نسبة 93% من المرضى نتائج بين ممتازة وجيدة .

وبناء على الحد الأدنى من المتابعة ، توصي الدراسة باستخدام هذه الطريقة في علاج عدم استقرار مفصل الكتف.




Keywords: Arthroscopic evaluation, rowe scale, shoulder dislocation


How to cite this article:
Ghosh P, Ghosh S, Chaudhuri A, Datta S, Sirdar BK, Sanyal P. Arthroscopic evaluation and management of instability of shoulder joint. Saudi J Sports Med 2015;15:56-61

How to cite this URL:
Ghosh P, Ghosh S, Chaudhuri A, Datta S, Sirdar BK, Sanyal P. Arthroscopic evaluation and management of instability of shoulder joint. Saudi J Sports Med [serial online] 2015 [cited 2019 Aug 20];15:56-61. Available from: http://www.sjosm.org/text.asp?2015/15/1/56/149541


  Introduction Top


Rotator cuff tears lead to debilitating shoulder dysfunction and impairment. [1] The rotator cuff is a group of muscles and tendons that cover the shoulder joint. These muscles and tendons hold the arm in the ball and socket of shoulder joint, and they help to move shoulder in different directions. The tendons in the rotator cuff can tear when they are overused or injured. [2] The goal of rotator cuff repair is to eliminate pain and improve function with increased shoulder strength and range of motion. The clinical outcomes of the surgical methods of rotator cuff repair methods provide an array of advantages and disadvantages. All-arthroscopic approach decreases patient morbidity through decreased surgical trauma. In addition to surgery-specific rotator cuff rehabilitation program, effective communication, and coordination of care by the physical therapist and surgeon are essential in optimal patient education and outcomes. [1],[2],[3]

In recurrent dislocation of the shoulder with combined Bankart and SLAP lesion, arthroscopic repair using absorbable suture anchors produce favorable clinical results. The concomitant unstable SLAP lesion should be repaired in a manner that stabilizes the glenohumeral joint, as the Bankart lesion can be repaired if the unstable SLAP lesion is repaired first. [3]

Arthroscopic repair of combined Bankart and SLAP lesions may present technical difficulties. Nevertheless, it is possible to get good results in selected patients in whom intraarticular pathologies are diagnosed and treated appropriately. [4] The results of arthroscopic Bankart repair and posterior capsular plication are satisfactory in the treatment of anterior glenohumeral instability with capsular laxity. However, the use of capsular plication with arthroscopic Bankart repair should be considered in selected cases. [5] Addition of the selective capsular shift technique to the Bankart repair procedure improves stability and preserves the range of motion of the glenohumeral joint in patients with anterior-inferior glenohumeral instability accompanied by a Bankart lesion and capsular injury or laxity. [6]

Anterior glenohumeral instability typically involves lesions associated with the inferior glenohumeral ligament complex. These lesions are indicative of the high-force traumatic nature of anterior shoulder dislocation. [7],[8] Recurrent posterior glenohumeral instability, although a less common clinical entity than anterior instability, must be recognized and appropriately treated for a successful outcome. Pathological findings that may need to be addressed include posterior Bankart lesions, humeral avulsion of the posterior inferior glenohumeral ligament (PIGHL), intrasubstance ligament attenuation, and combined lesions. [7],[8],[9]

The present study was conducted to investigate the exact pathology of unstable shoulder joint and study the effects of arthroscopic Bankart repair for the management of traumatic anterior glenohumeral instability and functional recovery.


  Materials and methods Top


This prospective study was conducted in a tertiary care hospital of West Bengal in a time span of 1 year, after getting the approval of the Institutional Ethical Committee. The patients were properly counseled regarding the merits and demerits of the procedure, well explained in their own language. Informed consent was taken from all patients.

Inclusion criteria

Patients aged between 20 and 40 years with posttraumatic recurrent anterior dislocation of the shoulder.

Exclusion criteria

Those with multidirectional instability, generalized ligament laxity, with big Hill-Sach's lesion involving 30% of the humerus and humeral avulsion of the glenohumeral ligaments, age >40 years, neuromuscular disorder, epilepsy and abnormal mental status.

After case selection, through clinical history was taken. Physical examination was done by apprehension test, Jobe relocation test, speed test, sulcus sign.

Diagnostic testing

Radiographic examination included anteroposterior and axillary lateral view of the shoulder. Anteroposterior view of the shoulder in internal rotation demonstrates Hill-Sachs lesion. Ultrasonography was done to exclude any soft tissue pathology. Ultimately, the diagnosis was conformed with arthroscopy at the time of operation.

Arthroscopic evaluation and management

After general anesthesia patient was placed in the lateral decubitus by tilting the patient 20-30 degrees posterior. Stability testing was then performed to confirm the degree and direction of instability. Then the arm was suspended with 10-15 pounds of traction in 45 degree abduction and 20-30 degree of forward flexion which offers the advantage of joint distraction.

The primary posterior portal was created 1.5-cm inferior and medial to the posterolaleral corner of the acromion between the infraspinatus and teres minor, the posterior soft spot. Initially evaluation of joint was performed, with use of 20 ml of air and then it was done with normal saline solution. On entering the joint, the biceps tendon was located and used as a landmark. Then diagnostic arthroscopy was performed, including evaluation of articular cartilage and surface of the glenoid, the humeral head, the glenohumeral ligaments, biceps tendon, and the extent of labral detachment around the glenoid, the degree of capsular laxity, and the quality of the tissue by direct visualization and palpation with a probe.

Surgical pathology

Type-I Bankart lesion (avulsion of the cartilaginous labrum and the capsule from the anterior part of the glenoid rim) was present in 14 patients, Type- II Bankart lesion (avulsion of the labrum, anterior part of the capsule and a small fragment of the rim of the glenoid) was present in two patients. There was no labral lesion in three patients; where excessive laxity of the shoulder capsule was present, the degree of laxity was estimated by the amount of redundancy in the capsule. We performed the modified Boytchev procedure after confirmation of diagnosis by shoulder arthroscopy in these cases. In rest of the 16 patients, we performed arthroscopic Bankart repair.

Post-operative protocol

The patients were placed in an immobilizer for 3 weeks. Once the post-operative pain was reduced the patients were instructed to touch their forehead just like the saluting position. Then from the second week they were instructed to reach the back of their head. At 3 weeks the patients started passive over head elevation and internal rotation. At 6 weeks if the was progress satisfactory, strengthening exercises were started. Strengthening exercises were continued until full strength was regained, mostly at the end of 3 months. No overhead activities that accelerate the arm and contact sports were allowed until 6 months after the surgical procedure. Eight months post-operative patients returned to full activities.


  Results and analysis Top


In the present series, 20 patients with recurrent traumatic anterior dislocation of shoulder joint were included. All the patients subjected to arthroscopic evaluation initially. Bankart lesion was present in 16 patients. There was no labral lesion in three patients; where excessive laxity of the shoulder capsule was present, in one patient bony Bankart lesion was present. We performed open surgery for these four cases, the modified Boytchev procedure. In rest of the 16 patients we performed arthroscopic Bankart repair with suture anchors. These patients were followed up weekly for 1 month, then two weekly for another 3 months, then at monthly interval for 6 months, then three monthly till 1 year 7 months in some patients. The clinical examination was done according to the Rowe scale. [7]

Age of the patients ranged from 20 to 40 years. Majority of the patients were of the age group of 20 to 30 years (90%). Nineteen were males and one female. Instability was more commonly on the dominant on right side (17 right sided and 3 left). Ten were sedentary workers, 9 manual laborers and one athlete. Fifteen patients had history of fall, one was an injured sports personnel, and 4 had road traffic accidents. The rating system of Rowe et al., was used to evaluate the clinical outcome of the procedure. This 100-point system assigns 50 points for function, 30 points for stability, 10 points for motion, and 10 points for pain. Excellent: 90-100, Good: 70-89, Fair: 40-69, Poor: 39 points or less. 10% had fair and 90% had poor Rowe score during preoperative period. All the patients had positive apprehension test and sense of subluxation. Fifteen patients had moderate type of pain; rest five patients had no pain. All the patients had some restriction of movement, 18 patients presented with moderate limitation of work, and five patients with mild limitation of work. Frequency of dislocation before surgery: 5% had ≥4/year, 65% had 3-4/year and 30% had 1-2/year.

Statistical analysis was carried out and level of significance set at P < 0.05. All the patients were operated arthroscopically and were followed up for maximum 1 year 7 months and minimum 6 months. Functional level: At last follow-up, 13 patients were able to work above shoulder level normally; two patients had mild limitation of work. One patient had moderate type of restriction of activities. This patient had a history of trauma 3 months after operation [Table 1],[Table 2] and [Table 3].
Table 1: Post‑operative function

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Table 2: Post‑operative stability

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Table 3: Post‑operative range of movement

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The pain reduced for all the patients with time. While three patients had moderate type pain at last follow-up [Table 4], among these three patients one had history of trauma 3 months after operation.
Table 4: Post‑operative pain

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Overall post-operative Rowe score in 13 patients (81.25%) were >90 %, in two patients (12.50) score were 80%; in one patient (6.25) with poor score was 30% [Table 5]. No patient showed any infection or any neurological deficit.
Table 5: Overall result (By Rowe score)

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  Discussion Top


We did a prospective analysis to assess the outcome in rest of the 16 patients with arthroscopic Bankart repair with suture anchors done in our institute. In our present study group we found that 93.75% patients had excellent to good result and they were satisfied in post-operative follow-up. One patient had positive apprehension test and sense of instability (6.25%) at a mean follow-up of 1 year and 7 months.

A study was conducted by Cho et al.,[3] to evaluate the clinical results and operation technique of arthroscopic repair of combined Bankart and superior labrum anterior to posterior (SLAP) lesions, all of which had an anterior-inferior Bankart lesion that continued superiorly to include separation of the biceps anchor in the patients presenting recurrent shoulder dislocations. They reviewed 15 cases with combined Bankart and SLAP lesions among 62 patients with recurrent shoulder dislocations who underwent arthroscopic repair. The average age at surgery was 24.2 years (range, 16-38 years), with an average follow-up period of 15 months (range, 13-28 months). During the operation, they repaired the unstable SLAP lesion first with absorbable suture anchors and then also repaired Bankart lesion from the inferior to superior fashion. They analyzed the pre-operative and post-operative results by visual analog scale (VAS) for pain, the range of motion, American Shoulder and Elbow Surgeon (ASES) and Rowe shoulder scoring systems and compared the results with the isolated Bankart lesion. VAS for pain was decreased from preoperative 4.9 to postoperative 1.9. Mean ASES and Rowe shoulder scores were improved from preoperative 56.4 and 33.7 to postoperative 91.8 and 94.1, respectively. There were no specific complication and no significant limitation of motion more than 10 degree at final follow-up. The range of motions after the arthroscopic repair in combined lesions was gained more slowly than in patients with isolated Bankart lesions.

A study was conducted in 2011 [4] to compare clinical outcomes between a primary dislocation group (group P) and a recurrent dislocation group (group R) with combined lesion of Bankart and type II SLAP lesions (type V SLAP lesion) and to evaluate incidence of type V SLAP lesion. Clinical outcomes of these patients were evaluated by dividing two groups according to the sequence for Bankart and SLAP lesion suture. Group P included 42 patients, and group R, 68 patients. Among all patients, 58 patients who had Bankart lesions sutured first were included in group B, and 52 who had their SLAP lesions sutured beforehand, group S. VAS, range of motion, Rowe and Constant score were used to compare results between group P and group R, also group B and group S. The incidence rates of type V SLAP lesion were 42.8% in group P and 32.0% in group R. The overall treatment results were good.

Ozbaydar et al., retrospectively evaluated patients who underwent arthroscopic treatment for superior labrum anterior posterior (SLAP) lesions combined with antero-inferior labral detachment (Bankart lesion, Maffet type 5). The study included eight male patients (mean age 31.8 years; range 23-50 years) who were treated with suture anchors for type 5 SLAP lesions. In all the patients the symptoms started after trauma, and all presented with shoulder instability findings. All the patients were examined by standard shoulder magnetic resonance scans. Functional results were evaluated according to the University of California at Los Angeles (UCLA) shoulder score, and the Rowe rating scale for Bankart repairs. The mean follow-up was 37.8 months (range 24-52 months). Functional results were excellent-good in five patients, fair in two patients, and poor in one patient. The mean UCLA score increased from a preoperative 15 (range 14-17) to a postoperative 30 (range 20-35), with a corresponding increase in the mean Rowe score from 25 (range 15-45) to 81 (range 50-95) (P < 0.05). [5]

Ozbaydar et al., in 2007 evaluated patients who underwent arthroscopic repair for posttraumatic, recurrent anterior-inferior glenohumeral instability with capsular laxity. Seventeen patients (4 females, 13 males; mean age 27 years; range 18-40 years) were treated with arthroscopic Bankart repair and posterior capsular plication for post-traumatic, recurrent anterior-inferior glenohumeral instability with capsular laxity. Involvement was on the right side in 11 patients, and on the left in six patients. The mean duration from the first dislocation to surgery was 5.2 years (range 1-11 years). All the patients received conservative treatment before surgery. Range of motion was measured with a goniometer and muscle strength was measured manually. Apprehension test, Jobe apprehension-relocation test, and posterior apprehension test were used to assess instability. Preoperatively, all the patients were examined by anteroposterior and axillary radiographs and magnetic resonance imaging. Shoulder functions were assessed with the Rowe rating scale for Bankart repairs. The mean follow-up was 35.6 months (range 24-50 months). Instability recurred in three patients (17.7%). The Rowe score increased from a mean of 41 (range 15-45) to 78 (range 43-100) postoperatively. Functional results were excellent-good in 13 patients (76.5%), fair in one patient (5.9%), and poor in three patients (17.7%). One patient underwent arthroscopic revision following redislocation. Pre- and post-operative values for active forward flexion, external rotation, and internal rotation did not differ significantly (P > 0.05). [6]

Ozbaydar et al., evaluated the functional results of treatment with the selective capsular shift technique in patients with recurrent post-traumatic anterior-inferior glenohumeral instability. The study included 16 patients (15 males, 1 female; mean age 30 years; range 25-38 years) who underwent selective capsular shift operation for recurrent post-traumatic anterior-inferior glenohumeral instability. Dislocations occurred following severe (n = 14) or mild (n = 2) trauma. Preoperatively, the mean number of dislocations was 14 (range 4-45) and magnetic resonance imaging showed a Bankart lesion in all the patients and a Hill-Sachs lesion in 20%. The patients were evaluated according to the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Rowe's scoring for Bankart repair. Pre-operative and post-operative anteroposterior and axillary X-rays were obtained from all the patients. Range of motion was measured with a goniometer and manual muscle strength tests were performed. The mean follow-up was 41 months (range 21-74 months). The mean preoperative and postoperative ASES scores differed significantly (63.2 vs 95.8; P < 0.05). The mean Rowe score was 92.5 (range 70-100). Strength of the infraspinatus, supraspinatus, and subscapularis muscles increased significantly (P < 0.05). The results were excellent in 12 patients (75%), good in two patients (12.5%), and fair in two patients. Fifteen patients (93.8%) expressed satisfaction with the operation and results. [7]

The results of this present study confirm the overall excellent results published in many recent studies. Full thickness rotator cuff tears can be addressed successfully by arthroscopic repair, with a rapid return to pre-injury status.

Limitations of the study

This was a prospective analysis; and therefore the study needs more follow-up period for significant conclusion. There was no control group and shorter follow up period with small group of patients.


  Conclusion Top


We had selected 20 patients recurrent traumatic anterior dislocation. All of them subjected to arthroscopic evaluation initially. Bankart lesion was present in 16 patients out of 20 patients in whom we performed arthroscopic Bankart repair with suture anchors. We did proper rehabilitation program at regular interval after operation. Maximum follow-up was 1 year 7 months and minimum 6 months. Clinical evaluation was done according to Rowe Scale. Overall 93.75% excellent to good result comparable to most of the other studies. Based on this short series and minimum follow-up we can recommended though not very strongly, this method of management for shoulder instability due to Bankart lesion.

 
  References Top

1.
Ghodadra NS, Provencher MT, Verma NN, Wilk KE, Romeo AA. Open, mini-open, and all-arthroscopic rotator cuff repair surgery: Indications and implications for rehabilitation. J Orthop Sports Phys Ther 2009;39:81-9.  Back to cited text no. 1
    
2.
Van der Meijden OA, Paul Westgard P, Chandler Z, Gaskill RT, Kokmeyer D, Millett PJ. Rehabilitation after arthroscopic rotator cuff repair: Current concepts review and evidence-based guidelines. Int J Sports Phys Ther 2012;7:197-218.  Back to cited text no. 2
    
3.
Cho LH, MD, Lee CK, Hwang TH, Suh KT, Park JW. Arthroscopic repair of Combined Bankart and SLAP Lesions: Operative techniques and clinical results. Clin Orthop Surg 2010;2:39-46.  Back to cited text no. 3
    
4.
Kim DS, Yi CH, Yoon YS. Arthroscopic repair for combined Bankart and superior labral anterior posterior lesions: A comparative study between primary and recurrent anterior dislocation in the shoulder. Int Orthop 2011;35:1187-95.  Back to cited text no. 4
    
5.
Ozbaydar MU, Tekin C, Kocabaº R, Altun M. Arthroscopic repair of combined superior labrum anterior posterior and Bankart lesions. Acta Orthop Traumatol Turc 2006;40:134-9.  Back to cited text no. 5
    
6.
Ozbaydar MU, Tonbul M, Baca E, Yalaman O. Arthroscopic treatment of anterior-inferior shoulder instability. Acta Orthop Traumatol Turc 2007;41:120-6.  Back to cited text no. 6
    
7.
Ozbaydar MU, Tonbul M, Altun M, Yalaman O. Treatment of recurrent post-traumatic anterior-inferior glenohumeral instabilities with the selective capsular shift technique. Acta Orthop Traumatol Turc 2005;39:97-103.  Back to cited text no. 7
    
8.
Rothberg DL, Burks RT. Capsular tear in line with the inferior glenohumeral ligament: A cause of anterior glenohumeral instability in 2 patients. Arthroscopy 2009;25:934-6.  Back to cited text no. 8
    
9.
Pokabla C, Hobgood ER, Field LD. Identification and management of "floating" posterior inferior glenohumeral ligament lesions. J Shoulder Elbow Surg 2010;19:314-7.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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