Management of Acute Shoulder Instability: The Combined Lax Shoulder with Added Acute Trauma

Fig. 8.1

Apprehension and relocation tests. The involved arm is carefully placed in a position of abduction and external rotation. Symptoms of anterior instability or pain or both that resolve with a posteriorly directed force by the examiner indicate a positive finding of anterior shoulder instability. Copyright Kevin D. Plancher, MD

8.2.3 Imaging

Radiographic imaging should include a standard instability series including an anterior-posterior (AP), scapular-Y, Bergeneau, and axillary views to assess for concomitant bony injuries as well as alignment. The axillary view can detect anterior or posterior glenoid rim fractures and assists in the detection of AP subluxation or dislocation. Magnetic resonance imaging (MRI) and/or computed tomography (CT) scans can also aid in the detection of concomitant soft tissue pathologies and assist in quantifying bony lesions when present.

8.3 Indications and Technique

8.3.1 Indications

The inferior capsular shift in patients with MDI has been the gold standard treatment to restore function with less than 10% recurrence. In the setting of the patient with MDI that sustains an acute anterior shoulder dislocation with radiographic evidence of Bankart lesion, the authors recommend an arthroscopic Bankart repair with a modified inferior capsular shift to restore shoulder stability in these challenging patients.

8.3.2 Technique

An interscalene block supplemented with general endotracheal anesthesia can be used for most surgical patients. An intraoperative examination of shoulder stability and ROM should be conducted on both limbs to confirm preoperative impressions. Patients can then be positioned in the lateral decubitus position with the arm secured in a holder in approximately 45° of abduction and 15° of forward flexion with neutral rotation under seven to ten pounds of traction. Bankart surgery can be performed in the beach chair or lateral decubitus position; however, in the senior author’s experience, the lateral decubitus position allows for superior access to the 6 o’clock position of the shoulder and aids in positioning the glenoid parallel to the floor, creating a standard reference point and allowing for excellent visualization of the glenohumeral joint during surgery [11].

A modified 3-portal technique similar to that previously described by Nebelung should be utilized [12]. Posterior, anteroinferior, and anterosuperior portals are established using an outside-in technique and 18-gauge spinal needles for optimal positioning. The posterior portal is the primary viewing portal; the anterosuperior portal is used to visualize the pathology, prepare the glenoid rim, and perform the Bankart repair; and the anteroinferior portal provides access to the glenoid for optimal anchor placement. A thorough arthroscopic examination inspecting the 15 points originally described by Snyder and identifying associated glenoid or humeral defects, anterior labral lesions, and capsular tissue quality should be performed [13]. The extent of the labral tear is documented using a clock-face model as previously described [14].

Following confirmation of less than 20% glenoid bone loss, an arthroscopic shaver and hooded 3.5 mm burr are used to expose an area of bleeding cortical bone on the anterior aspect of the glenoid for anchor placement (Fig. 8.2). Two or three anchors are placed below the 3-o’clock position, perpendicular to the glenoid rim, and at least 3 mm inside the edge of the glenoid rim (Fig. 8.3a, b). A suture-passing instrument or suture shuttle device is used to pass sutures through the capsular tissue and labrum in an inferior to superior fashion (Fig. 8.4). Sutures should be secured on the nonarticular side of the repair with a modified sliding locking Weston knot or bioknotless anchor. A minimum of three additional anchors based on the size of the lesion should be placed from inferior to superior. High-strength suture either single- or double-loaded with bioabsorbable anchors or PLA-composite bioabsorbable suture anchors should be used to secure capsular imbrication, and this inferior capsular shift should be employed in patients at a high risk for recurrence. The authors also recommend an arthroscopic rotator interval closure using polydioxanone (PDS) sutures when these patients previously admitted to dislocating in their sleep. The need to prevent recurrence of instability or any subluxations is essential (Fig. 8.5a–c). Surgical incisions are closed using Vicryl and Monocryl sutures followed by infiltration of the joint with 10 mL of 0.25% Marcaine without epinephrine.

Fig. 8.2

Burr in place. The anterior glenoid rim is debrided to create a bleeding bony bed. Copyright Kevin D. Plancher, MD

Fig. 8.3

(a) An arthroscopic guide placed on the glenoid bumper for accurate placement. (b) An anchor in place with suture ready for lasso passer. Copyright Kevin D. Plancher, MD

Fig. 8.4

Arthroscopic suture lasso placed under the labrum to reconstruct for stability. Copyright Kevin D. Plancher, MD

Fig. 8.5

Rotator interval closure. (a) Spinal needles are placed through the upper border of the subscapularis. (b) A piercing instrument is used to close the rotator interval through the superior glenohumeral ligament. (c) The rotator interval is tied extraarticularly and now seen after arthroscopic closure. Copyright Kevin D. Plancher, MD

8.4 Rehabilitation

Following surgery, a conservative rehabilitation protocol should be followed to avoid stressing the repaired capsuloligamentous structures [9]. Patients should be placed in an immobilizing sling in neutral rotation for 4 weeks. The patient is permitted to remove the sling and let the arm hang by the side three times daily for 5 minutes. After 2 weeks, the sutures are removed, and active-assisted flexion ROM exercises in a supine position only are initiated. If the patient is not able to achieve 90° active-assisted supine forward flexion (FF) at 2 weeks, an adjusted rehab program is instituted. External rotation (ER) beyond 10° should be prohibited until 4 weeks postoperatively. After 4 weeks, the immobilizing abduction sling device is discontinued, and the use of a soft sling is introduced to be worn during sleep and when out in public for safety. Supine, active-assisted FF exercises to 120°, progressing to 160° while avoiding end range forced flexion, are also initiated. Light, end range stretching exercises are begun at week 5 with internal rotation behind the back. Proprioceptive and scapular-stabilization exercises are initiated at 6 weeks, and strengthening exercises are initiated at 8 weeks with progression until week 12 when isokinetics and sport-specific activities are introduced. Return to sports is permitted at 3 months for noncontact athletes, at 4–5 months for contact athletes depending on their position, and at 9 months for athletes participating in overhead sports.

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