Arthroscopic Repair of Primary Anterior Dislocations of the Shoulder

Primary traumatic anterior dislocations occur commonly in young athletes. The mechanism of injury may involve a collision or a fall with the arm in an abducted and externally rotated position. Many collision and contact sports competitions provide frequent opportunity for this mechanism of injury. An attempted arm tackle during football or rugby places the arm in an abducted, externally rotated position, and, coupled with collision or contact, can precipitate acute anterior dislocation. In many cases, recurrent instability may result, leading to significant disability despite compliance with a period of immobilization and shoulder rehabilitation. One of the major pathoanatomic features of this injury, the traumatic capsulolabral avulsion of the inferior glenohumeral ligament or Bankart-Perthes lesion, has been well described and found on arthroscopic examination in nearly all cases. To reverse the natural history of this injury, arthroscopic stabilization has been used to restore the normal anatomy and minimize the sequelae and disability. We present the evolution of our treatment approach over the past 13 years and the arthroscopic technique of stabilization of acute, primary, anterior dislocations of the shoulder. ANATOMY AND BIOMECHANICS Turkel (1) demonstrated that the inferior glenohumeral ligament (IGHL) complex is the primary restraint to anterior glenohumeral translation, especially with the arm in an abducted position. The anterior and posterior bands, with the intervening axillary pouch, were subsequently described by O'Brien (2) as anatomic portions comprising the inferior glenohumeral ligament. The pathoanatomy of anterior glenohumeral dislocations was originally described as an operative finding during open reconstruction nearly 100 years ago (3–5). The detachment of the anterior band of the IGHL from the anteroinferior glenoid is considered one of the major pathoanatomic features of anterior instability and is named the Bankart-Perthes lesion (Fig. 1)(6–7).FIG. 1.: A classic Bankart-Perthes lesion. (Reprinted with permission from Warner JP, Boardman ND. Anatomy, biomechanics, and pathophysiology of glenohumeral instability in the unstable shoulder. In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott, Williams and Wilkins, 1999, p. 68.)The arthroscopic pathoanatomy of acute primary anterior dislocations has also been well described and confirms many of the findings originally reported (3–5). Typically, the ligament is avulsed from the labrum at the anteroinferior glenoid and has been observed in 97% of our cases. Alternatively, the IGHL can be torn from its insertion via an avulsion fracture of the anteroinferior glenoid rim. In addition to the detachment of the anterior band of the IGHL from the glenoid, the injury may extend inferiorly into the capsule of the axillary pouch. Taylor and Arciero (5) reported one capsular tear in a series of 63 primary shoulder dislocations. This injury, although uncommon, can be addressed concomitantly with the Bankart lesion during arthroscopic repair. Alternatively, the injury may proceed superiorly into the labral attachment of the biceps tendon producing a concomitant superior labrum anterior posterior (SLAP) lesion as has been described by Snyder et al. (8). This associated lesion, especially the type II variant (Fig. 2), was observed in 31% of our cases (9) and is seen more frequently when the dislocation involves more extreme trauma. A more rare occurrence is the lateral detachment of the inferior glenohumeral ligament from the humeral neck, the so-called HAGL lesion (humeral avulsion of glenohumeral ligament), as described by Bach et al. (10) and subsequently by Wolf et al.(11)(Fig. 3).FIG. 2.: A type II superior labrum anterior posterior (SLAP) lesion. (Reprinted with permission from Getelman MH, Snyder SJ. SLAP lesions and lesions of the long head of the biceps tendon. In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott, Williams and Wilkins, 1999, p. 352.)FIG. 3.: Humeral avulsion of the glenohumeral ligaments (HAGL). Diagram demonstrating disruption of lateral capsule. (Reprinted with permission from Bach BR, Warren RF, Fronek J. Disruption of the lateral capsule of the shoulder: a cause of recurrent dislocation. J Bone Joint Surg [Br] 1988;70:274–6.)The forceful, traumatic humeral dislocation usually results in posterolateral humeral head compression against the bony glenoid rim. This produces the classic Hill–Sachs lesion, a chondral or osteochondral compression injury. Arthroscopically, this lesion can be differentiated from the normal, nonarticular “bare area” of the humeral head by the appearance of articular cartilage on both sides of the lesion. Additionally, the acute Hill–Sachs lesion has an irregular appearance, often with exposed cancellous bone (Figs. 4A and B).FIG. 4.: A. Arthroscopic image of Hill–Sachs lesion. Note cartilage on both sides of the osteochondral injury. B. Diagram of an anterior glenohumeral dislocation that results in a labral tear and a Hill–Sachs lesion. (Reprinted with permission from Warner JP, Boardman ND. Anatomy, biomechanics, and pathophysiology of glenhumeral instability in the unstable shoulder. In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott, Williams and Wilkins, 1999, p. 69.)Figure 4: ContinuedAnterior glenohumeral dislocation usually results from an indirect force that produces extreme external rotation of the humerus in an abducted position. With the arm in the abducted, externally rotated position, the anterior band of the IGHL is tensioned across the front of the glenoid. This checkrein in conjunction with the glenoid labrum normally prevents further translation of the humeral head over the glenoid edge. With sufficient force, the IGHL traumatically fails, and the humerus is levered over the anterior glenoid rim, resulting in dislocation. HISTORICAL PERSPECTIVE In 1938 Bankart(6) wrote that recurrent dislocation was too readily assumed the result of an ordinary traumatic dislocation of the shoulder joint. He noted that a rent in the capsule healed readily and that dislocation never recurred unless a tear in the glenoid labrum was present. Recurrence seems, however, to be significantly influenced by the patient's age when the primary dislocation occurs. McLaughlin and MacLellan (12) compared 256 recurrent dislocations with 315 primary dislocations. Ninety-six percent of patients with recurrent dislocation sustained their initial dislocation when they were younger than 30 years of age, whereas of the 315 cases of nonrecurrent dislocation, 90% occurred in patients older than 30 years. Rowe (13) similarly found a recurrence rate of 94% in 53 patients younger than 20 years of age, 79% in 64 patients 21 to 30 years of age, 50% in 16 patients 31 to 40 years of age, and 14% in 188 patients older than 40. The treatment of a dislocated shoulder entails expeditious reduction and then immobilization in a position of adduction and internal rotation for 3 to 6 weeks. This is typically followed by rehabilitation with a gradual return to full sporting activities. A review of the literature demonstrates recurrence rates between 45% and 94% with a variety of nonoperative treatment protocols (12,14–19). Henry and Genung(20), in a study of 121 primary dislocations in young athletes, reported no difference in the recurrence rate after treatment with no immobilization versus the use of immobilization for 3 weeks. Similarly, Hovelius et al. (21) reported a 48% recurrence rate in 247 patients with primary dislocations followed up for 10 years. The type and duration of the initial treatment had no effect on the recurrence rate. They also noted mild arthropathy in 23 patients (11%) and moderate to severe arthropathy in 18 patients (9%). In contrast to these findings, in 1948 Watson-Jones (22) reported no episodes of recurrence in several hundred patients treated with strict immobilization for 4 weeks. More recently, Yoneda et al. (23) reported a 17.3% recurrence rate at an average of 13 years' follow-up in 104 patients treated with 5 weeks of immobilization followed by 6 weeks of progressive exercises. In a study on nonoperative management by Simonet and Cofield (24) with excellent follow-up, the authors recommended at least 6 weeks of activity restriction. They found a recurrence rate of 66% in their patients younger than 20 years. However, they noted a much higher recurrence rate in young athletes than nonathletes of similar ages. In athletes younger than 30 years of age, they noted an 82% recurrence rate versus a 30% rate for nonathletes of the same ages. This study demonstrated that immobilization, rehabilitation, and delay in return to full activity had little effect in decreasing recurrence in athletes. Additionally, they noted that recurrent subluxation is a significant problem in athletes returning to sport. In a study performed at the United States Military Academy, Wheeler et al. (25) reported a 92% recurrence rate after conservative treatment for acute initial shoulder dislocation in 38 cadet athletes. In a subsequent prospective study, Arciero et al. (16) reported an 80% recurrence rate after nonoperative treatment despite a rigidly controlled, therapist-supervised rehabilitation including 4 weeks of initial immobilization. Several recent prospective studies have documented similar high recurrence rates with nonoperative management for primary shoulder dislocations in young athletes (17,19,26). Frustration with the poor results of nonoperative treatment at the United States Military Academy and development of better arthroscopic techniques led to a change in treatment approach. In a landmark study, Wheeler et al. (25) described a staple fixation technique in cadet athletes who sustained a primary, acute shoulder dislocation. In this relatively small group, the recurrence rate was 22% compared with 94% in the nonoperative group. Subsequently, Arciero et al. (16) reported an 80% recurrence rate in 15 cadets treated nonoperatively. Twenty-one cadets were followed up prospectively after a transglenoid arthroscopic repair following an acute, primary dislocation. With greater than 33 months' follow-up, the recurrence rate in this group was 14%. In a subsequent prospective study using a bioabsorbable tack to restore the avulsed capsulolabral complex, Arciero et al. (15) reported 3 of 21 patients who developed recurrent instability. With follow-up from 2 to 5 years, DeBerardino et al. (27) reported a 15% failure rate in 34 patients who were treated with arthroscopic stabilization. In two recent prospective, randomized studies with at least 2 years' follow-up, Kirkley (19) and Bottoni(26) reported recurrence rates with arthroscopic stabilization that were significantly less than nonoperative treatment in patients younger than 30 years of age. Regardless of the controversy concerning the natural history after acute primary anterior dislocations and the actual recurrence rates, several conclusions can be made. First, age at dislocation is the primary prognostic factor for recurrence. Second, nonoperative treatment has little predictable effect on recurrence. Finally, the patient's activity level and type of sport may also play a role in determining recurrence rates. In summary, the rationale for arthroscopic stabilization of primary anterior dislocations in young athletes is based on (1) high recurrence rates with nonoperative treatment; (2) the observation in 97% of cases of detachment of the anteroinferior glenohumeral ligament; (3) the availability of arthroscopic techniques that permit direct repair with little operative morbidity; and (4) the observation that damage to the capsule is the least after a single event. INDICATIONS AND CONTRAINDICATIONS Arthroscopic stabilization is used to restore the capsulolabral avulsion in traumatic, primary dislocations. The procedure and inherent risks are thoroughly discussed with the patient, as are the potential risks of recurrent instability associated with nonoperative management. Our inclusion criteria consist of (1) a primary anterior shoulder dislocation that required manual reduction by medical personnel, (2) a young athlete (younger than 25 years of age) who desires to continue participation in athletics, and (3) no comorbidities precluding surgical intervention. The exclusion criteria consist of (1) concomitant neurologic injury or greater tuberosity fracture, (2) a history of subluxation or “dead arm” syndrome, and (3) a sizable bony Bankart lesion. Although these guidelines were strictly followed for the prospective studies performed at West Point and Tripler Army Medical Center, (14–16,26) they should be considered general guidelines when selecting patients for arthroscopic stabilization. We prefer to operate on the acute dislocations within the first 10 days of the injury, taking advantage of the inflammatory repair mechanisms associated with acute injury and hemarthrosis. At West Point the patient population is unique in that all of the cadets are 18 to years and all are required to in and Additionally, to the between the and the the patients who a shoulder dislocation are to the usually within This may in a this our shoulder dislocations are by or The reduction is typically and less traumatic than the the dislocation is addressed the of often the reduction much an athlete is of a shoulder dislocation, and of the shoulder is reduction or at the arm may be of a humerus reduction should be sufficient are dislocation (Fig. and can in concomitant a reduction of anterior glenohumeral techniques for a dislocated shoulder have been We prefer to a reduction using a technique described by this is a technique is The patient is with the shoulder over the (Fig. to 10 of are to the and the patient is to to effect This and patient compliance to reduction is in 5 to 10 as described by and and subsequently reported by et al. usually effect a The is by the inferior and, the glenoid the humeral head to (Fig. reduction (Reprinted with permission from Arciero anterior and In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott, Williams and Wilkins, 1999, p. reduction (Reprinted with permission from Arciero anterior and In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott, Williams and Wilkins, 1999, p. A and B. (Reprinted with permission from Arciero anterior and In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott, Williams and Wilkins, 1999, p. our little or no is We have used an of for as described by and of is into the shoulder by the 2 inferior and lateral to the into the lateral by the inferiorly humeral This the of the dislocation and has a effect after In and the for or reduction is a is to neurologic injury or A is required to reduction and the for associated A with the arm in internal rotation is used to of the greater tuberosity (Fig. A bony avulsion of the humeral attachment of the glenohumeral ligaments as described by et al. can be as an avulsion from the of the A a better of the of of glenoid present. The West Point axillary is used to glenoid and bony of the attachment of the inferior glenohumeral ligament or bony Bankart lesion (Fig. In the can with the of dislocation reduction and This can be to in an acute than the West Point axillary no shoulder is A. for of shoulder. B. in internal rotation demonstrating associated greater tuberosity (Reprinted with permission from Arciero anterior and In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott, Williams and Wilkins, 1999, p. A. for West Point axillary B. West Point axillary demonstrating avulsion fracture of the anteroinferior glenoid. (Reprinted with permission from Arciero anterior and In: Warren RF, Craig EV, Altchek DW, eds. The unstable shoulder. Philadelphia: Lippincott, Williams and Wilkins, 1999, p. in acute studies are studies performed on all acute in one study have the pathoanatomy that is present at an is the in an acute dislocation to the and as a contrast Although SLAP and Bankart lesions can be with the pathoanatomy has been and have found that this study little dislocation can result in neurologic injury, commonly to the axillary and reported a of of these the axillary after glenohumeral dislocation or humeral although after reduction of a dislocation, can be of a should on to for This injury is seen more commonly in older patients who a glenohumeral dislocation. et al. reported on 31 patients with after anterior shoulder dislocations. one was older than 40 years of age, and the was an average of patients are also at greater for tuberosity fracture with shoulder dislocation. greater than may operative fixation to and of We use for this procedure and have had excellent operative and with this technique The patients with based on patient the patient's shoulder is The anterior and posterior is using the by Altchek and The with the arm abducted at to is used to and the of anterior instability of the glenohumeral joint. 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The tear of the humeral insertion of the capsule can be using Arthroscopic stabilization is a The should be well in shoulder be the arthroscopic and have a on this In of the associated with arthroscopic the should the patient as well as have a for to an open shoulder arthroscopic (1) to and from anterior and posterior (2) to and and and (3) arthroscopic The associated with arthroscopic stabilization associated with the actual of the required to restore the normal also associated with the required to during the The and may should be readily to of the procedure in the that of the associated with this procedure leading to an to the capsulolabral of the can to or recurrent in the This may to recurrent instability and used to the articular can result in for the humeral articular can result in a of the humeral cartilage as the shoulder on the edge. Additionally, or bioabsorbable can and that result in of articular bioabsorbable fixation have been associated with a as they are This may be as an in shoulder at 4 to 6 weeks after and a of glenohumeral The arthroscopic its open that the capsulolabral to the glenoid. We have a rehabilitation 4 weeks is to the patient's The first of immobilization in a arm with of and and during The is at all during this during The of progressive and We use during this with external rotation of the shoulder is with is The of progressive of as and and are used to of the arthroscopic procedure on a strict to the rehabilitation A shoulder with external rotation can the surgical and patients be the of the shoulder. have been using an arthroscopic repair approach and in technique during this period in and repair. We have from a staple technique to a transglenoid and results of these studies have been reported to used a bioabsorbable tack with an rate of in patients at 2 to 5 years' the has been using the technique for arthroscopic stabilization. The technique fixation of the and, more superior translation of the This results in a effect that to capsular We this technique more the open technique described by and and our Our results are this of the first patients treated age, 21 patients have had a result with to and with follow-up to 18 Arthroscopic stabilization for acute, primary anterior shoulder dislocation is a treatment and has the natural history of this injury. Although the procedure can restore the capsulolabral complex to its anatomic position. patient surgical technique and rehabilitation to with this