Rev. bras. ortop. vol.52 número2

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Functional

outcome

after

arthroscopic

repair

of

triple

shoulder

instability

夽

Glaydson

Gomes

Godinho

_,

_Flávio

_de

_Oliveira

_Franc¸a

_,

José

Márcio

Alves

Freitas

_,

_Lander

_Braga

_Calais

_Correia

_Pinto

_,

Carolina

Lima

Simionatto

_,

_Pedro

_Paulo

_Gomes

_Viana

_Filho

a_{HospitalOrtopédico,BeloHorizonte,MG,Brazil} b_{HospitalBeloHorizonte,BeloHorizonte,MG,Brazil} c_{HospitalLifecenter,BeloHorizonte,MG,Brazil}

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Articlehistory: Received25April2016 Accepted30May2016 Availableonline6March2017

Keywords:

Arthroscopy/methods Shoulder

Rotatorcuff Patientsatisfaction Articularmotionrange

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Objective:Toevaluatethefunctionaloutcomesofpatientssubmittedtoarthroscopicrepair oftriplelabrallesion.

Methods:Thiswasananalyticalretrospectivestudyofpatientswhounderwentarthroscopic treatmentoftriplelabrallesionfromMarch2005toDecember2014.Patientswithatleastone yearofpostoperativefollow-upwereincluded.Atotalofninepatientswereevaluated.The meanagewas32.3yearsandthedominantsidewasaffectedinfivepatients.Patientswere functionallyassessedregardingtherangeofmotion(ROM)inelevation,externalrotation withthearmclosetothebodythearminabductionof90◦_{,andinternalrotation,andby}

theCarter–Rowescore.Thedegreeofsatisfactionwasassessedattheendofthefollow-up period.

Results:Threepatientshadlessthanfiveepisodesofinstability,fourpatientshadbetween fiveandtenepisodes,andtwopatientshadmorethantenepisodes.Sevenpatientshad pos-itiveO’BrientestforSLAPlesionsandpositiveapprehensiontestinabductionandexternal rotation,andonlyonepatienthadapprehensioninadductionandinternalrotation.Three patientspersistedwithpositiveO’Brientestandonewithapprehensioninabductionand externalrotationattheendoffollow-up.Therangeofmotionwascompleteinallcases. ThemedianCarter–Rowescoreincreasedfrom40preoperativelyto90(p=0.008).

Conclusion:Thearthroscopicrepairoftriplelabrallesionsallowsfortherestorationofthe stabilityoftheglenohumeraljoint,achievingexcellentfunctionalresults.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedatHospitalLifecenter,HospitalBeloHorizonte,andHospitalOrtopédico,BeloHorizonte,MG,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](F.O.Franc¸a).

http://dx.doi.org/10.1016/j.rboe.2017.02.004

Resultado

funcional

após

reparo

artroscópico

da

tríplice

instabilidade

do

ombro

Palavras-chave: Artroscopia/métodos Ombro

Bainharotadora Satisfac¸ãodopaciente Amplitudedomovimento articular

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Objetivo: Avaliarosresultadosfuncionaisdospacientessubmetidosareparoartroscópico datríplicelesãolabraldoombro.

Métodos:Estudoanalíticoretrospectivodepacientescomtríplicelesãolabraldoombro, sub-metidosatratamentoartroscópicodemarc¸ode2005adezembrode2014.Foramincluídos pacientescompelomenosumanodeseguimentopós-operatório.Novepacientesforam avaliados.Amédiafoide32,3anoseoladodominantefoiafetadoemcincopacientes. Ospacientesforamavaliadosfuncionalmentepormeiodaamplitudedemovimentoem elevac¸ão,rotac¸ãoexternacomobrac¸ojuntoaocorpoecomobrac¸oemabduc¸ãode90◦_,

rotac¸ãointernaepormeiodoescoredeCarter-Rowe.Ograudesatisfac¸ãofoiavaliadono fimdoseguimento.

Resultados: Trêspacientestiverammenosdecincoepisódiosdeinstabilidade,quatroentre cincoedezedoismaisdedez.SetepacientestiveramtestedeO’Brienpositivoparalesãodo lábiosuperiordeanteriorparaposterior(Slap,doinglêssuperiorlabrumanteriortoposterior lesion)eapreensãoemabduc¸ãoerotac¸ãoexternapositiva;apenasumapresentouapreensão emaduc¸ãoerotac¸ãointerna.TrêspacientespersistiramcomtestedeO’Brienpositivoe umcomapreensãoemabduc¸ãoerotac¸ãoexternanofimdoseguimento.Aamplitudede movimentoestevecompletaemtodososcasosnaúltimaavaliac¸ão.Amédiadoescorede Carter-Roweaumentoude40nopré-operatóriopara90(p=0,008).

Conclusão: Oreparoartroscópicodatríplicelesãolabralpermiterestauraraestabilidadeda articulac¸ãoglenoumeralealcanc¸aexcelentesresultadosfuncionais.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Thestabilityoftheglenohumeraljoint dependsona com-plexcombinationofthestaticanddynamicstabilizersofthe shoulder.1 _{For anterior dislocation, there isan avulsion of}

theanterior-inferiorlabrumcomplexoftheperiosteumofthe glenoid,whichgeneratesanteriorinstability,especiallyinthe movementsofabductionandexternalrotation.2

Symptomsofposteriorinstabilityarevague;itmaypresent onlyaspainincertainmovements,especiallyadductionand internal rotation. It can be caused by a single trauma or byrepetitivemicrotraumas,throwingactivities,orcanresult fromconvulsionsandelectricshocks.3

Superiorlabrum anterior to posterior(SLAP) lesions are stilluncommonshoulderinjuries,withanincidenceof6%, diagnosedduringarthroscopicprocedures,accordingto Sny-deretal.4_{Clinicalandimagingdiagnoseshavelowsensitivity}

andspecificity,5_{andthisconditionmaycontributetoamajor}

functionaldeficitandshoulderpain.6

LoandBurkhart7_{definedthetriplelabrallesionasa}

con-ditionthatinvolves unusuallesionsofthe glenoid labrum: superiorly, a SLAP lesion type II; anteroinferiorly, Bankart lesions; and posteroinferiorly, lesions such as the reverse Bankart(Fig.1).

Habermeyer et al.8 _{reported that the emergence of a}

triple labral lesion is related tothe number ofrelapses in anteriordislocations,denotingthechronologicaland evolu-tionary character of these lesions. A very detailed clinical

examination should be performed, including the tests for anteriorand posteriorinstabilityandSLAP. AccordingtoLo andBurkhart,7_{theincidenceoftriplelabrallesionwas2.4%}

inagroupof297patientswithligamentandlabrallesionsof theglenoid.

This study aimed to evaluate the functional results of patients who underwent arthroscopic correction of triple labrallesionsandtoraiseawarenessofthediagnostic diffi-cultyandunderestimationofthiscondition.

Material

and

methods

Thiswasaretrospectiveanalyticalstudyofpatients submit-tedtothearthroscopictreatmentoftriplelabrallesionsfrom March2005toDecember2014.Duringthisperiod,15patients werediagnosedandtreatedforthisconditionbytheShoulder Groupofthisinstitution.

Forthestudy,patientswhohadatriplelabrallesionanda minimumfollow-upof1yearwereselected.Exclusion crite-riawere:previousshouldersurgery,fracturesequelaeinthe region,advancedglenohumeralarthrosis,andlessthanone yearoffollow-up.Ofallpatientswhounderwentsurgery dur-ingthisperiod,11mettheinclusioncriteria.Tworefusedto participateinthestudy.Oftheninepatientsselected,seven werepersonallyassessedandtwobytelephoneduetothefact thattheylivedoutsidethecityoforiginofthestudy.

Fig.1–ArthrographyMRIimageoftherightshoulderinthecoronalandaxialT2-weightedcutsshowingtheSLAPlesion (left)andtheBankartandposteriorlabrallesions(right).

side was affected in four patients (44.4%) and left side in five(55.6%).Thedominantlimbwasaffectedinfivepatients (55.6%).

Fourpatients(44.4%)hadatraumaticlesion;four(44.4%) lesionswerecausedbyrepetitivemicrotraumasinsports prac-tice,twoofwhichwereprofessionalathletes;andonepatient (11.1%)hadhadaseizure.

TheCarter–Rowe9 _{score, whichtakes into consideration}

thestability,rangeofmotion(ROM),andfunction,wasused forthefunctionalassessment(Table1).

ROM for anterior elevation,lateral rotation with arm in abductionandnearthebody,andmedialrotationwere com-pared. Thedegree of satisfaction of patients with surgical treatmentwasalsoassessed.Attheendoffollow-upperiod,

Table1–Carter–Rowescore.

Stability Note

Norecurrences,subluxations,or apprehension

50

Apprehensionwhenthearmwas placedincertainpositions

30

Subluxations(withnoneedfor reductions)

10

Recurrentdislocation 0

Movement

100%ofthemovement 20

75%ofnormalmovement 15

50%ofthenormalER,75%ofthe normalAEandIR

5

50%ofthenormalAE,IR,andER 0

Function

Withoutlimitationtosportor workactivities.Minimalorno discomfort

30

Smalllimitationandminimal discomfort

25

Moderatelimitationand discomfort

10

Severelimitationandpain 0

Totalpossiblepoints 100

AE,anteriorelevation;ER,externalrotation;IR,internalrotation.

patientsunderwentradiographytoassesspresenceof arthro-sis.

Atthelastpostoperativephysicalexamination,the ante-rior apprehension test in 90◦ _{of abduction and external}

rotation,theO’Brientest,andtheposteriorapprehensiontest inadductionandinternalrotationwereassessed.

Allpatientsfilledoutaninformedconsentformfor disclo-sureofclinicaldata,andthestudywasapprovedbytheEthics CommitteeoftheOrthopedicHospital.

Surgicaltechnique

The procedure was performed with patient in contralat-erallateraldecubitus,undergeneralanesthesiaandbrachial plexusblock.Initially,thearthroscopewasinsertedthrough theposteriorportallocated2cmdistaland2cmmedialtothe posterolateralcorneroftheacromion.

Diagnosisoftriplelabrallesionwasmadebyjoint inspec-tion,inthepresenceofBankartlesion,reverseBankartlesion, andSLAPlesion(II,III,orIV).7_{Apeelbackmaneuverand}

pal-pationofthesuperiorlabrallesionwithaprobeconfirmedthe presenceofSLAPlesion10_{(Figs.2and3).}

Post

Ant

_{Slap II}

Fig.3–Arthroscopicimageoftherightshoulder,

demonstratingtheanterior,posterior,andsuperiorlabral lesions.

Throughtheanterosuperior,anteroinferior,andposterior portals,threecannulaswereinserted.Theanterosuperior por-talwas usedforvisualization throughanarthroscope, and surgicalinstrumentswerepassedthroughtheanteroinferior andposteriorportals.

Thearea ofthelesions was thendebrided and opened, withdecorticationoftheedgesoftheglenoidand regulariza-tionoftheglenoidlabrum.Thefirstlesiontoberepairedwas Bankart’sreverse lesion.However,theposteriorportaldoes notprovideasuitableapproachangleforinsertingthe mini-anchorsattheposteriorborder oftheglenoid.Therefore, a needle(JelcoNo.18)wasusedtodeterminea45◦ _anglewith theglenoidsurface,andmini-anchorswereinserted percuta-neously.Generally,oneortwoanchorsaresufficientforthe posteriorrepair. Thewireswere threadedandtied,andthe posteriorlesionwasfixated.

Nextstepwasthereinsertionoftheanteriorlabrum,which correctstheBankartlesion.Mini-anchors,spacedata1cm dis-tance,wereinsertedintheanteriorborderoftheglenoid,also ata45◦_{angleinrelationtotheglenoidsurface.Thedirection} followedwasinferiortosuperior.Wireswerethenthreaded andtied.

Finally,theSLAPlesionwasrepaired,withtheintroduction ofamini-anchoronthesuperioredgeoftheglenoid;wires werepassedwithaneedleofthesurgeon’spreferenceanda mattresssuturewasmade.Thefixationandstabilityofthe glenoidlabrum wasassessedwithaprobe,inapanoramic view of the repairs (Fig. 4). The followingsteps were skin suture,dressing,andimmobilizationwithaVelpeauslingfor 21days.

Statisticalanalysis

Toassessthepre-andpost-operativerangeofmotion(ROM) and theCarter–Rowe scores, non-parametric Wilcoxontest wasused.

Data were analyzed in the statistical program Predic-tive Analytics Software (PASW 18). In all statistical tests,

Ant

Post

Slap II

Fig.4–Arthroscopicimageaftertherepairoflesionsthat comprisethetriplelabrallesion.

a5%significancelevelwasadopted.Thus,statistically signif-icant associationsare those whosep-valuewas lowerthan 0.05.

Results

FunctionalevaluationofpatientsisshowninTable2. TheROMoftheassessedpatientsispresentedinTable3. Data on number ofepisodesofinstability are shownin

Fig.5.

Regardingphysicalevaluation,Table4presentsa compar-isonbetweenpre-andpostoperativeresultsofeachpatient intheO’Brientest,apprehensiontestinabductionand exter-nalrotation,andapprehensiontestinadductionandinternal rotation.

Ofthesevenpatientswhoagreedtoundergoradiographic evaluation at the end of the follow-up period, only one

2

3

4

< 5 episodes 5-10 episodes > episodes

Table2–Pre-andpost-operativecomparisonoftheCarter–Rowescore.

Carterpre Carterpost

Stability ROM Function Total Stability ROM Function Total p-Value

DLAN 0 20 25 45 50 15 25 90 <0.05

GCV 0 20 10 30 30 20 25 75 <0.05

BL 0 15 25 40 50 15 30 95 <0.05

ECR 30 15 10 55 50 20 10 80 <0.05

FFS 0 15 10 25 30 20 10 60 <0.05

GNS 0 15 10 25 50 15 25 95 <0.05

YAC 30 20 10 60 50 15 25 90 <0.05

CFGS 30 20 10 60 50 20 30 100 <0.05

CJF 10 20 10 40 50 20 30 100 <0.05

MEAN 42.2 87.2 <0.05

Table3–Comparisonofpre-andpost-operativeROM.

DLAN GCV BL ECR FFS GNS YAC CFGS CJF Mean p-Value

AE

Pre-op 180 180 180 180 180 180 150 180 180 177 0.317

Post-op 180 180 180 180 180 180 180 180 180 180

ER2

Pre-op 90 90 90 90 100 90 60 90 120 91.1 0.357

Post-op 80 45 90 90 100 90 80 90 100 85

ER1

Pre-op 60 80 45 80 80 80 45 80 100 72.2 0.715

Post-op 60 50 80 80 80 80 70 80 90 74.4

IR

Pre-op T9 T7 T8 T7 T7 T7 T12 T7 T7 T7.8 <0.05

Post-op T9 T7 T8 T8 T7 T7 T7 T7 T7 T7.4

AE,anteriorelevation;IR,internalrotation;ER1,externalrotation1(withthearmclosetothebody);ER2,externalrotation2(withthearmat 90◦_{ofabduction).}

Table4–Pre-andpostoperativecomparisonoftheO’Brientest,apprehensiontestinabductionandexternalrotation, andapprehensiontestinadductionandinternalrotation.

DLAN GCV BL ECR FFS GNS YAC CFGS CJF

O’Brientest

Pre-op Neg + + + + Neg + + +

Post-op Neg + Neg + Neg Neg + Neg Neg

ApprehensioninabductionandER

Pre-op + Neg + + + Neg + + +

Post-op Neg + Neg Neg + Neg Neg Neg Neg

ApprehensioninadductionandIR

Pre-op Neg Neg Neg Neg Neg Neg Neg + Neg

Post-op Neg Neg Neg Neg Neg Neg Neg Neg Neg

ER,externalrotation;IR,internalrotation.

presentedaninitialdegenerativeconditioncompatiblewith SamilsonandPrieto11_{typeIarthrosis.}

Regarding the degree of satisfaction, out of the nine patientsassessed,onlyonewasdissatisfied withthe treat-ment.

Discussion

Todefinethetriplelabralshoulderlesion,LoandBurkhart7

consideredasanterior,posterior,andsuperiorlabrallesions those thataffect atleast two-thirds ofthe area comprised

in the2–6 o’clock,6–10o’clock, and 2–10o’clockpositions, respectively(assumingarightshoulder).

In the present study, the criteria set forth by Lo and Burkhart7 _{was notused, since regardlessof the degree of}

engagement in each region (anterior, posterior, and supe-rior),thepatientspresentedcharacteristicclinicalsigns,and diagnosis wasconfirmedduringarthroscopy.Therefore, the clinicalcorrelationoflesionswasweightedmoreheavilythan theisolatedanatomicalaspect.

Intheirseries,LoandBurkhart7_{identifiedanterior}

posteriorinstabilityasthecauseinonlyonecase.Duetothe recoilmechanism,anteriorinstabilitiescouldleadtoa poste-riorlabrallesion.Thistheoryisbasedontheconceptofcyclic capsulolabraldysfunctionreportedbyWarrenetal.,12_inwhich

anisolatedanteriorlabrallesion wouldnotbesufficientto causeadislocationunlesstheposteriorstabilizingstructures werealsoinjured.

Thisfact was also observedin the present study, since 55.5%ofthepatientswereinvolvedintraumaticepisodeswith anteriorinstability.Noneofthepatientshadaninitial trau-maticepisodeofposteriorinstability.

Inthisseries,aprofessionalsoccerplayer,afteranterior traumaticdislocation and sixrecurrences, presentedtriple labrallesion.Inthiscase,theorigin oftheposteriorlesion canbejustifiedbytherecoilmechanismdescribedbyLoand Burkhart7_{Theupperlabrallesionwouldderivefromanterior}

traumaticinstabilityitself,sincetheassociationbetweenSLAP andBankartlesionswasdescribedin50%ofthecasesinthe studybyGodinhoetal.,5_{andreached77.8%inthestudyby}

Warneretal.13

Anothermechanismthatwouldexplaintheoriginoftriple labrallesionoftheshoulderisthatobservedinthrowing ath-letes.Inthisgroupofathletes,the genesisoftheposterior labrallesion and the SLAP lesion is throughthe peelback mechanism,14_{associatedwithinternalimpact.}15_Ifthereisan

anteriordislocation,atriplelabralshoulderlesionis charac-terized,aslongastheanteriorlabrallesionispresent.

Inthiscontext,avolleyballathleteofthisseries,afteran episode of traumatic anterior dislocation due to a seizure crisis, presentedatriple labrallesion of the shoulder. The SLAPlesionmayhavebeencausedbytherecoilmechanism describedbyLoandBurkhart7_{orbythecombinationofactive}

forcesduringtheseizure.

Thetriplelabrallesionoftheshoulderisnoteasilydetected bytheavailableimagingmethods;itcanbediagnosedinup to32.3%ofcaseswhenMRIarthrogramisusedandin8.7% whenMRIisused.16_{Thisfactisprobablyduetothedifficulty}

indiagnosingSLAPlesions,asdemonstratedbyGodinhoetal.5

In the present study, alterations compatible with triple labrallesions wereevidenced inonlyfour patients(36.3%), which demonstrates how this diagnosis can be underesti-mated.

Treatmentofglenoidlabral lesionsinathletesmay lead tounsatisfactoryresults, especiallyregardingreturn tothe pre-injurylevel.ThesuccessrateafterisolatedrepairofSLAP lesionsisaround80%.17,18 _{Inturn,inanteriorlabrallesions,}

the successrate rangesfrom 68% to 77%.19,20 _{Therefore, it}

isexpectedthatinthepresenceofthetriplelabralshoulder lesionthesuccessrateisevenlower,duetotheassociationof injuries.

However,inthepresentstudy,asignificantimprovement wasobservedintheCarter–Rowe9_{scores.Meanscorewas42.2}

pointspreoperativelyand87.2postoperatively(p<0.05).Two ofthepatients,oneofwhomwasawrestlerandtheothera volleyballplayer,arestillabletoperformprofessionalsports activities.Regarding ROM, nostatistically significant differ-enceswereobservedbetweenpre-andpostoperativeperiods. Onlyonepatientwasdissatisfiedattheendoftreatment,due tothefactthathesufferedanaccidentfollowedbya recur-renceofthelesion.Allpatientswhopracticedsports,whether

professionallyor recreationally,returned tothose activities withoutdeficit.

The literature isstill very scarceregarding this typeof lesion.Newstudieswithmoreexpressivesamplesizeshould beconductedinordertoachieveamoreaccuratestatistical assessment.

Conclusion

Arthroscopic treatment oftriple shoulderlesion leads toa significantfunctionalimprovement,withoutlossofROMand withsatisfactoryreturntothepracticeofsport.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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