Rev. bras. ortop. vol.52 número5

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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

Update

Article

Traumatic

instability

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shoulder

夽

João

Roberto

Polydoro

Rosa

∗

_,

_Caio

_Santos

_Checchia,

_Alberto

_Naoki

_Miyazaki

FaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo(FCM-SCSP),DepartamentodeOrtopediaeTraumatologia,SãoPaulo,SP, Brazil

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Articlehistory:

Received27August2016 Accepted1September2016 Availableonline22September2017

Keywords:

Jointinstability Orthopedicprocedures Recurrence

Shoulderdislocation Shoulderjoint

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Theshoulderisthemostunstablejointinthehumanbody.Traumaticanteriorinstability oftheshoulderisacommoncondition,which,especiallyinyoungpatients,isassociated withhighrecurrencerates.Theeffectivenessofnon-surgicaltreatmentswhencompared tosurgicalonesisstillcontroversial.Thepurposeofthisstudywastoreviewtheliterature forcurrentconceptsandupdatesregardingthetreatmentofthiscondition.

Instabilidade

traumática

do

ombro

Palavras-chave:

Instabilidadearticular Procedimentosortopédicos Recidiva

Luxac¸ãodoombro Articulac¸ãodoombro

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Aarticulaçãodoombroéamaisinstáveldocorpohumano.Suainstabilidadeanteriorde causatraumáticaéumacondiçãocomumecomaltataxaderecidivaempacientesjovens.A eficáciadotratamentoconservadorcomparadocomotratamentocirúrgico,emsuas diver-sasabordagens,aindaédebatida.Opropósitodesteestudofoirevisaraliteratura,rever conceitoseúltimasatualizaçõessobreotratamentodessaafecção.

夽

PaperdevelopedattheFaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo(FCM-SCSP),DepartamentodeOrtopediae Trau-matologia,SãoPaulo,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:jopoly01@yahoo.com.br(J.R.Rosa). http://dx.doi.org/10.1016/j.rboe.2017.09.003

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Thefirstepisodeofshoulderdislocation(primarydislocation) hasanincidenceof1.7%inthegeneralpopulation.Amongthe differenttypesofthisjointinstability,theanteriordislocation duetotraumaisthemostcommontype,corresponding to morethan90%ofthecases.1–3 _On_this_topic,_Hovelius_et_al.

developedthreestudies ofgreatrelevance. Inthe first,257 patientswere followedforaprospective10 yearsafter pri-maryshoulderdislocation,andfounda49%recurrencerate. Thesecondstudy,whichfollowedthefirst(butthistimewith a25-yearfollow-up),hadtwoimportantresults:(1)72%ofthe patientswithless than22yearsatthetimeoftheprimary dislocationprogressedwithrecurrence,whereasthisratewas only27%inthoseolderthan30years;(2)almosthalfofthe casesofprimarydislocationoccurredbetween15and29years. Inthethirdstudy,from2008,Hoveliusetal.wereawarded aprizeforresearchonthedevelopmentofarthrosisinthe samepopulationofthesecondstudy.Ofthegroupthat pro-gressedwithinstability,29%developedmildarthrosis,9%had moderatearthrosis,and17%hadseverearthrosis.Incontrast, 18%ofthepatients,whohadonlyoneepisodeofdislocation, developedmoderatetoseverearthrosis.Detailedevaluationof thesubgroupsallowedtheidentificationofthreeriskfactors forthedevelopmentofarthrosis:under25yearsofageatthe timeoftheprimarydislocation,alcoholismandhigh-energy sports.Itisimportanttonotethatevenpatientswhohadonly oneepisode ofdislocationalsopresent risksof developing arthrosis.4–6_Due_to_the_anatomical_{peculiarities}_and_the

con-troversiesaboutthetreatmentofprimarydislocation,besides thehighrecurrencerateinyoungpatients,wewilladdressthe mostimportantaspectsthatwillhelpusunderstandandtreat thiscondition.

Primarydislocationnon-surgicaltreatment

Inthecaseofacuteanterior primarydislocation,the most preferablyusedtreatmentisthereductionofthejointandits immobilization,followedbyavariableperiodofrehabilitation torestoretherangeofmotionandmusclestrengtharoundthe shoulder.7

Themostfrequentcomplication,areasonforsubsequent instability,istheavulsionoftheanteroinferiorportionofthe glenoidlabrum,andthe lowermarginoftheglenoid fossa, knownasBankartlesion.8,9_If_it_heals,_which_can_occur_in_up

to50–80%ofthetime,therecurrencebecomes,intheory,less frequent.10_It_is_therefore_debated_whether_the_duration_and

positionoftheshoulderimmobilizationarefactorscapableof influencinglabrumhealing.

Ameta-analysisbyPatersonet al.,which includednine studies withlevelsI and IIevidence, showedno benefitin immobilizationformorethanoneweek.However,itshowed alowertendencyofrecurrencewithimmobilizationinlateral andmajorrotationifthepatient’s agewasover30years.11

In1999,Itoi etal. proposedthatthis initiallateralrotation immobilizationwould promote, byligamentotaxis,a better reductionoftheBankartlesionand,therefore,higherhealing rates.12

betweentwogroupsof20patientseach.Theresultsshoweda significantreductionintherateofrecurrenceinthose immo-bilized inlateral rotation forthreeweeks, whencompared withthoseinmedialrotation,especiallyinpatientsunder30 years.In2007,thesameauthorsconductedasimilarresearch, but this time ina largerpopulation (159patients) and the resultscorroborated thefindings ofthe firstsurvey.14 _More

recently,in2010,Taskoparanetal.alsofoundfavorableresults forlateralimmobilization(inthisstudy,itwasmaintainedat tendegreesforthreeweeks,andwasremovedonlyfor per-sonalhygiene).15

Incontrast,in2009Finestoneetal.didnotfinddifferences inrecurrencerateswhenimmobilizing51patientsduringfour weeks(27oftheminlateralrotationof15to20degreesand 24inmedialrotation).Liavaagetal.publishedastudywith 188patientsin2011–95patientsimmobilizedinmedial rota-tion and 93 in 15-degreelateral rotation forthree weeks– anddidnotfinddifferencesbetweenthetwogroups.16–18_The

systematicreview(whichalsoincludedtheselattertwo stud-ies)developedbyPatricketal.10_did_not_show_a_decrease_in

recurrencewithlateralrotationimmobilization.However,in a newstudy in2015, Itoi et al.19 _show _that _the _best

posi-tion for injury reduction would be in 30-degree abduction with60-degreelateralrotation,andthatabove30-degree lat-eralrotationwealreadyfindreductionoftheanteriorlesion, butnotoftheinferiorone.Itmaybefinallyarguedthatthe 10–20degreesofrotationusedintheotherstudieswere insuf-ficient forinjury reduction.Another hypothesis isthat the jointhematomawouldpreventthecoaptationofthelabrum lesiontoitsbed,andthatthejointdrainagecouldfacilitateits coaptation.10,19,20

Finally,wecanseethattheexistingpublicationstodate donotsupport, withsufficientscientificevidence,the best periodand thebest positionforimmobilization;new stud-iesarenecessarytodeterminethebestwayfornon-surgical managementofthiscondition.

Primarydislocationsurgicaltreatment

Theindicationofsurgicaltreatmentintraumaticprimary dis-locationiscontroversial.

Several authors havedemonstrated favorableresultsfor surgical stabilization afterprevious traumatic primary dis-location in young and activepatients, inorder to avoidor decreaserecurrencerates.21–27_Between_August₂₀₀₀_and

Octo-ber 2008,14 shoulders were treated, of14 patients, bythe ShoulderandElbowGroupofSantaCasadeSãoPaulo. Satis-factoryresults(with100%excellentresults)wereobtainedin allcases,accordingtotheRoweevaluationcriterion.28

How-ever, this strategy unnecessarily exposessome patients to surgical risk, because notall ofthem would progresswith recurrences. On the other hand, we must remember that a recurrence can lead to anincrease in osteocartilaginous lesionsandlesionsoftheshoulderstabilizingligaments.6,23,29

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Fig.1–Leftshoulder,jointviewthroughtheposteriorportal.(A)Bankartlesion;(BandC)preparationforlesionrepair;(D) Bankartlesionarthroscopicrepair.

Table1–SystematicreviewcomparingopenrepairandarthroscopicrepairofBankartlesionsregardingthenumberof recurrences.

Authors Publicationdate Quorom Lowernumberof

recurrences

Freedmanetal.44 _July₂₀₀₄ ₁₅ _Open_repair

Mohtadietal.40 _June₂₀₀₅ ₁₃ _Open_repair

Hobbyetal.34 _September₂₀₀₇ ₁₄ _Discordant

Lentersetal.45 _February₂₀₀₇ ₁₆ _Discordant

Ngetal.41 _June₂₀₀₇ ₁₆ _Discordant

Pulavartietal.46 _October₂₀₀₉ ₁₆ _No_differences

Petreraetal.42 _March₂₀₁₀ ₁₇ _No_differences

betterinformed and want tobase their decisionson solid evidence.Weshouldalwaysconsiderthepatient’sage, domi-nance,sportmodality,andtypeofworkactivity.Climbersand surfers,forexample,areatriskofdeath(fallingordrowning) iftheydislocateashoulderduringtheiractivities.Professional athletesmayalsohavetheirsurgicalprocedureadvancedor postponedbasedontheircompetitionschedules.29,30

Habermeyer31 _introduced_the _Severity_Shoulder

Instabil-ity Score (SSIS). It uses some risk factors as criteria for recurrence.Itsgoalistofacilitatethedecisionbetween non-surgical and surgical treatment. Among the criteria, there are:patient’s age, sports modality practiced,typeoflesion found in the glenoid cavity (Bankart lesion associated or notwithglenoidfractureand/orSLAPinjury),mechanismof trauma,presenceofotherassociatedlesions(rotatorcuffand HillSachslesions),presenceofgeneralizedligament hyper-laxity, type ofdislocation reduction (whether spontaneous orassisted), andthe degreeofpatientreliabilitytocomply witharehabilitationprotocol.Whenapplyingthisscoreina groupof80patients, Habermeyer31 _obtained_2.9%_of

recur-renceinpatientstreatedsurgicallyand10.9%inthosetreated non-surgically.31

Openversusarthroscopicrepairofalabrumlesion

Recurrentdislocations occur between 25% and 100% ofall casessubmittedtoconservativetreatment.5,9,21,22,32,33

How-ever, surgical treatment reduces the risk of recurrence by 6–22%.21,22,33–35_Although_the_aim_of_surgical_treatment_is_to

repairtheinjuredstructurestorestorethephysiological sta-bilityoftheglenohumeraljoint,thereisstilldoubtastothe bestmethodofrepair.36

Thereismuchdiscussionofthemethodsofapproach(open orarthroscopic)forthefixationoftheBankartlesion.37–43_The

argumentsinfavorofopenrepairarethatitallowsthe sur-geontoperformamoreanatomicallabrum repair,and the positioning of anchors ina safer direction. Thosein favor of arthroscopy (Fig. 1), intheir turn,argue that there is a reductionofcomplicationswhencomparedtoopensurgery, suchasahigherinfectionrate,greater bleeding, subscapu-lardehiscenceandarthrofibrosis,withequivalentandfaster repair.38,40–42_Chalmers_et_al.,36_in_2015,_published_a

system-aticreviewofeightmeta-analyzescomparingtheresultsof thesetwotherapeuticmethods.Init,themeta-analyzeswere scored(from0to18points)accordingtoatoolcalledQuorom (QualityofReportingofMeta-Analyzes)(thehigherthescore, thebetterthelevelofevidence).Twometa-analysespublished before2007,withaQuoromscoreof15and13,showedfewer recurrencesafterrepair.Thethreemeta-analysesconducted in2007,withscoresof14,16and16,werediscordant.Thelast three,publishedafter2008(scoresof12,16and17),didnot finddifferencesinrecurrencerateswhencomparingthetwo methods.Notethatamongthesethereisthemeta-analysis withthebestlevelofevidence(17points)36₍_Table₁_).34,40–46

Mohtadietal.40_performed_a_prospective_and_randomized

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didnotfinddifferencesinrecurrenceratesbetweenthetwo techniquesbutobtainedshortersurgicaltimeandbetterrange ofmotionwiththearthroscopicapproach.Inthegroup sub-mitted to open repair, two of the 29 patients experienced recurrences.Intheothergroup(32arthroscopies),therewas onlyonerecurrence.37

Bankartlesionopenrepairversusopenboneblock procedure

Helfet47_was_the_one_who_described_the_procedure_popularized

byBristow,whichconsistsoftransferringthetipofthe cora-coidprocesstotheanteriorborderoftheglenoidthroughthe fibersofthesubscapularismuscle;inthismuscle,the trans-feris fixedtothe joint capsulewithout theuse ofscrews. Latarjet48 _and _Patte _et _al.49 _modified _the _technique_in _two

ways:(1)thepositioningofthecoracoidgraft,whichputin toa“lying”position(withitslargestaxisinaverticalposition; paralleltothearticularsurfaceoftheglenoid)and(2)its fixa-tionthroughtwocompressionscrews.48–50_Nowadays,_this_is

themostcommonlyusedtechnique.49

Although this procedure has been criticized,51,52 _good

resultshavebeenfoundinseveralstudies.Stabilityisbelieved to be achieved by a triple mechanism of humeral head restraint:thatofthe“brace”,inwhich thecoracobrachialis andshortheadofthebicepstendonsandthelowerportion ofthesubscapularisrestraintheanteroinferiorjointcapsule; thatofthe boneblock procedure,in whichthe transferred choroidalprocessfunctionsasanextensionoftheglenoid cav-ity;andthatofligamentreinforcement,sincethestumpofthe coracoacromialligamentissuturedtothejointcapsule.49

Hovelius et al.,53 _in _2012, _described _the _results _of ₉₇

consecutivecasesofpatientsundergoingLatarjetprocedure comparedto88casesofopenrepairoftheBankartlesion;the latterwasperformedwithanchorsorthroughtransglenoidal orifices.Witha17-year postoperativefollow-up,recurrence occurredin14%ofthe patients(13of97cases) undergoing Latarjetprocedure,withasatisfactionindexabove95%.Onthe otherhand,ofthe88casesundergoingBankartlesionrepair, 25progressedwithrecurrence(28%), with80%satisfaction. Amongthefindingsofthisstudy,thebestscoreswereDash (Disabilitiesofthearm,shoulderandhand),Wosi(Western OntarioShoulderInstabilityIndex)andSSV(subjective shoul-dervalue)scores.Finally,theycametotwoconclusions:(1)the Latarjetprocedureleadstobettersubjectiveresultsand pro-videsgreaterstabilitytotheshoulder;(2)theliprepairthrough transglenoidalorifices wassuperiortothat performedwith anchors.53

ArthroscopicrepairofBankartlesionversusopenbone blockprocedure

Althoughbeingrathervariable,therateofrecurrenceofthe arthroscopicrepairoftheBankartlesionisstillconsideredan effectiveprocedurewithgoodreproducibility,especiallywhen thepatientiswellselected.

Thus,BalgandBoileau54_developed_the_Instability

Sever-ity Index Score (ISIS) in 2006as a means for determining whichpatientsshouldbenefitfromanarthroscopicanchorage

the researchers identified six risk factors that when com-binedinascoringsystemresultinunacceptablehighrates ofBankartarthroscopicrepairfailure.Patientswithascore abovesixhad70%ofrecurrence,whereasinpatientswitha scoreequaltoorlowerthansixfellto10%.54_According_to_the

ISIS,patientswithascoreabovesixshouldundergothe Latar-jetprocedureandwithsixorlesstheBankart’sarthroscopic repair.

In2013,Rouleauetal.,55 _in_a_multicenter_study_with₁₁₄

consecutivecases,validatedISIS.TheresultsshowedthatISIS ishighly reproducible,thatis,easy toapply;quality oflife questionnairesdidnotcorrelatewithISIS,alsoshowingthat patientswithISIS greaterthan sixhadahighernumberof recurrencesbeforesurgery;andthatinthemedicalcenters whereitwasapplied,itwasanindicatorofwhichpatients would require more complex surgeries, such as Hill-Sachs lesionfilling(remplissage)oraLatarjetprocedure.55

It was observed that ISIS was used by authors, but it has been adapted. Some authors, such as Boileau, have described that somepatients with ISISgreater than three, andglenoidcavitybonedefectswerecandidatesfor Bankart-Britow-Latarjetarthroscopicsurgery.56_Thomazeau_et_al._used

ascoreoflessthanorequaltofourtoindicatearthroscopic surgery.57

Like Boileauetal.,56 _there_is_a_current _trend_toward_the

indicationofboneblocks(Latarjet,Eden-HybinetteorBristow surgeries)whenthereisglenoiderosion.58,59 _Defects_greater

than20%oftheanteroposteriorjointdiameterareconsidered the limit forseveral authors.58–60 _However, _both_this _value

and the erosion measurementtechnique are still topicsof debate.61_For_some,58–60_the_practice_of_competitive_sports_is_an

independentriskfactorforrecurrenceand,therefore,isalso anindependentindicatorforboneblocks.

Despiteprovidingfewerrecurrences,“boneblocks”arenot freeofcomplications. Paladinietal.62 _showed_a_loss_of_the

isometriccontractionforceofthesubscapularisaftertheir L-shapedtenotomyand,therefore,theyrecommendthat the glenoidapproach(whichisnecessarilyperformedthroughthe subscapular)bemadelongitudinally(by separationoftheir fibers). Subscapular muscle deficiency explains the lossof activemedialrotationaftersurgery.

Other possible complicationsare loss oflateral rotation thatleadstoglenohumeralarthrosisandthoserelatedtograft positioning, which should be done as closeas possible to the glenoidjointsurface(less than10mmofmedialization andbelowthe“equatorline”).Ifitsfixationistoomedialor toohigh,forexample,theremaybetherapeuticfailure(with maintenanceofinstability). AcaseseriesbyHoveliusetal. showedpoorpositioningin42%oftimes(32%oftimesabove the“equatorline”and6%toomedial).53_Overhanging_grafts,

intheirturn,cancausearthrosisregardlessofotherfactors.63

Bipolar

defects

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to bipolar defects is not clear when the defect is in the glenoidcavityandhumeralheadsimultaneously(Hill-Sachs lesion).65

Greisetal.65_demonstrated_that_the_greater_the_bone_loss

oftheglenoidcavity,thegreaterthecontactpressureofthe humeralhead against the glenoid cavity. For example,the labral lesion reducesthe contact area by7% and 15% and increasesthecontactpressureby8%and20%.Alossof30%of theglenoidcavityincreasesthepressureintheanteroinferior regionby300%and400%,andconsiderablyincreasestherisk ofrecurrence.

BurkhartandDeBeer66 _identified_the_risk_of_arthroscopy

failurewhen, duringthe procedure, it isobservedthat the appearanceoftheglenoidcavityhastheshapeofan“inverted pear”.Onthehumeralside,Hill-Sachslesions,inwhich engag-ingat90degreesofabductionandlateralrotationtakesplace, areconsideredasriskylesionsonlyfortheperformanceof Bankartlesionrepair.

Yamamoto et al.,67 _in ₂₀₀₇ _demonstrated _the _contact

area ofthe humeralhead and the glenoid cavityfrom the pointofglenohumeraldislocation,anddefinedthiszoneof contact as glenoid track. This intact region ensures bone stability.

Theintraoperative test forengaging performed prior to thearthroscopicrepairoftheBankartlesionisoverestimated becauseligamentinsufficiencyallowsforagreater transloca-tionofthehumeralhead.68_The_test_after_Bankart_lesion_repair,

definedbyKurokawaastrue“engaging”,leadstotheriskof damagetotherepairperformed.Kurokawaetal.69_evaluated

100shoulders,in94casestherewereHill-Sachslesions,only sevencases(7.4%)weredefinedastrueengaging.Parkeetal.70

evaluated983shoulders,found70 casesoftrue “engaging” (7.1%)ofthecases.BeforeBankartlesionrepair,anincidence ofengagingbetween34%and46%ofthecasesisdescribed.

Forthisevaluation,withouttheriskofcausingoverloadto Bankart’sinjuryrepair,weusetheglenoidtrack.Through a tomographicstudyweevaluatedifthemedialmarginofthe Hill-Sachslesionisincontactwiththeglenoidtrack;then,the lesioniscalledontrack;however,iftheHill-Sachslesionis moremedialthantheglenoidtrack,itiscalledofftrack,in whichtheriskofengagingisgreater.68

Thisevaluationleadstofourcategories:thefirstincludes patientswith glenoidalcavity defects<25%, and with Hill-Sachs on track lesion; the second, patients with glenoid cavitydefects<25%andHill-Sachsoff-tracklesion,thethird ofpatientswithdefects≥25%and withHill-Sachsontrack lesion,andthefourth,patientswithdefects≥25%and Hill-Sachsoff-tracklesions.68

Therefore,basedonthereportabove,thesuggestionisto treatpatients ofthefirst categorywith arthroscopic repair oftheBankartlesion;thesecond,withcomplementationof thetreatmentwiththeremplissagetechnique;thethird,with Latarjet procedure, and the fourth with Latarjet procedure associatedornotwiththeHill-Sachslesionfilling (remplis-sage)orbonegraftofthehumeralhead68₍_Table₂_).

Hill-Sachslesiontreatment

In1940,HillandSachswerethefirsttodescribethe postero-lateralfractureofthehumeralheadbyimpactionagainstthe

Table2–Categoriesofanteriorinstabilityand recommendedtreatment.

Groups Glenoidfossa defect

Hill-Sachs lesion

Recommended treatment

1 <25% Ontrack Arthroscopicrepairof Bankartlesion 2 <25% Offtrack Arthroscopicrepairof

Bankartlesion+remplissage

3 ≥25% Ontrack Latarjetprocedure

4 ≥25% Offtrack Latarjetprocedurewithor

withouthumeralhead procedure(remplissageor graft)

glenoid,whichoccurssecondarytotheanteriordislocation oftheshoulder.71_Its_incidence_in_the_primary_dislocation_is

47–80%and,intherelapsingdislocation,ofupto93%. Sev-eral treatments havebeen used72_; _currently,_the _technique

oflesionfillingwiththeinfraspinatustendon(remplissage) has become the most popular treatment.73 _In _2014, _Buza

et al.74 _described _a _systematic _review _with _the _inclusion

of167patientsundergoingtheremplissagetechnique,with a mean follow-up of 26.8 months, in which there was a small lateral rotation deficit (57.2◦ _to _54.6◦_), _and _5.4% _of

recurrences.

AretrospectiveevaluationbyBoileauetal.showedthathe usedremplissagein47of459patients(10.2%)inhisseries.The meanlateralrotationdeficitwas8degrees.Ofthe41patients whopracticedsports,37returnedtopractice(90%),with28at thesamesportslevel(includingpitchers).Therecurrencerate wasonly2%.75

Gracitelli et al. published a retrospective analysis of ten shoulders simultaneously undergoing remplissage and Bankartlesionrepair(bothbyarthroscopy).Theindicationwas forlesionswithlessthan25%impactionofthehumeralhead, and withengaging duringthearthroscopic evaluation.The resultswereimprovedRowescoresfrom22.5to80.5,andUCLA from18.0to31.1withtwocasesofrecurrence,onedislocation andonesubluxation.76

Conflicts

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