Lance LeClere

Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss.

Recurrent instability of the glenohumeral joint is usually associated with a Bankart tear—a soft-tissue injury of the glenoid labrum attachment. However, patients with recurrent shoulder instability often present with osseous injury to the glenoid and humeral head as well. Understanding and appropriately addressing irregularities in the osseous architecture of the glenohumeral joint are critical to the overall success of surgical repair for the treatment of glenohumeral instability1. The integrity of the osseous architecture of the glenoid has recently been highlighted as one of the most important factors related to the success of surgical repair2,3. After the initial traumatic shoulder dislocation, an associated glenoid rim fracture or attritional bone injury may compromise the static restraints of the glenohumeral joint, making further instability more likely. With recurrent instability, there can be further attritional glenoid bone loss. Glenoid bone deficiency with recurrent shoulder instability is an increasingly recognized cause of failed shoulder stabilization surgery. It is critical to evaluate all patients with recurrent shoulder instability for the presence of osseous injuries to the glenoid. Specific findings in the history and the physical examination provide important clues to the presence of glenoid bone loss, and a careful preoperative evaluation to diagnose and quantify anterior glenoid deficiency is crucial for the success of surgical treatment. Appropriate preoperative imaging is essential for detection and quantification of osseous abnormalities in patients with recurrent shoulder instability. The apical oblique view described by Garth et al.4, the West Point view5, and the Didiee view6 are recognized as being the most sensitive radiographs for detecting osseous abnormalities of the glenoid. Magnetic resonance imaging and magnetic resonance arthrography may be used, but they are primarily employed to assess the surrounding soft tissues. If any osseous lesion is discovered on radiographs, …

Anatomic Osteochondral Glenoid Reconstruction for Recurrent Glenohumeral Instability With Glenoid Deficiency Using a Distal Tibia Allograft

The treatment of glenoid bone loss in the setting of recurrent shoulder instability remains a challenge. This is because of the nonanatomic nature and resultant incongruous joint resulting from most bony augmentation procedures. We present a novel technique for the management of glenoid bone deficiency by using a fresh osteochondral distal tibial allograft. We have found that the distal tibia has excellent articular conformity to unmatched humeral heads, fits nearly anatomically on the distal two thirds of the glenoid, is composed of dense weight-bearing cortical and metaphyseal distal tibia bone, and provides for a cartilaginous surface for which the humeral head to articulate. This article describes the technique, initial results, and postoperative findings with the use of a distal tibia allograft (the lateral portion of the distal tibia) for the treatment of glenoid bone deficiency (mean loss of 30%) in a series of 3 patients.

Arthroscopic Repair of Circumferential Lesions of the Glenoid Labrum: Surgical Technique

BACKGROUND Symptomatic pan-labral or circumferential (360°) tears of the glenohumeral labrum are an uncommon injury. The purpose of the present study was to report the results of surgical treatment of circumferential lesions of the glenoid labrum with use of validated outcome instruments. METHODS From July 2003 to May 2006, forty-one shoulders in thirty-nine patients (thirty-four men and five women) with a mean age of 25.1 years were prospectively enrolled in a multicenter study and were managed for a circumferential (360°) lesion of the glenoid labrum. All patients had a primary diagnosis of pain and recurrent shoulder instability, and all underwent arthroscopic repair of the circumferential labral tear with a mean of 7.1 suture anchors. The outcomes for thirty-nine of the forty-one shoulders were assessed after a mean duration of follow-up of 31.8 months on the basis of the rating of pain and instability on a scale of 0 to 10, a physical examination, and three outcome instruments (the Single Assessment Numeric Evaluation score, the modified American Shoulder and Elbow Surgeons score, and the Short Form-12 score). RESULTS Significant improvement was noted in terms of the mean pain score (from 4.3 to 1.1), the mean instability score (from 7.3 to 0.2), the mean modified American Shoulder and Elbow Surgeons score (from 55.5 to 89.6), the mean Short Form-12 score (from 75.7 to 90.0), and the mean Single Assessment Numeric Evaluation score (from 36.7 to 88.5). Six shoulders required revision surgery because of recurrent instability (two), recalcitrant biceps tendinitis (two), or postoperative tightness (two). All patients returned to their preinjury activity level. CONCLUSIONS Pan-labral or circumferential lesions are an uncommon yet extensive injury of the glenohumeral joint that may result in recurrent instability and pain. The present study demonstrates that arthroscopic capsulolabral repair with suture anchor fixation can restore the stability of the glenohumeral joint and can provide a reliable improvement in subjective and objective outcome measures.

Arthroscopic Repair of Circumferential Lesions of the Glenoid Labrum

BACKGROUND Symptomatic pan-labral or circumferential (360 degrees ) tears of the glenohumeral labrum are an uncommon injury. The purpose of the present study was to report the results of surgical treatment of circumferential lesions of the glenoid labrum with use of validated outcome instruments. METHODS From July 2003 to May 2006, forty-one shoulders in thirty-nine patients (thirty-four men and five women) with a mean age of 25.1 years were prospectively enrolled in a multicenter study and were managed for a circumferential (360 degrees ) lesion of the glenoid labrum. All patients had a primary diagnosis of pain and recurrent shoulder instability, and all underwent arthroscopic repair of the circumferential labral tear with a mean of 7.1 suture anchors. The outcomes for thirty-nine of the forty-one shoulders were assessed after a mean duration of follow-up of 31.8 months on the basis of the rating of pain and instability on a scale of 0 to 10, a physical examination, and three outcome instruments (the Single Assessment Numeric Evaluation score, the modified American Shoulder and Elbow Surgeons score, and the Short Form-12 score). RESULTS Significant improvement was noted in terms of the mean pain score (from 4.3 to 1.1), the mean instability score (from 7.3 to 0.2), the mean modified American Shoulder and Elbow Surgeons score (from 55.5 to 89.6), the mean Short Form-12 score (from 75.7 to 90.0), and the mean Single Assessment Numeric Evaluation score (from 36.7 to 88.5). Six shoulders required revision surgery because of recurrent instability (two), recalcitrant biceps tendinitis (two), or postoperative tightness (two). All patients returned to their preinjury activity level. CONCLUSIONS Pan-labral or circumferential lesions are an uncommon yet extensive injury of the glenohumeral joint that may result in recurrent instability and pain. The present study demonstrates that arthroscopic capsulolabral repair with suture anchor fixation can restore the stability of the glenohumeral joint and can provide a reliable improvement in subjective and objective outcome measures.

An Analysis of Shoulder Outcomes Scores in 275 Consecutive Patients: Disease-Specific Correlation Across Multiple Shoulder Conditions

OBJECTIVES To determine the outcomes scores of military patients who initially present with a variety of shoulder conditions, identify which scores demonstrate the highest correlation per diagnosis, and determine if a difference exists for patients who went onto surgery. METHODS Two-hundred and seventy five consecutive patients with mean age of 36.5 +/- 12.9 at presentation completed baseline outcomes assessments that included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) Score, Western Ontario Shoulder Instability Index (WOSI), Western Ontario Rotator Cuff Index (WORC), the Simple Shoulder Test (SST), and the Disabilities of the Arm, Shoulder, and Hand Index (DASH). The patients were grouped by clinical, radiographic, and surgical findings into 10 diagnostic categories. OUTCOMES The initial mean outcomes scores were SANE 48.8, ASES 50.1, WOSI 1279 (40% normal), WORC 1122.4 (47% normal), SST 6.7, and DASH 33.1. Patients with superior labrum anterior-posterior tears demonstrated the lowest mean scores, followed by instability and rotator cuff tear patients. For all conditions, scores were lower for patients who went onto surgery compared with those managed nonoperatively (p = 0.008). CONCLUSIONS Our findings may be utilized as a baseline to compare and track patient-derived disability across multiple shoulder conditions and serve to define mean diagnosis-specific shoulder patient preoperative scores.

Avoiding and Managing Complications of Surgery of the Acromioclavicular Joint

Injuries to the acromioclavicular (AC) joint are common, especially in a young, active population. Of all shoulder girdle injuries, approximately 9% involve the AC joint.2 AC joint injuries are often seen in young, active individuals, especially those participating in sports. Almost half of AC joint injuries occur in patients in their twenties, and there is a five to one male to female ratio.2 AC joint dislocations represent 12% of all shoulder girdle dislocations, and 8% of all joint dislocations throughout the body.3,4

Prospective Evaluation of Surgical Treatment of Humeral Avulsions of the Glenohumeral Ligament.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) is an infrequent but significant contributor to shoulder dysfunction, instability, and functional loss. Purpose: To prospectively identify patients with HAGL lesions and then conduct retrospective evaluation of the clinical history, examination findings, and surgical outcomes of these patients. Study Design: Case series; Level of evidence, 4. Methods: Over a 6-year period (2006-2011), patients with shoulder dysfunction and a HAGL lesion that was confirmed via magnetic resonance arthrogram (MRA) were prospectively evaluated with a minimum 2-year follow-up. Patient demographics, presentation, examination, and surgical findings were documented. Outcomes of return to activity as well as Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) scores were recorded at final follow-up. Anterior HAGL (aHAGL) lesions were repaired with a partial subscapularis tenotomy approach, while reverse (rHAGL) lesions were repaired arthroscopically. Results: Of 28 patients, 27 (96%) completed the study requirements at a mean of 36.2 months (range, 24-68 months). The sample contained 12 females (44%) and 15 males (56%), who had a mean age of 24.9 years (range, 18-34 years). The chief complaint reported was pain in 23 patients (85%), while only 4 (15%) patients complained primarily of recurrent instability symptoms. Fourteen patients (52%) had aHAGL lesions, 10 patients (37%) had rHAGL lesions, and 3 patients (11%) had combined aHAGL and rHAGL lesions. Ten patients (37%) had concomitant HAGL lesions and labral tears, whereas 17 patients (63%) had isolated HAGL lesion without labral tear. The 17 patients (63%) with aHAGL lesions or combined lesions underwent a partial subscapularis tenotomy approach, while the remaining 10 patients (37%) with rHAGL lesions underwent arthroscopic surgical repair. After surgery, WOSI outcomes improved from 54% to 88% and SANE outcomes improved from 50% to 91% (P < .01 for both), with no reports in recurrence of instability symptoms at final follow-up. Conclusion: This study demonstrated that patients with symptomatic HAGL lesions predominantly report shoulder pain and dysfunction, with few chief complaints of recurrent instability complaints. After surgery, patients showed predictable return to full activity, improvement in objective and patient-reported outcomes, and satisfaction with treatment outcome.