Shoulder arthroscopy: part I Is it justifiable after acute first-time anterior shoulder dislocation?

We reported on 34 young labor men, mean age 31.4 years with high physical demands who sustained first-time anterior dislocation of the shoulder. All were treated initially with closed reduction and immobilization, followed by shoulder therapy programs. Despite this, patients still suffered episodes of pain, discomfort and/or insecurity and feelings of joint being out on performing a particular activity. MRI was done for all cases, then, arrangement was made for arthroscopic evaluation some weeks to few months after primary treatment. The pathologic findings at arthroscopy divided the cases into 5 groups: capsular tears only in 5 patients; 4 [11.8%] of them [G1] the tear was defined at the glenoid attachment - in the rest one [2.9%] it was at the humeral insertion [G2]. Capsular tears associated with partial labral detachment [G3] in 9 [26.5%], capsular tears and complete labral detachment [G4] in 17 [50.0%], and complex injury [G5] in the remaining [8.8%] shoulders that demonstrated full labral detachment from the glenoid, frank tearing and fraying of the capsular structure which was seen as well avulsed from the labrum. No bony Bankart lesions, or mid-capsular tears were defined. The decision, based on the literature review [1-4-5-8-12-13-14-15-17-18-32] was to continue conservative treatment and observation for the 5 patients suffered capsular tears, but, an arthroscopic repair was an option in our mind for the 4 shoulders with glenoid capsular detachment, and an open surgery for the humeral avulsion of the glenohumeral ligament. While the option for the fifth group of cases was open shoulder stabilization procedures. The third, and fourth groups of cases including 26 shoulders were considered as an ideal candidates for arthroscopic treatment. This study emphasizes that a systemic arthroscopic examination of the glenohumeral joint is not only more confirmatory, defining the exact pathologic anatomy associated with first-time anterior shoulder dislocation, but as well how best in patient selection, and decision making

Shoulder arthroscopy: part II arthroscopic Bankart repair for anterior shoulder instability using suture anchor reconstruction technique

Suture anchor reconstruction technique was used in 19 shoulders over the last 2.7 years in 19 patients in an attempt to restore anterior stability. All the patients had traumatic anterior instability diagnosed on physical examination and at arthroscopy. Discrete Bankart lesion and well formed glenohumeral ligaments, with or without capsular laxity was the evidence consistent with instability in all patients, and each underwent a standardized procedure, however, the number of anchors were different for every patient, range 1-to-3 according to the size of the lesion. Additional capsulorraphy procedures were done to reduce excess capsular volume including; plication sutures in 8 shoulders, and thermal shrinkage in 7. All patients were young active men with high physical demands, the average age at the time of operation was 25.2 years. All were right handed, the dominant side was affected in 11 patients. None of the patients had prior instability operations. The follow-up averaging 18 months, range 9-to-3 1 months. None of the patients developed redislocation, subluxation, or positive apprehension during the follow-up period. No major intra-operative, or pen-operative complications were reported during this study. 75%-to-full range of motion of the shoulder joint as compared with the opposite asymptomatic side was preserved 21 in most patients. Using the shoulder evaluation scale advocated by Rowe; and Zarins, 1981 1421, the patients had excellent-to-good results with an overall average score of 85.82 points; but 5 patients had episodes of moderate pain with activity, and 7 had moderate limitation in overhead work. It would appear that arthroscopic repair of pathologic Bankart lesion in a carefully selected patients using suture anchor technique is a favorable answer restoring stability to the shoulder better than non-operative treatment of first-time dislocation and to surgical treatment of recurrent shoulder dislocation

Shoulder arthroscopy: part III arthroscopic versus open anterior shoulder stabilization

To evaluate the efficacy of a particular line of treatment, criteria based on functional basis and complication rate must be considered. This work was carried out because of the authors' conviction that any new operative procedure must be critically assessed, on this basis, comparison with other procedures must be included. Forty one shoulders were allocated to an arthroscopic repair group [19 shoulders], and an open repair group [22 shoulders]. The two groups were generally comparable in terms of age [a mean of 25.2 years in the arthroscopic group and 27.3 years in the open group], gender [all patients in either group were males], mechanism of injury and etiology of instability [all patients related a history of a traumatic event], dominant extremity [the right and the dominant side was the most vulnerable], duration of symptoms [a mean of 13 months and 19 months for the arthroscopic and open groups respectively], level of daily activities and effort demand [all were young active with high physical demand]. Three variations were existed: [1] pre-selection and pre-conditioning was the strategy in the arthroscopic repair group, so that, procedural option was determined on the basis of the pathological findings, only at the time of surgery, modification of treatment was possible. [2] the arthroscopic procedure involved an anatomic repair of the avulsed anterior capsule and labrum to the glenoid lip using standardized suture anchor technique and an incorporation of capsulorraphy in most shoulders. While in the open repair group, different operative modalities were employed using familiar techniques including: 2 soft tissue reconstructions; Magnuson - Stack [4 shoulders] and Putti-Platt [6 shoulders]. In addition, coracoid tip with its attached muscles transfer [Bristow operation in 9 shoulders] and rerouting [Boytchev operation in 3 shoulders]. [3] the duration of the follow-up, which considered short-to-mid term [averaging 18 months] and long-term [averaging 71 months] in the arthroscopic and open groups respectively. The treatment outcomes for each group were determined according to the recurrence rate, the presence or absence of -pain, the range of motion, the strength and the return to pre-injury activity. Analysis of the measured parameters for both approaches; open and arthroscopic showed no significant differences, both yielded comparable results

Shoulder arthroscopy: part IV idiopathic frozen shoulder: arthroscopic distension, release, and debridment

Twenty three carefully selected patients with frozen shoulder with variable degrees of complaint and severity constituted the material of the present study. All failed to response to the conventional lines of conservative treatment as an initial measures, and then, arthroscopic management was undertaken followed by a well designated physical therapy program and stretching mobilization. The indication for surgery was persistent pain, stiffness, and limited function. There were 15 [65.2%] males, and 8 [34.8%] females with an average age of 49.6 years. All were right handed, and all but 2 were unilateral dominant-side presentation - for bilateral affection, arthroscopy was done in one shoulder, the one with the severe symptoms. Before operation, all the patients had shoulder pain and motion restriction for at least 6 months despite conservative treatment. At operation, synovectomy, rotator interval capsulotomy, and glenohumeral joint and subacromial space debridment and clean-up were done for all cases, additionally, selective release procedures were performed in a controlled manner according to the findings, varied from limited freeing-up to a more aggressive or a complete release of the contracted anterior capsulo-ligamentotendinous structures. The range of external rotation at the side and in abduction was examined intermittently to check improved laxity and motion arc. The functional mobility, the range of motion in the different planes, the power, and pain were assessed and recorded before and after surgery according to the Constant scoring system [9]. Functional assessment was carried out at 3 post-operative intervals during the course of follow-up; immediate postoperative, at 10 th week, and finally at 20 th week. Final re-assessment at the end of the treatment showed appreciable improvement with no significant recorded complications. On conclusion, the combination strategy; arthroscopic management with shoulder exercises can offer effective treatment for frozen shoulder

Shoulder arthroscopy: part V post-arthroscopic immediate pain control, and then, early mobilization

Any evolution in surgical procedure must seek to improve established results, minimize previous complications, and maximize applicability to the general patient population. Arthroscopic examination and treatment of selected shoulder disorders have undoubtedly earned a permanent role in the practice of orthopaedic surgery, with an exciting and expanding future. The current study was designed to evaluate the clinical value of a post-arthroscopic local analgesic method using a single intra-articular injected dose of a mixture of 20mg [4 ml] tenoxicam, 20mg [0.5 ml] triamcinolone acetonide, 0.2% [10 ml] ropivacaine, and 0.5 ml of a 1: 1000 epinephrine solution, in an attempt to achieve a pain-free post-operative period to allow for early rehabilitation. The study was conducted in 76 patients, mostly were young active men, all underwent shoulder arthroscopic surgery for diagnostic and therapeutic purposes. Visual analogue scale [VAS] scores as regards pain intensity and relief were taken before surgery and then, at recovery, 1, 2, 4, 8, 24 hours postoperatively. In addition, patients were assessed for quality of sleep and for daily living. The physiotherapist's opinions about the analgesia provided were also recorded as indicated by the patient's ability to participate in the immediate post-operative mobilization programs. The results revealed a significant benefit as it offered an immediate post-operative pain relief, high therapist compliance, and good patient satisfaction. In addition, the incidence of adverse actions was negligible