Diagnosis and treatment of traumatic anterior instability of the shoulder.

Traumatic anterior glenohumeral joint dislocation is the most common type of shoulder instability. Lesions that usually result are avulsion of the anterior capsule and glenoid labrum from the glenoid rim (Bankart lesion), compression fracture of the posterosuperior humeral head (Hill-Sachs lesion), and laxity of the joint capsule. Another common lesion is a lengthwise disruption of the rotator cuff at the interval between the subcapularis and supraspinatus tendons. The shoulder that dislocates repeatedly after trauma has an excellent success rate when treated by surgical repair. The aim of the Bankart procedure is to restore stability to the shoulder by repairing the traumatic lesion of the anterior glenoid rim without altering normal anatomy.

Recurrent anterior transient subluxation of the shoulder. The "dead arm" syndrome.

Attention is directed to a subtle, unresponsive cause of shoulder disability in the young adult who has sustained a forceful overextension of the shoulder. A careful office evaluation will identify this lesion. A number of factors differentiate it from the numerous other causes of shoulder disability. 1. Usually a young athletic adult. 2. A characteristic history of forceful overextension of the shoulder. 3. Poor response to routine types of treatment. 4. Negative radiographic study. 5. Usually a frustrated and discouraged patient because no one has diagnosed or helped his "dead arm." 6. Consistent physical findings of a positive apprehension test.

Injection technique for the shoulder and elbow.

1. Injections of the shoulder or elbow can be carried out effectively with little or no discomfort, with the patient in the sitting position. 2. Aseptic technique should be observed. 3. The corticosteroid solution should not be injected into the tendons of the shoulder joint or elbow. 4. It is safer, less painful, and more effective to inject the solution into the overlying bursal space or the tendon sheath. 5. Repeated injections are not advised.

Recurrent transient anterior subluxation of the shoulder. The "dead arm" syndrome.

The recurrent transient anterior subluxation (the "dead arm" syndrome) is an accepted clinical syndrome seen most commonly in young athletes or individuals whose arms have been forcefully hyperextended in elevation and external rotation. Care must be taken to differentiate other causes of painful shoulder. With an accurate diagnosis, the results of conservative or operative treatment are most favorable. If surgical treatment is carried out, careful layer-by-layer dissection is required to properly identify and correct anatomic abnormalities.

Combined anterior cruciate-ligament reconstruction using semitendinosus tendon and iliotibial tract.

We are reporting the results of a reconstructive procedure designed to decrease anterior tibial subluxation due to disruption of the anterior cruciate ligament. The operation combines both intra-articular and extra-articular methods. The semitendinosus tendon and the iliotibial tract are both routed from opposite directions over the top of the lateral femoral condyle and through the same oblique drill-hole in the proximal part of the tibia: the semitendinosus tendon is passed up through the tibial drill-hole, across the knee joint, over the top of the lateral femoral condyle, and deep to the fibular collateral ligament, and the iliotibial tract is passed deep to the fibular collateral ligament, over the top of the lateral femoral condyle, across the knee joint, and down through the drill-hole. Both grafts are simultaneously pulled tight while the semitendinosus tendon is sutured to the iliotibial tract laterally and the iliotibial tract is sutured to the semitendinosus tendon medially below the drill-hole. The posteromedial and lateral parts of the capsule are advanced to tighten the secondary restraints. One hundred of the first 106 consecutive patients with chronic instability who had this procedure were evaluated using subjective and objective criteria at three to seven and one-half years after surgery. The positive anterior-drawer sign tested at 25 degrees of flexion was eliminated or reduced to 1+ in eighty knees, and the positive pivot shift was reduced to zero or 1+ in ninety-one knees. The objective assessment of isokinetic muscle performance and passive tibial rotation showed significant improvements in strength and normalization of tibial rotation.

Failed surgery for recurrent dislocations of the shoulder.

By careful dissection, the causative factors could be identified and repaired surgically in 38 previously failed procedures for recurrent anterior dislocation of the shoulder. A routine Bankart procedure was performed in 20 shoulders (in two of which a Connolly procedure was added), a Putti-Platt procedure in four, and capsulorrhaphies in four shoulders. Seven shoulders were treated with exercises with an excellent result in one and good results in four. It was most encouraging that in the patients followed from 2 to 13 years, only 5% have had recurrences.

Current concepts in the diagnosis and treatment of shoulder instability in athletes.

Glenohumeral joint instability is a fairly common clinical disorder in athletes, especially in sports that involve the throwing motion. The direction of shoulder instability can be anterior, inferior, posterior, or multidirectional. The cause can be trauma, congenital laxity, or voluntary muscle action. Normal shoulders that have been disrupted by injury respond well to surgical correction. Shoulders that have inherently lax supporting structures, as found in patients with atraumatic and voluntary dislocation, have less consistent success with surgical repair. A common condition encountered in the shoulder of a throwing arm is anterior subluxation, which can be diagnosed by the positive apprehension sign and confirmed by arthroscopy. A torn glenoid labrum is a common injury also. Improvement in the diagnosis and treatment of shoulder disorders has been made recently by arthroscopy which allows direct visualization of the joint; many conditions can now be corrected by means of arthroscopic surgery. Radiographic techniques have also been improved.

Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment.

We analyzed the cases of thirty-nine patients who were treated for recurrent anterior dislocation of the shoulder after unsuccessful surgical repair for the same condition in order to identify factors responsible for failure of the earlier operations and to determine the results of treatment of the post-surgical recurrence. The prior operations included nineteen Bankart, seven Putti-Platt, five Magnuson, three duToit, two Bristow, and three Nicola procedures. Thirty-two shoulders were treated by reoperation. At reoperation the most common pathological lesion associated with recurrence of the dislocation after the prior repair was a Bankart lesion (avulsion of the capsule and labrum from the anterior glenoid rim). This was present in 84 per cent of the thirty-two shoulders that were treated by reoperation. Excessive laxity of the capsule was found in 83 per cent of the twenty-nine shoulders in which laxity was assessed, and was considered to be the primary cause of instability in four shoulders. A Hill-Sachs lesion of the humeral head was found in 76 per cent of the twenty-nine shoulders that were evaluated for this lesion and was large in three of the shoulders. Other factors that were associated with recurrent instability were scarring of the subscapularis muscle, generalized ligament laxity, technical errors at surgery, and severe reinjury. The success rate of reoperation after previous failure was very encouraging. Of the twenty-four shoulders that were reoperated on and were followed for two years or longer, ten were graded excellent; twelve, good; and two, poor. One (4 per cent) of the twenty-four shoulders that were reoperated on continued to dislocate and another shoulder continued to subluxate, making the incidence of recurrent instability after reoperation 8 per cent. Seven of the thirty-nine shoulders did not have a reoperation but were treated with specific resistive exercises. The results in these were one excellent, four good, one fair, and one poor. Eight patients were lost to follow-up.

Historical development of shoulder care.

The development over the last century and a half of treatment for dislocation of the shoulder, fractures, acromioclavicular dislocation, arthroplasty, and rupture of the rotator cuff is outlined.

Rotational motion of the knee.

This study deals with the quantitation of axial rotation at the knee. Passive rotation of the knee was measured at various degrees of flexion on 17 subjects with normal knees and 19 patients with unilateral anterolateral rotatory instability. Normal subjects were found to have bilateral symmetric rotational knee motion at each angle of flexion tested. When the knee is in a position of flexion between 30 and 90 degrees, there are approximately 45 degrees external and 25 degrees internal rotation. Rotatory motion decreases with further extension and, at 5 degrees of flexion, the knee has 23 degrees external and 10 degrees internal rotation. The knee with a torn anterior cruciate ligament and anterolateral rotatory instability was found to have an arc of rotation similar to the contralateral knee and to the control knees between 30 and 90 degrees flexion. At 15 degrees of flexion, a slightly greater arc of rotation was measured compared to normal knees. At 5 degrees of flexion, a significantly greater range of external (to 41 degrees) as well as internal (to 14 degrees) rotation was measured.

Effect of patellectomy on the function of the quadriceps and hamstrings.

The Cybex-II isokinetic dynamometer was used to measure quadriceps and hamstrings function after unilateral patellectomy in twelve patients. The interval between surgery and testing averaged twenty-six months (range, fourteen to forty-two months). Data on isokinetic and isometric performance were compared with those of the untreated limb and with those of subjects who had not been operated on but who had been matched by age, sex, and weight. On the side that had been operated on, the peak torque of the quadriceps was significantly decreased whereas the peak torque of the hamstrings was preserved. Deficits in time factors related to the development of tension and high-speed performance were documented, revealing abnormalities in both muscle groups. Although patellectomy was successful in achieving relief of pain in these patients, the results of the study confirmed that the function of the knee muscles was compromised postoperatively. The objective findings documented alterations in muscle function that correlated well with the functional limitations described by the patients.

Arthrodesis of the shoulder used in treating painful conditions.

By the time a patient's shoulder problem has reached the stage in which an arthrodesis is being considered, the patient usually is willing to accept the restraints of an arthrodesed shoulder. If there is a chance of relieving chronic pain and restoring some reasonable degree of function in the upper extremity, arthrodesis warrants consideration. However, failure to relieve pain and restore function may cause unhappiness. Because of recent advances in the surgical technique and the improved, more comfortable anatomic position of the arm at the side of the body, the patient is considering arthrodesis of the shoulder with much greater optimism. With the ability to reach the face and hair, the back and buttocks region, and the feet with ease, the patient with an arthrodesed shoulder is much happier, more comfortable, and less depressed.

Chronic unreduced dislocations of the shoulder.

We evaluated the results of treatment in twenty-three patients with twenty-four shoulder dislocations that had gone unreduced for at least three weeks. Fourteen dislocations were posterior, eight were anterior, and one each was superior and inferior. Seventy-nine per cent of the posterior dislocations had not been recognized by the initial treating physician. Fourteen shoulders (58 per cent) were operated on. Of seven that were treated by open reduction with preservation of the humeral head, the results in two were graded as excellent; in three, as good; and in two, as fair. A Neer total shoulder-replacement prosthesis was used in one patient with an excellent result, and a Neer humeral-head prosthesis was used in two patients with a good and a fair result. In four patients, the humeral head was removed and a Jones procedure was performed, with one good and three fair results. There were no poor results after surgical treatment and it was not necessary to arthrodese any shoulder. We did not find it necessary to transfix the shoulder joint by screws or pins, or to use plaster spica casts to maintain stability of the shoulder following open reduction. Supporting the arm at the side in a position posterior to the coronal plane for a posterior dislocation, and anterior to the coronal plane for an anterior dislocation, proved to be comfortable and effective. There were no postoperative dislocations using this simple method. These results show that the over-all prognosis for surgical treatment of the chronic unreduced dislocation shoulder is more favorable than has previously been reported. A rating system based on 100 units was used to evaluate our final results, and is recommended as a standard system for future comparative studies.

The Bankart procedure: a long-term end-result study.

Of 161 patients with 162 shoulders operated on during a thirty-year period (1946 to 1976), 124 were re-examined and twenty-one answered a questionnaire. The lesions found at surgery were separation of the capsule from the anterior glenoid rim in 85 per cent, a Hill-Sachs lesion of the humeral head in 77 per cent, and damage to the anterior glenoid rim (including fracture) in 73 per cent. There were five recurrences (3.5 per cent) after repair by the method described in the 145 shoulders that were followed. Only one of the forty-six patients with dislocation on the dominant side and one of the thirty-one with dislocation on the non-dominant side failed to return to the competitive athletic activities in which they participated prior to injury. The results at follow-up were rated excellent in 74 per cent, good in 23 per cent, and poor in 3 per cent. Ninety-eight per cent of the patients rated their result as excellent or good. Sixty-nine per cent of the shoulders had a full range of motion, and only 2 per cent of these shoulders redislocated. A fracture of the rim of the glenoid did not increase the risk of recurrence, while a moderate to severe Hill-Sachs lesion increased the risk only slightly. We concluded that with the meticulous technique of the Bankart repair as described, postoperative immobilization is not necessary, early return of motion and function can be expected, and resumption of athletic activities with no limitation of shoulder motion is possible for most patients.