Current Evidence Regarding Shoulder Instability in the Paediatric and Adolescent Population.

Paediatric and adolescent shoulder instability is caused by a unique combination of traumatic factors, ligamentous laxity, and pattern of muscle contractility. The multifactorial nature of its aetiology makes interpretation of the literature difficult as nomenclature is also highly variable. The purpose of this review is to summarize the existing literature and shed light on the nuances of paediatric and adolescent shoulder instability. The epidemiology, clinical features, imaging, and management of all forms of paediatric shoulder instability are presented. The main findings of this review are that structural abnormalities following a dislocation are uncommon in pre-pubertal paediatric patients. Young post-pubertal adolescents are at the highest risk of failure of non-operative management in the setting of traumatic instability with structural abnormality, and early stabilisation should be considered for these patients. Remplissage and the Latarjet procedure are safe treatment options for adolescents at high risk of recurrence, but the side-effect profile should be carefully considered. Patients who suffer from instability due to generalized ligamentous laxity benefit from a structured, long-term physiotherapy regimen, with surgery in the form of arthroscopic plication as a viable last resort. Those who suffer from a predominantly muscle patterning pathology do not benefit from surgery and require focus on regaining neuromuscular control.

MRI findings of acute anterior instability of the knee in the absence of recent trauma.

BACKGROUND: Anterior knee instability is usually encountered in the context of trauma, with the clinical examination and imaging focusing on anterior cruciate ligament (ACL) disruption. Limited data exist on magnetic resonance imaging (MRI) of acute anterior knee instability in the absence of recent trauma. PURPOSE: To provide the first comprehensive account of MRI findings in acute anterior knee laxity in the absence of acute trauma and to evaluate predictors of ACL integrity and pain. MATERIAL AND METHODS: A total of 84 consecutive patients with non-traumatic knee instability were prospectively studied. Instability was assessed with Lachman's, pivot shift, and Lelli's tests. MRI findings were recorded, and ACL integrity was surgically confirmed in all 24 cases of MRI suggesting tear and in 21/60 cases of MRI suggesting no tear. Binary logistic regression models were used to identify predictors of ACL tears and pain, and Mann-Whitney U test served for comparisons between continuous variables. The study was approved by the institutional review board. RESULTS: Osteoarthritis and notch bony outgrowth (NBO) were present in 44% and 42.9% of all knees, respectively. NBO did not correlate with osteoarthritis (P = 0.606). NBO (odds ratio [OR] = 4.157; P = 0.016) and ACL grafts (OR = 9.277; P = 0.01) predisposed to non-traumatic ACL tears (torn in 28.6% of total cases). Presence of osteoarthritis was predictive of pain (OR = 17.671; P < 0.001). CONCLUSION: We present a comprehensive analysis of MRI findings in clinically significant non-traumatic anterior instability, showing that NBO and ACL grafts predispose in non-traumatic ACL tears, whereas osteoarthritis is the only predictor of pain.

Long-term outcomes of open modified inferior capsular shift for traumatic anterior shoulder instability: over 20 years of follow-up.

BACKGROUND: This study aimed to assess the long-term outcomes of the open modified inferior capsular shift procedure across more than 20 years in patients with traumatic anterior shoulder instability. METHODS: Participants in this study comprised 84 patients (86 shoulders; 67 men, 17 women). Mean follow-up was 28.0 years. We compared the recurrent instability rate after surgery, apprehension, revision rate, satisfaction, return to preinjury sporting activity, and patient background characteristics between recurrent and nonrecurrent groups. Twenty-seven patients who were examined directly were evaluated for differences in range of motion and muscle strength between affected and nonaffected sides. Clinical outcome scores used for this study were the Western Ontario Shoulder Instability Index and the Rowe score. RESULTS: Nine shoulders (10.5%) showed recurrent instability, as dislocation in 3 shoulders and subluxation in 6 shoulders, but no revisions were required. All patients with recurrent instability were males with new trauma. Three shoulders developed recurrent instability ≤5 years after surgery, and the remaining 6 shoulders showed recurrent instability >5 years after surgery. No significant differences in any patient characteristic were identified between the recurrent and nonrecurrent groups. Significant differences between affected and nonaffected sides were seen in the mean active range of motion or muscle strength for external rotation in the anatomic position or in 90° of abduction. Western Ontario Shoulder Instability Index and Rowe score were significantly worse in the recurrent group than in the nonrecurrent group. Patients reported that 84 shoulders (97.7%) were "much better." Most athletes (88.4%) had returned to sports activity at a level >70%. CONCLUSION: We investigated long-term outcomes of the open modified inferior capsular shift procedure for traumatic anterior shoulder instability. Our data suggest that recurrent instability might result from new trauma even if a long time has passed since the open modified inferior capsular shift procedure, so follow-up should be continued as long as possible after surgery. As in other reports, satisfaction was high and clinical scores were good. We thus believe this surgical method offers good results even after more than 20 years.

Differences in glenohumeral joint morphology between patients with anterior shoulder instability and healthy, uninjured volunteers.

BACKGROUND: Traumatic glenohumeral joint (GHJ) dislocations are common, resulting in significant shoulder disability and pain. Previous research indicates that bony morphology is associated with an increased risk of injury in other joints (eg, the knee), but the extent to which bony morphology is associated with traumatic GHJ dislocation is unknown. This study assessed GHJ morphology in patients with anterior GHJ instability and in a control population of healthy volunteers. METHODS: Bilateral computed tomography scans were used to measure GHJ morphology in both shoulders of 11 patients with instability and 11 control subjects. Specific outcome measures included the glenoid radius of curvature (ROC) in the anterior/posterior (A/P) and superior/inferior (S/I) directions, humeral head ROC, A/P and S/I conformity index, and A/P and S/I stability angle. RESULTS: Compared with the control subjects, the glenoid of the instability the injured shoulder in patients with instability was flatter (ie, higher ROC) in the A/P (P = .001) and S/I (P = .01) directions and this finding was also true for uninjured, contralateral shoulder (A/P: P = .01, S/I: P = .03). No differences in GHJ morphology were detected between the instability patients' injured and contralateral shoulders (P > .07). Similarly, no differences in GHJ morphology were detected between the control subjects' dominant and nondominant shoulders (P > .51). CONCLUSIONS: There are significant differences in GHJ morphology between healthy control subjects and both shoulders (injured and uninjured, contralateral) of patients diagnosed with anterior instability after GHJ dislocation. These findings are important clinically because they suggest that glenoid morphology may influence the risk of GHJ dislocation.

Anterior decompression, fusion and plating in cervical spine injury: Early experience in Abuja, Nigeria.

BACKGROUND: We present a review of the results of the current surgical management of acute cervical spine injuries in the Federal Capital Territory, Abuja, Nigeria. This is the first detailed retrospective study on the surgical management of patients with cervical spine injuries from Nigeria. METHODS: The medical reports of patients with traumatic cervical spine and spinal cord injuries undergoing surgery from 1 August 2009 till 30 August 2010 were reviewed. Management and early results of outcome were ascertained and detailed consecutively in a prospective Microsoft Office Access(®) database (Microsoft Group of Companies). Frankel grading was used for pre- and immediate post-operative evaluation (within 48 hours). The Barthel index (BI) was used to classify patients as dependent or independent at follow-up. RESULTS: Twenty consecutive patients presented with acute cervical spine and spinal cord injuries since August 2009. Twenty anterior cervical spine decompression and fixation with an iliac graft and an anterior cervical plate (ACDF) were performed in 18 patients. All operations were performed with general anaesthesia using standard techniques but without a microscope or a high speed drill. Of the 18 patients who were operated, 4 patients died within a short period following surgical intervention. Seven patients have made a full recovery and seven remain fully dependent. Only two of the dependent quadriplegic patients have become reintegrated back into the society. CONCLUSION: The management of spinal cord injuries in Abuja is evolving. The operations were performed adequately with much limited complement of equipment. Poor intensive care therapy is a major challenge and improvements in this area of care will likely lead to better patient outcomes.

Recurrent Traumatic Glenohumeral Instability Associated with Glenoid Bone Defect : 3 Case Report

PURPOSE: Capsulolabral reconstruction in a traumatic anterior instability of the glenohumeral joint is successful not only for the prevention of recurrent instability but also for the restoration of function. MATERIALS AND METHODS: However, a capsulolabral procedure alone cannot guarantee a successful result when there is severe bone loss of the glenoid. RESULTS: We report the surgical technique and results of capsulolabral repair and extraarticular bone block with an autogenous iliac crest graft performed on three cases (all male, average age 28 years, minimum follow-up 12 months) with traumatic anterior instability associated with more than 30% glenoid bone loss.

Clinicial and biomechanical performance of lower cervical spine fixation procedures.

The break with the demand for maximum rigity of implant fixation of a traumatized unstable lower cervical spine is based on analyis and implementation of scientific and clinical data on the biomechanics of the native, the unstable and the implant-fixed spinal column. In view of these facts, recommendations for stabilization of the lower cervical spine can presently be formulated as follows:- The surgical procedure is to bring about decompression, restoration of form and stability.- The anterior approach should be the primary and preferred one. With regard to surgical and positioning technique, this access clearly involves less problems than the posterior approach; if required, unrestricted additional cord decompression can take place; implant fixation is technically simple: and the awareness of instability and type of implant permits functional therapy, also and above all for the paraplegic patient.- For traumatic conditions, posterior methods are reserved for exceptional indications, and being single procedures, they require the anterior column to be intact and a multisegmental procedure. They are therefore less recommendable for traumata but rather suitable for degenerative, rheumatoid or tumorous instabilities. The cerclage wire technique depends on intact, osseous posterior elements, while after laminectomy only screwed implants can secure safe stability. This disadvantage of the posterior access for the proprioception of the cervial muscles and the subjective well-being of the patient are known and to be taken into account.- Combined techniques are indicated for highly unstable or particularly complex injuries. On the cervicothoracic junction or in cases of Bechterew's disease, the decision is justifiably made in favor of the technique, which ca be performed as one-stage or two-stage operation.- Whenever possible, selection of the implant should take into account the foreseeable developments in diagnostic procedures; and therefore, with a view to follow-up examinations required later and to modern imaging techniques, the implant chosen should be made of titanium.