Rockwood Adults CH34

1090

SECTION TWO • Upper Extremity

Conversely, there are patient-specific factors that lead to a high rate of recurrent instability even following surgery. These factors were originally described by Balg and Boileau 11 and consist of age below 20 years, glenoid bone loss, humeral bone loss, frequent or advanced sports participation, collision sport participation, and the presence of shoulder hyperlaxity. The classification system is termed the Instability Severity Index Score (ISIS). Each of the above criteria is worth 2 points if present with the exception of type of sport and presence of shoulder hyperlaxity which are each worth 1 for a total of 10 points (Table 34-3). The authors found that patients with scores above 6 had a 70% chance of recurrent dislocation after a soft tissue repair, and, they favored a bony stability surgery in these individuals. With this scoring system (ISIS), Phadnis et al. 182 found in their series that a score of 4 or higher was asso- ciated with a 70% risk of failure. These studies also demon- strate high rates of recurrent instability even following surgery in young, competitive athletes who have glenoid or humeral bone loss; thus, these patients should not be routinely treated with conservative management. Along with determining which patients are best served with nonoperative treatment, it is also important for clinicians to realize situations in which nonoperative treatment should not be recommended as a primary treatment option in patients presenting with glenohumeral instability, including age below 30 years, contact sports, recurrent instability, inability to ade- quately and safely perform job duties, or sport, and significant humeral or glenoid bone loss where further instability is immi- nent and/or progressive loss is inevitable. 34

TABLE 34-3. Instability Severity Index Score

Prognostic Factors

Points

Age at Surgery ≤ 20 yr

2 0

> 20 yr

Degree of Sports Participation (Preoperatively) Competitive

2 0

Recreational or none

Type of Sports (Preoperatively) Contact or overhead

1

Other

0

Shoulder Hyperlaxity Hyperlaxity (ER > 90) anterior or inferior

1 0

Normal

Hill–Sachs on AP Radiograph Visible on external rotation Not visible on external rotation

2 0

Glenoid Loss of Contour on True AP Radiograph Loss of contour or glenoid bone loss

2 0

No glenoid bone loss

Total points

10

Indications/Contraindications

into an immobilization group consisting of a sling and swathe for 3 to 6 weeks or to a no-immobilization group. There was an exceedingly high failure rate in both groups. After 18 months follow-up, there was a 90% recurrence in the immobilized patients and an 85% recurrence in the nonimmobilized group. The length of immobilization did not affect the recurrence rate and 79/120 (66%) patients ultimately received surgery for a recurrent dislocation. This was one of the first reports that con- cluded that young athletes should receive special consideration for surgical intervention after a first-time dislocation given the high recurrence rate. Simonet et al. tracked the natural history of nonoperatively treated anterior glenohumeral instability in 116 patients at a mean 4.6 years follow-up. They documented an overall 33% rate of recurrent instability. Patients less than 20 years old had a 66% rate of recurrence. Athletes had a higher rate of sustaining a recurrent dislocation (82%) versus nonathletes (30%). 215,216 Wheeler et al. evaluated military cadets who were treated with either arthroscopic repair (9 patients) or nonoperative treat- ment (38 patients) at an average of 14 months. 262 They found a recurrence rate of 92% in the nonoperatively treated group compared with a 22% recurrence rate in the patients who had stabilization surgery. Military cadets were further evaluated by Arciero et al. 8 with either arthroscopic repair and rehabilitation (21 patients) or 1 month of immobilization followed by rehabil- itation with a goal of returning to full activity by 4 months. They also found a substantial difference between the two groups with

Nonoperative Treatment of Glenohumeral Instability: INDICATIONS AND CONTRAINDICATIONS Indications

Relative Contraindications

• First-time subluxators or dislocators (anterior or posterior) without significant glenoid or humeral bone defect • Patients greater than 30 years of age and low demand • Patients who do not engage in athletics • Patients with MDI • Voluntary dislocators

• Demonstrated recurrent instability (subluxation or dislocation) • Instability with glenoid bone loss • Instability with engaging humeral bony defect • Primary dislocators that are young ( < 30), male, and play high-demand or contact sports • Bony Bankart lesions • Instability with sleep or lower levels of shoulder ROM

Outcomes Multiple reports with Level I–IV evidence have reported the results of nonoperative treatment with regard to anterior gleno- humeral instability. Henry and Genung 86 reported on the out- come of nonoperative treatment of 120 athletes with shoulder instability who averaged 19 years of age. Patients were divided