Rockwood Adults CH34

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CHAPTER 34 • Glenohumeral Instability

Anterior shoulder instability (recurrent)

MR arthrogram ( é ABER view) and CT with 3D reconstruction

Glenoid bone loss (%)

> 30%

< 13.5% to 17.3%

17.4% to 30%

Nonengaging Hill–Sachs (on track)

Engaging Hill–Sachs (off track)

Arthroscopic or open Bankart repair + remplissage

Glenoid bone grafting (autograft or allograft)

Latarjet

Arthroscopic or open Bankart repair

Algorithm 34-2.  Authors’ preferred treatment for recurrent anterior shoulder instability.

value between arthroscopic stabilization versus open Latarjet should be based on the patient’s activity level, type of sports (collision vs. noncontact), and expectations. The best option for treatment is based on informing the patient both the risk and benefits of arthroscopic versus open bone procedure and a shared decision-making model. Thus, the authors sug- gest that in patients with < 13.5% to 17.3% anterior glenoid bone loss and non–engaging Hill–Sachs (on-track) lesions, arthroscopic or open Bankart repair is indicated. In patients with < 13.5% to 17.3% bone loss with an engaging Hill–

Sachs (off-track) lesion, a remplissage procedure should be considered in addition to the arthroscopic or open Bankart repair. A Latarjet procedure can also be used in this setting to stabilize the shoulder. In patients with > 17.3% but less than 30% bone loss, an open Latarjet procedure is recommended for the best outcome. An anterior glenoid bone grafting with either autograft (iliac crest) or allograft (distal tibia allograft) is indicated when the patient has > 30% glenoid bone loss or has failed open Latarjet procedure. Both autograft and allograft have similar reported outcomes in the literature.

Postoperative Care

of 120 degrees in flexion. In phase III of the postoperative ther- apy, between weeks 8 and 14, the main goal is to restore full ROM in flexion and external rotation. Mild strengthening exer- cises are initiated around week 8 for the rotator cuff, deltoid, and scapula stabilizers. The patient should transition into active ROM with isokinetic training during this phase. In the final phase of the recovery process between weeks 14 and 18, the goal is to restore normal neuromuscular function with full ROM and strength. Sports-specific activity program is also incorpo- rated into this phase. Full return to sports or high-demand job activities may begin around 5 to 6 months, and the patient must have similar ROM and strength compared with the contralateral shoulder.

After arthroscopic or open Bankart repair or Latarjet procedure, the patient is placed in a sling with an abduction pillow for the first 4 to 6 weeks to protect the repair or reconstruction. Formal physical therapy is started 2 weeks after surgery. In phase I of the recovery, passive ROM in forward flexion is done with the patient in the supine position where the goal is flexion to 90 degrees and external rotation to 25 degrees. Elbow and wrist active and passive ROM is encouraged with modalities as needed for both pain and edema control. In phase II, between weeks 4 and 8, the patient will start to wean from their sling. Passive ROM is transitioned to active assisted ROM with a goal