Rockwood Adults CH34

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SECTION TWO • Upper Extremity

to play. Furthermore, arthroscopic stabilization with suture anchors results in fewer recurrences and revisions than anchor- less repair in high-demand athletes. In the subset of patients who present with chronic posterior glenohumeral instability and critical bone loss of greater than 20% or failed arthroscopic or open posterior stabilization pro- cedure, posterior bone-blocking procedure is considered the treatment of choice. This can be done with either allograft or autograft. Most of the studies in the literature are of Level IV evi- dence consisting of small case series. Barbier et al. 13 reported on the outcome of 8 patients after iliac crest bone block procedure and found satisfactory results in 80% of their cases; however, three of eight patients required revision surgery and several patients experienced limitation in external rotation of more than 20 degrees postoperatively. Sirveaux et al. 217 compared the outcome between iliac crest bone block and an acromial pedic- ulated bone block in 18 patients and reported both procedures were effective in stabilizing the shoulder from recurrences in long-term follow-up. Less posttraumatic glenohumeral arthritis was noted when compared to bone block procedures for ante- rior shoulder instability. However, the authors recommended additional capsuloplasty when inferior laxity is associated with posterior instability. In the largest multicenter series of 66 patients with posterior shoulder instability and bone block procedures, the authors reported significant improvement in the Constant scores and Rowe scores after surgery. Addition- ally, pain scores were reduced and 85% of the patients were satisfied or very satisfied with the outcome. 47 Recently, several authors have reported on the outcome of arthroscopic poste- rior bone block procedure for posterior instability and found similar results compared with the open technique. 259 However, arthroscopic techniques are still evolving and long-term out- comes are not available at this time.

bone loss with bony augmentation procedures can be consid- ered. Rotator cuff insufficiency/tears can be identified on physi- cal examination and are confirmed with MRI. Clinically relevant rotator cuff tears must be addressed with surgical repair. Tech- nical errors resulting in failed surgery are numerous and include failure of anchor fixation resulting in recurrent labral tears and loose bodies, inadequate number of suture anchors, and errors in rehabilitation. Persistent pain from cartilage loss and arthritic changes are particularly challenging especially in the young patient, and salvage procedures such as glenohumeral arthrod- esis or shoulder arthroplasty are possible but associated with unpredictable long term outcomes. Glenoid dysplasia treatment includes consideration for glenoid osteotomy or a posterior gle- noid bone grafting procedure. Secondary adhesive capsulitis can be managed in a variety of ways depending on severity, dura- tion of symptoms, and pain. Treatment options include gleno- humeral cortisone injections, physical therapy with stretching exercises, and arthroscopic capsular release. Neurologic injuries, while rare, unfortunately have little potential for improvement but may be treated with nerve or muscle transfers. 38,207 MULTIDIRECTIONAL GLENOHUMERAL INSTABILITY Indications/Contraindications Indications for operative management of multidirectional gleno- humeral instability include patients with symptomatic recurrent instability who have undergone nonoperative strengthening for a period of 6 to 12 months. Patients who are voluntary dislo- cators or those with serious psychological or secondary gain issues are contraindicated. Operative treatment should only be discussed after the patient has demonstrated a failure to improve with a lengthy duration of nonoperative treatment to include either physical therapy or home-based exercises. While no specific duration exists that is evidence-based, however, most clinicians feel that 6 months to a year is needed prior to offering surgical intervention. Common surgical techniques include either an open infe- rior capsular shift or arthroscopic capsular plication. 246 Thermal capsulorrhaphy is no longer recommended as it was found to be associated with a high rate of subsequent failure and linked to chondrolysis. 3,154 Surgical management by any means must be thoroughly discussed with the patient. A recent systematic review revealed, with only low-quality evidence, that surgery was superior to nonoperative management for only impair- ment-based outcome measures while nonoperative treatment was favored for most patient-based outcome measures. 245 The inferior capsular shift was described by Neer and Foster in 1980 as a procedure that could be performed through either an anterior or posterior approach. 163 It has been further described with slight modifications, 5,9 but the basic tenets of the surgery remain the same. The surgery entails typically an anterior approach, accessing the capsule through a subscapu- laris tenotomy. The capsule can then be split and advanced in a pants-over-vest technique with subsequent fixation to decrease intra-articular volume. As arthroscopic equipment has improved throughout the years, so have the arthroscopic techniques to address glenohumeral joint stability. As such, arthroscopic man- agement of MDI has become increasingly popular. 17,44,87,228

Management of Expected Adverse Outcomes and Unexpected Complications Related to Posterior Glenohumeral Instability

Posterior Glenohumeral Instability: COMMON ADVERSE OUTCOMES AND COMPLICATIONS

• Recurrence of instability • Persistent pain after surgery • Posttraumatic arthritis • Nerve injury (axillary) • Stiffness or loss of motion • Hardware irritation

The most common adverse outcome after posterior shoulder instability surgery is recurrent instability. A variety of factors must be evaluated for determining the cause of failure. Bone loss from the posterior glenoid, rotator cuff tears or insuffi- ciency, arthritic changes, glenoid dysplasia, soft tissue defi- ciency, technical errors in surgical technique, postoperative secondary adhesive capsulitis, and neurologic injury are all known complications that can result from surgery to treat pos- terior glenohumeral instability. Suspected bone loss should be evaluated with a 3D CT scan to determine the degree and severity of the defect. Treatment of