Rockwood Adults CH34

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CHAPTER 34 • Glenohumeral Instability

program at around 3 months. Aggressive passive stretching is avoided throughout the first 6 months. Return to athletics is permitted when patients have achieved painless ROM and have attained necessary rotator cuff strength and scapular stability. This is typically at the 6- to 8-month mark depending on the activities to which the patients wish to return.

instability. Gartsman et al. reported on their series of 47 patients at an average age of 30 years and almost 3 years of follow-up after arthroscopic treatment of MDI. 70 Multiple outcome scores were compared preoperatively and postoperatively. No patients were rated as good to excellent preoperatively; however, 44 of 47 (94%) were rated as such postoperatively. One patient underwent a revision procedure. Open Procedures Bigliani et al. 20 reported on the outcomes of 68 shoulders in 63 athletic patients treated with an open anterior-inferior capsular shift procedure. Good to excellent results were achieved in 94% of the patients and 75% were able to return to their previous level of athletic competition. Postoperative dislocation occurred in only 2 patients. Adolescents with Ehlers–Danlos syndrome presenting with MDI were assessed after undergoing an open inferior capsular shift after a follow-up of 7.5 years. 239 Out of 15 patients with 18 procedures, 13 (87%) reported improvements in pain and stability and were satisfied with the procedure with 9 (64%) patients able to return to sport. Multidirectional Glenohumeral Instability: COMMON ADVERSE OUTCOMES AND COMPLICATIONS • Tightness due to over-constrained joint or postoperative stiffness • Recurrent instability • Pain • Chondrolysis The most frequent complication associated with surgery for MDI is incomplete resolution of pain and/or instability. Multi- ple previous studies reported in this chapter have demonstrated that a certain percentage of patients have always failed treat- ment, regardless of which treatment was chosen. Revision sur- gery remains a possibility for these patients, 23 but reports on outcomes are scarce and it is difficult to counsel the patient on expectations following a revision surgery. When thermal capsulorrhaphy was performed routinely, along with poor operative results, 65,154 there were multiple sig- nificant complications reported, including postoperative chon- drolysis 50,199,274 as well as injury to the axillary nerve. 75,258 Management of Expected Adverse Outcomes and Unexpected Complications Related to Multidirectional Glenohumeral Instability

Potential Pitfalls and Preventive Measures

Multidirectional Glenohumeral Instability: SURGICAL PITFALLS AND PREVENTIONS Pitfall Prevention

• Overly constraining the joint

• Limit capsular tissue penetration with suture passer to 1 cm, place shoulder in slight external rotation when securing sutures anteriorly and slight internal rotation when securing sutures posteriorly • Limit the number of nonabsorbable sutures by using plication stitches with PDS or similar absorbable suture between anchors • Use of longitudinal traction and abduction should create a large intra- articular volume due to patulous capsule. Also, a small bump can be used under the axilla to help with joint distraction • Use of percutaneous portals will allow access to inferior glenoid for instrumentation, and care should be taken to avoid neurovascular structures

• Suture abrasion to cartilage

• Iatrogenic damage to cartilage from instruments

• Inability to obtain insertion anchor below the 5 or 7 o’clock position for the anchors

Outcomes Arthroscopic Procedures

Duncan and Savoie 63 were one of the first to report their out- comes on an arthroscopic modification of the open inferior cap- sular shift that had been previously described by Altcheck et al. 5 They performed this procedure on 10 patients with MDI and assessed them at 1 to 3 years follow-up. All patients reported satisfactory outcomes. Two patients had a follow-up surgery to remove symptomatic sutures. The senior author (FHS) later reported on a series of 25 patients with MDI also treated with arthroscopic capsular shift after an average of 5 years. They found that 21 (88%) of patients met the criteria for a satisfactory results and concluded that results of arthroscopic management of MDI could be considered comparable to open treatment even after 5 years. 233 Results of 50 patients with MDI who had failed nonoperative methods and treated with arthroscopic capsular plication were reviewed at an average of 2 years. 267 They found that of the 43 patients available to report outcome scores, 41 had good or excellent results. Patients with a higher Beighton score demon- strated less improvement and 2 patients demonstrated recurrent

SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO GLENOHUMERAL INSTABILITY

ANTERIOR GLENOHUMERAL INSTABILITY Advances with new repair and reconstruction techniques and understanding the importance and interaction of bipolar bone loss (humeral head and glenoid), along with adjuvant proce- dures (i.e., remplissage or infraspinatus capsulotenodesis), will