Evaluation and Management of Failed Shoulder Instability Surgery

Abstract

Background:Failed shoulder instability surgery is mostly considered to be the recurrence of shoulder dislocation but subluxation, painful or non-reliable shoulder are also reasons for patient dissatisfaction and should be considered in the notion.Methods:The authors performed a revision of the literature and online contents on evaluation and management of failed shoulder instability surgery.Results: When we look at the reasons for failure of shoulder instability surgery we point the finger at poor patient selection, technical error and an additional traumatic event. More than 80% of surgical failures, for shoulder instability, are associated with bone loss. Quantification of glenoid bone loss and investigation of an engaging Hill-Sachs lesion are determining facts. Adequate imaging studies are determinant to assess labrum and capsular lesions and to rule out associated pathology as rotator cuff tears. CT-scan is the method of choice to diagnose and quantify bone loss. Arthroscopic soft tissue procedures are indicated in patients with minimal bone loss and no contact sports. Open soft tissue procedures should be performed in patients with small bone defects, with hiperlaxity and practicing contact sports. Soft tissue techniques, as postero-inferior capsular plication and remplissage, may be used in patients with less than 25% of glenoid bone loss and Hill-Sachs lesions. Bone block procedures should be used for glenoid larger bone defects in the presence of an engaging Hill-Sachs lesion or in the presence of poor soft tissue quality. A tricortical iliac crest graft may be used as a primary procedure or as a salvage procedure after failure of a Bristow or a Latarjet procedure. Less frequently, the surgeon has to address the Hill-Sachs lesion. When a 30% loss of humeral head circumference is present a filling graft should be used.Conclusion:Reasons for failure are multifactorial. In order to address this entity, surgeons must correctly identify the causes and tailor the right solution.

Management of Failed Surgery for Anterior Glenohumeral Instability: Synopsis of Clinical Evidence

“…Posterolateral humeral head impression (Hill–Sachs lesion) becomes a significant risk factor for anterior shoulder instability when it exceeds 20%–25% of the humeral head spherical surface, 3 especially if the humeral head impression’s long axis is parallel to the anterior glenoid rim and is situated on the humeral head in a position that could cause slippage over the anterior glenoid rim during functional, not extensive, shoulder movement, usually during abduction and external rotation (engaging Hill–Sachs lesion). 2 , 13 Isolated bony glenoid deficiency usually causes anterior shoulder instability when it exceeds 20%–30%, as estimated by computed tomography (CT) imaging by approximation of the lower glenoid to the spherical shape, 14 or by direct anterior–posterior measurements during glenohumeral arthroscopy. 15 …”

“… 1 – 3 Naturally, this wide range of surgical failures is based on the surgical technique, the surgeon’s experience, and the patient’s compliance, but also on the definition of surgical “failure.” Obviously, re-dislocation or persistent subluxations of the glenohumeral joint can be defined as failure of the initial surgery, but persistent shoulder pain and shoulder stiffness cannot be neglected and can usually also be defined as surgical failure. 2 , 4 …”

Arthroscopic Bankart Repair Using a Lasso-Loop Stitch

“…Indications for this operation are shoulder instabilities with repairable damage to the labrum: Bankart lesion, bony Bankart lesion, ALPSA, Perthes lesion, and reversed (posterior) Bankart lesions as well as injuries to the long head biceps tendon anchor (SLAP). Contraindications for this operation are arbitrary shoulder dislocations during growth period without damage to the labrum and chronic bony glenoid defects >15% of the glenoid surface [11][12][13]. HAGL lesions require softtissue refixation at the humeral site [14].…”

Surgical technique and clinical outcome of arthroscopic shoulder stabilization via suture anchors using the lasso-loop stitch

“…Contraindications are arbitrary shoulder dislocations during growth period without damage to the labrum and chronic bony glenoid defects > 20% of the joint surface. [11][12][13] HAGL lesions acquire a humeral refixation. 14 Patient consent should contain the following issues apart from the standard operation risks: cartilage damage, lesion to the axillary nerve, suture rupture, switching to open surgical procedure in case of larger bony defects, standardized postoperative treatment, restriction of motion (especially external rotation), redislocation, anchor dislocation, osteolysis in case of resorbable anchors, posttraumatic arthritis, pain, hospitalization for 1-2 days, day surgery possible, work leave dependent on job and arm dominance 2 days to 16 weeks.…”