Open capsular repair without bone block for recurrent anterior shoulder instability in patients with and without bony defects of the glenoid and/or humeral head

Michael J Pagnani
American Journal of Sports Medicine 2008, 36 (9): 1805-12

BACKGROUND: Bony defects of the humeral head and glenoid have been associated with high failure rates after arthroscopic stabilization for anterior instability. Biomechanical studies have indicated that such lesions reduce stability and may predispose to failure and motion loss after capsular repair.

PURPOSE: The present investigation was designed to evaluate the effect of bony deficiency of the glenoid and/or humeral head on recurrence rates with a conventional open technique of anterior stabilization without a bone block.

STUDY DESIGN: Case series; Level of evidence, 4.

MATERIALS AND METHODS: One hundred nineteen consecutive patients with recurrent anterior shoulder instability were treated by a single surgeon with an open anterior stabilization procedure. Patients were studied prospectively for recurrent instability after the presence and size of bony defects of the humeral head and/or glenoid were recorded during an arthroscopic examination before the open procedure. One hundred three patients (mean age, 20.7 years), including 98 men and 5 women, were available for 2-year minimum follow-up. Eighty-three of the patients participated in contact athletics.

RESULTS: Eighty-four percent of the patients had demonstrable Hill-Sachs lesions at the time of arthroscopy (27% "engaging" and 57% "nonengaging"). Fourteen percent had deficiency of the anterior glenoid, 9% had large (Rowe classification) defects of the humeral head, and 4% had severe (>20%) defects of the glenoid. The overall recurrence rate was 2%. Both recurrences were noted in patients with Hill-Sachs lesions, but the recurrence rate in patients with Hill-Sachs lesions was not significantly higher (P = .71). There was 1 recurrence among the 9 patients with large defects of the humeral head (P = .17). Patients with engaging Hill-Sachs lesions did not have a statistically significant increase in recurrence (4%) (P = .47). There were no recurrences in patients with glenoid deficiency. Patients with large defects of the glenoid lost a mean of 7 degrees of external rotation (P = .001) when compared with the remaining population (12 degrees vs 5 degrees ). Patients with large defects of the humeral head lost a mean of 4 degrees more external rotation (P = .003) when compared with the remaining population (9 degrees vs 5 degrees ). Two patients in the series lost > or =20 degrees of external rotation. When contact athletes were isolated as a population, there were no statistically significant increases in recurrence due to the presence of bony lesions of the glenoid or humeral head.

CONCLUSION: Bony defects of the humeral head or glenoid did not appear to result in a statistically significant increase in the risk of recurrence with conventional open techniques of stabilization. Large defects on either side of the joint were uncommon in the study population. Bone-block or grafting procedures do not appear to be necessary to restore stability in the majority of patients with bone loss. Although the loss of external rotation in patients with large defects is a relative cause for concern, the author recommends open capsular repair as the primary method of treatment given the high complication rate historically associated with bone-block techniques.

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