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Introduction
  • TUBS (Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery)
  • Epidemiology
    • incidence
      • one of most common shoulder injuries 
      • 1.7% annual rate in general population
    • demographics
      • have a high recurrence rate that correlates with age at dislocation q
      • up to 80-90% in teenagers (90% chance for recurrence in age <20)
  • Pathophysiology
    • mechanism
      • anteriorly directed force on the arm when the shoulder is abducted and externally rotated  
    • "on-track" versus "off-track" concept (instability as a bipolar concept)
      • Hill-Sach's defect is "off-track" and will "engage" on the glenoid if size HS defect > glenoid articular track
      • conversely, Hill-Sach's defect is "on track" and will NOT "engage" if HS defect < glenoid articular track 
      • GT=0.83D-d (GT = Glenoid Track, D = diameter of inferior glenoid, d = width of anterior glenoid bone loss) 
      • may have implications regarding surgical management 
  • Associated injuries  
    • labral & cartilage injuries
      • Bankart lesion q q q
        • is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid.
        • is present in 80-90% of patients with TUBS
      • Humeral avulsion of the glenohumeral ligament (HAGL)  q q 
        • occurs in patients slightly older than those with Bankart lesions
        • associated with a higher recurrence rate if not recognized and repaired q
        • an indication for possible open surgical repair q
      • Glenoid labral articular defect (GLAD)
        • is a sheared off portion of articular cartilage along with the labrum
      • Anterior labral periosteal sleeve avulsion (ALPSA)
        • can cause torn labrum to heal medially along the medial glenoid neck
        • associated with higher failure rates following arthroscopic repair 
    • fractures & bone defects 
      • Bony Bankart lesion
        • is a fracture of the anterior inferior glenoid
        • present in up to 49% of patients with recurrent dislocations
        • higher risk of failure of arthroscopic treatment if not addressed
        • defect >20-25% is considered "critical bone loss" and is biomechanically highly unstable
          • stability cannot be restored with soft tissue stabilization alone (unacceptable >2/3 failure rate)
          • require bony procedure to restore bone loss (Latarjet-Bristow, other sources of autograft or allograft)
          • recent studies suggest critical bone loss may be as low as 13.5%
      • Hill Sachs defect  
        • is a chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim.
        • is present in 80% of traumatic dislocations and 25% of traumatic subluxations q
        • is not clinically significant unless it engages the glenoid
      • Greater tuberosity fracture
        • is associated with anterior dislocation in patients > 50 years of age
      • Lesser tuberosity fracture
        • is associated with posterior dislocations 
    • nerve injuries
      • Axillary nerve injury
        • is most often a transient neurapraxia of the axillary nerve q 
        • present in up to 5% of patients
    • rotator cuff tears 
      • 30% of TUBS patients > 40 years of age
      • 80% of TUBS patients > 60 years of age
Anatomy
  • Glenohumeral anatomy  
  • Static (bony anatomy, capsule, labrum, glenoid) and dynamic (rotator cuff, long head of biceps tendon) constraints
    • labrum contributes 50% of additional glenoid depth 
  • Anterior static shoulder stability is provided by 
    • Anterior band of IGHL (main restraint)
      • provides static restraint with arm in  90° of abduction and external rotation
    • MGHL
      • provides static restraint with arm in 45° oabduction and external rotation
    • SGHL
      • provides static restraint with arm at the side
Classification
 
Anteroposterior Translation Grading Scheme
Grade 0  • Normal glenohumeral translation
Grade 1+  • Humeral head translation up to glenoid rim
Grade 2+  • Humeral head translation over glenoid rim with spontaneous reduction once force withdrawn
Grade 3+  • Humeral head translation over glenoid rim with locking
 
Sulcus Test Grading Scheme
Grade 1  • Acromiohumeral interval <1cm
Grade 2  • Acromiohumeral interval 1-2cm
Grade 3  • Acromiohumeral interval >2cm
 
Instability Severity Score
Variable Parameter SCORE
AGE < 20 years 2
> 20 years 0
DEGREE OF SPORTS PARTICIPATION  Competitive 2
Recreational/none 0
TYPE OF SPORT PARTICIPATION  Contact/forced overhead 1
Other 0
SHOULDER HYPERLAXITY  Hyperlaxity (anterior/inferior) 1
Normal 0
HILL SACHS ON AP XRAY  Visible on external rotation 2
Not visible on external rotation 0
GLENOID  CONTOUR LOSS ON AP XRAY  Loss of contour 2
No lesion 0
Clinical Implications Total Possible = 10
An acceptable recurrence risk of 10% with arthroscopic stabilization. < 6 points
A score of > 6 points has an unacceptable recurrence risk of 70% and should be advised to undergo open surgery (i.e. Laterjet procedure). > 6 points
 
Presentation
  • Symptoms
    • traumatic event causing dislocation
    • feeling of instability
    • shoulder pain complaints
      • caused by subluxation and excessive translation of the humeral head on the glenoid
  • Physical exam topic
    • load and shift
      • Grade I - increased translation, no subluxation
      • Grade II - subluxation of humeral head to, but not over, glenoid rim
      • Grade III - dislocation of humeral head over glenoid rim
    • apprehension sign
      • patient supine with arm in 90/90 position
      • positive sign in mid-ranges of abduction is highly suggestive of concomitant glenoid bone loss 
    • relocation sign
      • decrease in apprehension with anterior force applied on shoulder
    • sulcus sign
      • tested with patient's arm at side
    • generalized ligamentous laxity
      • assess via Beighton's criteria
      • shoulder specific laxity defined as
        • hyperexternal rotation at side > 85 degress
        • hyperabduction > 120 degrees (Gagey's maneuver)
        • OR > 2+ load shift in 2 or more planes (anterior, posterior, inferior)
Imaging
  • Radiographs
    • see imaging of shoulder 
    • a complete trauma series needed for evaluation 
      • true AP
      • scapular Y
      • axillary
    • other helpful views
      • West Point view
        • shows glenoid bone loss
      • Stryker view
        • shows Hill-Sachs lesion
  • CT scan
    • helpful for evaluation of bony injuries
  • MRI  
    • best for visualization of labral tear
    • addition of intraarticular contrast 
      • increases sensitivity and specificity 
Treatment
  • Nonoperative
    • acute reduction, ± immobilization, followed by therapy
      • indications
        • management of first-time dislocators remains controversial
        • risk factors for re-dislocation are
          • age < 20 (highest risk)
          • male
          • contact sports
          • hyperlaxity
          • glenoid bone loss >20-25%
      • reduction
        • simple traction-countertraction is most commonly used
        • relaxation of patient with sedation or intraarticular lidocaine is essential
      • immobilization
        • some studies show immobilization in external rotation decreases recurrence rates
          • thought to reduce the anterior labrum to the glenoid leading to more anatomic healing
          • subsequent studies have refuted this finding and the initially published results have not been reproducible
      • physical therapy
        • strengthening of dynamic stabilizers (rotator cuff and periscapular musculature) 
  • Operative
    • Arthroscopic Bankart repair +/- capsular shift   
      • indications
        • relative indications
          • first-time traumatic shoulder dislocation with Bankart lesion confirmed by MRI in athlete younger than 25 years of age
          • high demand athletes
          • recurrent dislocation/subluxation (> one dislocation) following nonoperative management 
          • < 20-20% glenoid bone loss 
          • remplissage augmentation with arthroscopic Bankart may be considered if Hills-Sachs "off-track"
      • outcomes
        • results now equally efficacious as open repair with the advantage of less pain and greater motion preservation
    • Open Bankart repair +/- capsular shift
      • indications
        • Bankart lesion with glenoid bone loss < 20-25%  q q q 
        • revision stabilization following failed arthroscopic Bankart repair without glenoid bone loss >20%
        • humeral avulsion of the glenohumeral ligament (HAGL)
          • can also be performed arthroscopically but is technically challenging
    • Latarjet (coracoid transfer) and Bristow Procedures for glenoid bone loss  
      • indications
        • chronic bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid) 
        • transfer of coracoid bone with attached conjoined tendon and CA ligament 
        • Latarjet procedure performed more commonly than Bristow
        • Latarjet triple effect = bony (increases glenoid track), sling (conjoined tendon on top of subscapularis), capsule reconstruction (CA ligament)
    • Autograft (tricortical iliac crest) or allograft (iliac crest or distal tibia) for glenoid bone loss
      • indications
        • bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid) 
        • revision of failed latarjet
    • Remplissage technique for Hill Sachs defects
      • indication
        • engaging large (>25-40%) Hill-Sachs defect q
        • "off-track" Hill-Sachs lesions with <20-25% glenoid bone loss 
      • technique
        • posterior capsule and infraspinatus tendon sutured into the Hill-Sachs lesion
        • may be performed with concomitant Bankart repair
    • Bone graft reconstruction for Hill Sachs defects
      • indication
        • engaging large (>40%) Hill-Sachs lesions
      • technique
        • allograft reconstruction
        • arthroplasty
        • rotational osteotomy
    • Historical procedures: Putti-Platt / Magnuson-Stack / Boyd-Sisk
      • all procedures some variation of tightening subscapularis (advancment, plication, etc)
        • led to over-constraint and arthrosis
        • typical presentation of open procedure performed in 1970s-80s, now with presenting complaint of pain and stiffness from glenohumeral OA, especially lack of ER, and signigicant posterior glenoid wear and retroversion 
Techniques
  • Arthroscopic Bankart repair +/- capsular plication  
    • approach
      • shoulder arthroscopic approach 
    • technique
      • drive through sign might be present prior to labral repair and capsulorraphy
      • studies support use of ≥ 3 anchors (< 3 anchors is a risk factor for failure)
    • complications
      • recurrence, most often due to unrecognized glenoid bone loss or lack of concomitantly addressing "off-track" HS lesion 
      • stiffness, especially in external rotation, further loss of ER may occur with the addition of remplissage 
      • axillary nerve injury
      • chondrolysis (from use of thermal capsulorraphy which is no longer used)
  • Open Bankart repair +/- capsular shift
    • approach
      • shoulder anterior (deltopectoral) approach 
    • technique
      • subscapularis transverse split or tenotomy
      • open labral repair and capsulorraphy
    • complications
      • recurrence, most often due to unrecognized glenoid bone loss
      • stiffness, especially in external rotation
      • subscapularis injury or failed repair (if tenotomy performed for approach)
      • axillary nerve injury
  • Open Capsular shift
    • approach
      • shoulder anterior (deltopectoral) approach 
    • technique
      • inferior capsule is shifted superiorly
    • complications
      • subscapularis injury or failed repair
        • post-operative physical exam will show a positive lift off and excessive ER
      • overtightening of capsule
        • leads to loss of external rotation
        • treat with Z lengthening of subscapularis
      • axillary nerve injury
        • iatrogenic injury with surgery (avoid by abduction and ER of arm during procedure)
      • late arthritis
        • usually wear of posterior glenoid
        • may have internal rotation contracture
        • seen with Putti-Platt and Magnuson-Stack procedures
  • Latarjet and Bristow Procedure  
    • approach
      • shoulder anterior (deltopectoral) approach 
      • can be performed arthroscopically
    • technique
      • coracoid transfer to anterior inferior glenoid bone defect
      • traditional or congruent arc technique for coracoid graft placement
      • after harvest, coracoid is passed through a split in the distal 1/3 or middle 1/2 subscapularis
    • complications
      • generally higher than arthroscopic or open Bankart, some studies report up to 25% incidence 
      • nonunion
      • graft lysis
      • hardware problems
      • stiffness, particularly in external rotation 
      • glenohumeral osteoarthritis 
        • will rapidly occur with lateral overhang of graft into the joint space 
      • nerve injury
        • majority are traction or contusion neuropraxias and resolve spontaneously
          • treat with observation for 3-6 weeks; delayed EMG if deficits persist  
        • musculocutaneous and axillary nerves most common
  • Putti-Platt & Magnuson-Stack (historic)
    • approach
      • shoulder anterior (deltopectoral) approach 
    • technique
      • Putti-Platt is performed by lateral advancement of subscapularis and medial advancement of the shoulder capsule
      • Magnuson-Stack is performed with lateral advancement of subscapularis (lateral to bicipital groove and at times to greater tuberosity)
    • complications
      • both lead to decreased external rotation and loading on posterior glenoid
        • which leads to degenerative joint disease (capsulorrhaphy arthropathy)
  • Boyd-Sisk (historic)
    • technique
      • transfer of biceps laterally and posteriorly
    • complications
      • high rate of recurrence
Complications
  • Recurrence
    • often due to unrecognized glenoid bone loss treated with a soft tissue only procedure (especially with glenoid bone loss >20-25%)
    • can be due to poor surgical technique (ie, < 3 suture anchors)
    • increased risk with preoperative risk factors including age < 20, male sex, contact/collision sport, ligamentous laxity, and unrecognized glenoid and/or humeral head bone loss (critical bone loss or "off-track" lesion)
  • Shoulder pain
  • Nerve injury
    • musculocutaneous
    • axillary
  • Stiffness
    • especially in external rotation (particularly with Latarjet and additional remplissage)
  • Infection
  • Graft lysis (Latarjet)
  • Hardware complications
    • anchor pull-out (Bankart repair)
    • screw pull-out (Latarjet)
  • Chondrolysis
    • historically due to use of thermal capsulorraphy (now contraindicated) or intra-articular pain pumps (now contraindicated)
 

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