Revision Stabilisation

Causes for failure

 

1.  Patient factors

 

A.  Recurrent Trauma

- contact athletes higher risk

 

B.  MDI / Ligamentous Laxity / Voluntary dislocaters

 

C.  Poor rehabilitation

- poor motivation

- too rapid

- patients rarely get stiff, better to go very slow

 

2.  Surgeon Factors

 

A.  Unrecognised bony defect

- large bony bankart

- large engaging Hill Sachs

 

B.  Non Anatomical repair

 

C.  Poor sutures / poor knots / insufficient anchors

 

D. Unaddressed capsular laxity / Laxity RC interval / poor anterior labrum

 

E.  Posterior capsular tear / incorrect diagnosis / MDI

 

Management

 

Identify cause of recurrent instability

 

History

- traumatic or atraumatic

 

Examination

- MDI

 

CT

- large Hill Sachs

- large Bony Bankart

 

MRI

- assess anchor position

- reassess labral repair / integrity

 

Rehabilitation

 

Long period non operative

- best results if muscle control  and strength are optimal

 

Revision Options

 

1.  Revision arthroscopic stabilisation

 

Indications

- no bony defect

- poorly done original surgery

- traumatic redislocation

 

Technique

- repair labrum

- capsular plication

- +/- rotator interval closure

 

2.  Open stabilisation

 

Indications

- as above

 

3.  Laterjet

 

Indications

- bony defect

- large Hill Sachs

 

Results of revision surgery in those without bony defects

 

Arthroscopic revision post failed arthroscopic stabilisation

 

Franchesci et al Am J Sports Med 2008

- revision labral repair / capsular plication +/- rotator interval closure

- 1 failure

 

Arthroscopic revision post failed open stabilisation

 

Boileau et al Arthroscopy 2009

- 22 cases post Latarjet and open Bankart

- arthroscopic labral reattachment / capsular plication +/- rotator interval closure

- 1 recurrent subluxation and 2 with positive apprehension

 

Open revision

 

Levine et al Am J Sports Med 2000

- 49 shoulders treated with capsular shift +/- Bankart repair if needed

- all patients who had a traumatic redislocation had a good result

- only 67% of patients with atraumatic recurrent instability had a good results

 

Cases

 

Case 1

 

Recurrence of instability without trauma

- anchors very high

- into glenoid face

- MRI suggests remaining inferior bankart

- no bony deficiency, no HAGL

 

Failed Open Stabilisation APFailed Open Stabilisation LateralFailed Open Stabilisation CT AxialFailed Open Stabilisation CT Sagittal

 

Failed Open Stabilisation MRIFailed Open Stabilisation MRI 2

 

Case 2

 

Recurrent instability

- non recognised bony defect

- revised with Latarjet

 

Revison Shoulder Stabilisation CT Bony DefectRevision Shoulder Stabilisation Bony Defect 2Revision Stabilisation with Latarjet