Repetitions of the instability of the shoulder after “”

The techniques of stabilization of the shoulder are currently well codified: the majority of the surgeons use anchors with joinings to reintegrate the and to retighten the capsular hammock   antéro-inferior. However, the repetition of instability represents still today the main complication of former stabilizations of the shoulder under . A careful and extensive analysis of the literature showed us that even with the technical projections most recent, the rate of recurrence of instability after stabilization varies between 10 and 30% (Hobby et al., Br 2007). After having developed a standardized and reproducible technique, we evaluated ourself and brought back our results after stabilization of the shoulder  : we found a rate of recurrence of 15% with two years the minimum retreat. (, Am 2006). Even if this rate appears acceptable, one should not be satisfied some because it is known that the repetitions of instability are related to the retreat and that they increase inevitably with time.

These results translate well fact that, even if a surgeon has a technique of stabilization of the well codified shoulder and even if it achieved its phase of training, it cannot propose (unless being unconscious or dishonest person) a “” with all the patients whom it sees in consultation under penalty of exposing a certain number of them to a failure by repetition of former instability. A preoperative selection of the patients is thus necessary. The question is: how to select the patients candidates for and to eliminate those which will not profit from this technique during the preoperative consultation?

scope #D1FFFF Scope? … tea question! (Doctor #D1FFFF Doctor? …)

In a a little diagrammatic and humorous way, one can say that the surgeons confronted with the reality of the repetitions of instability of the shoulder after “” are divided into three groups:

•  Those which make “the ostriches” and put the head in sand not to see reality and to deny these repetitions. These (“young people”, “kamikazes”, “”, with the choice…) swear only by their “superb technique of ”.  The question which arises for them is then: why do they change of technique every six months or every two years  ? …. especially if it is so well, this technique…

•  Those which make “the beavers” and establish solids barrages to dam up the flood of the novel methods and implement to all the patients “the receipt which goes”. These (“”, “the unadventurous ones”, “conservatives”, with the choice…) swear only by the only reliable technique and which proved reliable: stop with open sky. The question which arises for them is then: why not make profit with certain patients techniques? … especially if they allow a complete intra-articular diagnosis and especially when they go? …

•  Lastly, there are those which make “the monkeys” and are balanced between “the shaft thrust and that of ”… These alternate the techniques according to time, of their enthusiasm or more or less subjective criteria (return of congress, square pulse available to the surgical unit,…). More seriously, they try to choose “the good patient for ” according to objective criteria but which are difficult to determine, basing itself on examinations para-private clinics sophisticated, expensive and which take time: to scan, , MRI, arthro-MRI… Especially this last group of surgeons remains perplexed in front of the multiplicity of the mailmen of repetition reported in the literature: practically no patient could be operated by if the whole of the potential mailmen of repetition were taken into account at the time of the indication…

After having been ourselves, in turn, “ostrich”, “beaver” and “monkey”… we went in the search of a new animal specie, “”, only animal able to choose between obstinate and … able to choose its prey (the shoulder) with understanding to stabilize it with all the blows with the adapted technique! …

Comparative clinical study (Box Control Study - & Br 2007)

We put forth the assumption that the risk factors of repetition of instability after were present and identifiable as of the preoperative consultation thanks to the interrogation, a standardized clinical exam and radiographies of the shoulder of face and profile.

A retrospective clinical study enabled us to compare two patient groups after stabilization of the shoulder according to the technique of with anchors and joinings: a group forwarding a failure with repetition of luxation or the subluxation and another group constituting a success with absence of repetition of instability. Hundred thirty and one consecutive patients with a traumatic former instability, repeating of the shoulder were operated by “” and follow-ups. Nineteen patients forwarded a repetition of the instability former (14,5%) to the average retreat nths (24-nth). It is important to note that the technique was proposed with all the patients during the study period. The patients were informed of the two surgical possibilities to stabilize the shoulder by “obstinate with open sky” or “”. The advantages and the disadvantages of each technique were exposed, including the fact that the limits of the technique were not yet clearly established. We have excluded from study instabilities, the already operated shoulders, those forwarding of the lesions cap of the rotators and the patients preferring a conventional technique of butted to open sky. An statistical analysis was carried out to identify the risk factors of repetition clinical and radiological, detectable at the time of the preoperative inspection then we integrated these mailmen in a score of severity.

We identified six risk factors significantly associated with an increase in rate of recurrence while basing ourselves on a preoperative questionnaire, a standardized physical exam and a standard radiography of the shoulder

On the questionnaire, the age < 20 years, the practice of a sport contact or with army-countered, as well as the practice in competition were risk factors.

With the clinical exam, a was also associated with a repetition of instability. It could be a question of a former with an external rotation bends with the body >85°, according to the criteria of the (Figure 1) or of a lower with a test of asymmetrical and >20°, according to our criteria (Figure 2).

On the radiography of the shoulder of face, two mailmen translating of the losses of bone substance were found as being associated with a repetition of antéro-lower instability  : a visible lesion of higher on the radiograph in external rotation and an edge blunted (loss of contour ). 

The fact that the lesion of is present on a radiograph of face in external rotation implies that it is localized or that it extends to the high party of the humeral head (Figure 3).

The evaluation of is difficult on radiographies of face and it was postulated that the loss of the sclerotic edging to the lower margin of represented a significant erosion lower, i.e. a loss of bone substance (Figure 4).

These six risk factors then were integrated in a score of 10 points, score ( Index Score) and were retrospectively tested on the same population. The value of each mailman in this score was allotted according to the statistical significance found in the study (Table I).

The score of the patients having forwarded a repetition of instability was equal on average to 5.3 points, whereas that of those not having forwarded any repetition was equal on average a score to 2.7 points .

The risk of recurrence after “” was then evaluated according to the number of points obtained with this score (Table II).  The patients forwarding a score >6 points had a nonacceptable risk of recurrence of instability of 70% ; they must imperatively be excluded from the technique of isolated . The patients with a score <3 points had a risk equalizes to 5%, completely acceptable and comparable with that of butted with open sky.  Between 4 and 6 points, the risk is acceptable but there remains higher than that of the stop.

Figure 1: External rotation higher than 85° elbow with the body is regarded as a sign of former .

Figure 2: A differential of 20° between the two east coasts regarded as a sign of lower (= severe distension of the lower crucible ). To note that the front armlever of the inspector is posed on the lateral margin of the ; on the level of the normal shoulder, the two front armlevers (that of the patient and that of the inspector) are practically .

Figure 4: Lesions of on the radiography of face of the shoulder normal (pointed) of the lower margin of ; fracture-avulsion; of lower contour (= loss of lower substance of )

Score , an aid with “Recycling”

Score is intended to help the surgeons to select the patients for a technique of “” and to eliminate those for which this technique, made in an isolated way, will be insufficient to stabilize the shoulder in the event of chronic former instability. This score has the advantage of being simple to retain and use and of being able to be established as of the first consultation: we deliberately included in this score only of the clinical signs and radiological detectable into preoperative. The risk factors included in the score reflect the usual questionnaire, the usual physical exam and radiographies of standard face that any csotcina.comedic surgeon made during his preoperative consultation. The score was not made to be based on special tests or sophisticated and expensive imaging methods. It was conceived to have a simple and rational approach of the selection of the patients for whom could be considered.

Score does not make it possible to lay down rules absolutes; it is only about one indicator which makes it possible to make a first “recycling” of the patients. It forwards without any doubt of the insufficiencies. The participation in sports at the risk, for example, was underestimated at the time of our study: certain patients had stopped the sport into preoperative or had changed sport… whereas they renewed sports at the risk (with arm-countered or contact) after the intervention. For the interrogation, it would thus be necessary to attempt to determine the practice of a sport at the risk into preoperative but also the desire to take again a sport at the risk or in competition into postoperative to integrate these data in the score. The bone lesions were only evaluated on radiographies of the shoulder of face. These observations were not correlated with those found with the scanner or the MRI. Although more specific radiographies were proposed to detect the lesions of the (, ), they are difficult to obtain in practice clinical and we did not retain them voluntarily in the score.

In short, score is a simple predictive score, based on the preoperative information, easily collected at the time of the interrogation of the patient, his preoperative physical exam and radiographies of the shoulder, of face in three rotations (RN, IH, RE) that any surgeon asks in routine. This score makes it possible to the surgeon to make a first “recycling” of the patients profit from a stabilization of the shoulder:

•  the patients whose score >6 points have an unacceptable risk of recurrence (=70% of repetition); this value threshold thus constitutes a formal counter-indication in .

•  a score ranging between 4 and 6 points represents a counter-indication relating to with a rate of recurrence equal to 10% with nths the average retreat, rate higher than that of the stop.

•  If one wants to propose to the patients a risk equivalent to that of butted with open sky (i.e. a rate of recurrence <5%), he is necessary to be directed towards a score .

Our Current Indications in Chronic Instability: “The Menu with the Card”
(Table III)

Schematically, the ideal candidate for a “” is a patient of more than 20 years which does not practice a sport at the risk (contact or arm-countered), nor competition, is not and does not forward losses of bone substance humeral visible on simple radiographies of face; its score is logically lower than 3.

If score is equal to or higher than 4, isolated is contra-indicated or in any case, insufficient. One can in this case, to make a stop of the type to everyone… one is sure not to be mistaken much.

For our part, we discuss all the unstable patients under and prefer to choose the procedure according to the anatomo-pathological lesions met. To the systematic “”, is added complementary gestures adapted to the lesions of each patient:

•  in the event of loss of bone substance isolated from or mixed ( + humerus)
= “conventional” Stop of type (through the )

•  in the event of loss of bone substance isolated from the humerus
= Hill-Sachs-Filling (or Butted of type)

•  in the event of or of defective, lossless capsule of bone substance
= Butée of the type (above the ) for its “negotiable instrument straps”.

Some Aphorisms To finish