History of surgical stabilization for posterior shoulder instability

Abstract

Background

Posterior shoulder instability is common in young athletes. Although the posterior shoulder instability literature is less robust than its anterior counterpart, many surgical procedures have been developed and refined over the past several centuries to address this condition.

Materials and methods

This article represents a retrospective historical analysis of the most common procedures used to treat posterior shoulder instability after sports injuries. A systematic approach to obtain published information on posterior shoulder instability was performed using the PubMed/MEDLINE database, manual searches of high–impact factor journals, and conference proceedings and books.

Results

A wide array of both soft tissue–based and bone-based procedures have been developed for the treatment of posterior shoulder instability, ranging from procedures addressing the soft tissue alone (capsular shift, labral repair, reverse Putti-Platt) or bone-based procedures (glenoid and/or humeral osteotomy, glenoid bone block) to a combination of both bone and soft-tissue procedures (modified McLaughlin procedure).

Discussion

Over the past several centuries, a number of procedures have been developed to address posterior shoulder instability, particularly as this pathology has become better understood. Future work is required not only to continue to advance these procedures but also to assess their outcomes. An understanding of the historical perspective of posterior shoulder instability procedures is essential as surgeons continue to modify these procedures in an effort to best help their patients.

Posterior shoulder instability represents an array of disorders, ranging from symptomatic subluxation (symptomatic, excessive translation of the humeral head on the glenoid) to multiple frank dislocation events.⁶⁶ Classically, posterior glenohumeral instability has been classified into acute or chronic, locked, and voluntary or involuntary.⁴ Posterior glenohumeral instability is an increasingly common condition, especially in young athletic male individuals, in whom it represents 10% of all instability events.⁵⁸ Isolated posterior shoulder instability has been recognized as a significant problem in contact athletes.^46,93 Posterior instability that develops owing to participation in sports represents another presentation within the spectrum of patients who present with posterior shoulder instability.² Although posterior instability has been found to occur commonly in young athletes, it remains underdiagnosed because of a lack of specific diagnostic criteria.^41,86 The relative rarity of posterior shoulder instability makes it difficult to create evidence-based guidelines or to establish the efficacy of newer treatment methods. The goal of this review was to present the history and evolution of the most prominent treatment options for posterior shoulder instability after sports injury with or without glenoid bone loss.

Materials and methods

A systematic review was conducted to identify as much published literature as possible that covers operative techniques to treat posterior shoulder instability. A comprehensive literature search was performed via a computer-based search of the online PubMed/MEDLINE database. The search was not limited by study design or language of publication and used broad terms to help maximize capture of the literature. Referenced articles were selected by examining the title and abstract obtained from the database search. Studies were included if they included outcome data of a procedure used to treat posterior shoulder instability. Other referenced articles and books were included if there was a description of a procedure that was used to treat posterior shoulder instability. Additional studies were identified by reviewing the reference lists and citations of included articles. Articles were not included in the references if they were non–English-language articles that could not be interpreted and if they did not specifically focus on the treatment of posterior shoulder instability (eg, articles that discussed treatment of multidirectional shoulder instability were excluded).

General history of posterior shoulder instability

The earliest documentation of shoulder dislocation is found in the Edwin Smith Papyrus (3000-2500 bce).⁹⁶ In 1741, White⁴⁵ reported a treatment for chronic posterior dislocations. Nearly 30 years later, in 1770, White published a general surgical book entitled Cases in Surgery, With Remarks.⁹² In 1 case, he described admitting a patient to treat a severe dislocation of the head of the humerus passing beyond the coracoid process and lying underneath the pectoral muscle. After multiple attempts at manipulation, White heard a snapping noise and concluded that the arm returned to its proper articulation.⁷⁹

In 1822, Cooper and Cooper¹² documented the first description of posterior shoulder dislocation. Cooper¹¹ later wrote a report describing the posterior dislocation event in a patient after a seizure. In this report, Cooper characterized in particular detail many of the symptoms associated with posterior dislocation, including impairment in external arm rotation and inability to elevate the arm from the side. This description hints at the first documentation of a reverse Hill-Sachs lesion (McLaughlin lesion), an impaction fracture of the anteromedial aspect of the humeral head following a posterior dislocation of the humerus.

Thirty-three years later, in 1855, Malgaigne⁴⁷ documented 37 cases (3 of his own and 34 reviewed from the literature) of posterior dislocation of the shoulder, highlighting the importance of performing a proper physical examination in making the correct diagnosis of posterior glenohumeral instability.

The first published cases of surgical treatment of posterior shoulder dislocation were published in the early 1980s by Tibone et al.⁸⁴ They performed a staple capsulorrhaphy in 10 athletes, but unfortunately, none of the patients were able to return to their previous sports status. Regarding sports injuries and posterior shoulder instability, recurrent posterior shoulder dislocation is less common than recurrent posterior subluxation. In athletes, posterior shoulder instability presents more as recurrent posterior subluxation rather than true dislocation.⁸³

Extracapsular bone block procedures—acromion and iliac crest: 1947

Use of the bone block procedure was originally described and performed by Rocher⁶⁸ in 1931 using a rib graft. In 1943, Ilfeld and Holder³⁶ proposed the use of a free iliac crest for patients in whom posterior capsule stabilization procedures had previously failed. Thirty-three years later, in 1976, Gosset modified this procedure to provide additional screw fixation of the graft in combination with the posterior capsule procedure proposed by Fronek et al.^10,21,26 This procedure, which involves a larger graft extending beyond the height of the glenoid, is termed the “Gosset bone block procedure.”

The first bone block procedure for the treatment of posterior shoulder instability was described by Hindenach³⁴ in 1947. Hindenach placed a bone block on the posterior glenoid to increase the posterior glenoid surface and improve stability (Fig. 1). Two years later, Fried²⁰ performed a posterior bone block procedure to successfully treat recurrent posterior dislocation by creating an extracapsular bone block along the posterior aspect of the glenoid. Fried noted recurrence due to resorption of the graft in 1 of 5 patients. Historically, extracapsular bone block procedures involved either an iliac bone block from the ipsilateral iliac crest or an acromial block with a pediculated deltoid flap.³ The original use of the acromial bone block was described by Kouvalchouk et al⁴⁰ with an attached deltoid to treat 5 patients with recurrent posterior glenohumeral instability.

Figure 1.

Drawing of glenoid (G) bone block (BB) (taken from acromion or iliac crest).

The literature reports several extracapsular iliac bone block techniques for treating posterior glenohumeral instability. Mowery et al⁵⁵ performed iliac bone block procedures using a horizontal approach through the scapular spine, retracting the deltoid caudally and passing between the infraspinatus and teres minor. Essadki et al¹⁷ conducted a retrospective review of 6 athletes who received a Gosset posterior iliac bone block. They noted that stability and pain relief were achieved in all 6 cases and that 3 patients achieved complete mobility. Barbier et al³ reported complications with the iliac bone block procedure: In 3 of 8 patients who underwent the procedure, reoperation was performed for persistent pain to remove osteosynthesis material. Furthermore, Sirveaux et al⁷⁶ reported placement of an intra-articular screw associated with osteoarthritis in a patient.

The predominant procedure for an acromial bone block is the acromial pediculated block as described by Kouvalchouk et al.⁴⁰ Scapinelli⁷⁰ proposed an adjustment to the acromial bone block by inverting the posterior border of the acromion, claiming that the posterior border of the acromion exerted a slight pressure over the supraspinatus muscle during posterior instability.

Sirveaux et al⁷⁶ divided 18 patients into 2 equal groups and used an iliac crest bone graft combined with either a soft-tissue procedure or an acromial pediculated bone block as originally described by Kouvalchouk et al.^25,40 Sirveaux et al conducted a retrospective review of these 18 patients and found no recurrent dislocation or subluxation events, although 6 patients described apprehension. In addition, 9 patients returned to sports, 7 patients were pain free, and 10 patients had moderate discomfort with effort. Sirveaux et al concluded that the results of the acromial bone procedure looked promising. Unfortunately, long-term clinical results after the use of iliac crest bone grafts as posterior bone blocks have historically been disappointing, with studies reporting high rates of patient dissatisfaction, inability to return to desired levels of activity, and glenohumeral arthritis.^{25,43,52,73,78}

McLaughlin procedure: 1952

In 1952, McLaughlin⁵⁰ performed a surgical technique, called the McLaughlin technique, to treat what is now known as a reverse Hill-Sachs lesion. McLaughlin was the first author to recognize the importance of an anterior humeral head bone defect (reverse Hill-Sachs, or McLaughlin, lesion) and its resulting effect on posterior shoulder instability. In the McLaughlin technique, the subscapularis tendon is transferred from the lesser tuberosity of the humerus to the bony defect. This procedure was subsequently modified by Hawkins et al³⁰ in 1987. This modification, which has grown in popularity, involves transfer of the subscapularis and lesser tuberosity into the defect (Fig. 2).³⁰ This procedure has shown effectiveness for chronic posterior shoulder dislocation.⁹ Hawkins et al noted that their modification of the McLaughlin procedure does not involve posterior soft-tissue repair, which simplifies the procedure and may involve less bleeding.⁷⁵

Figure 2.

Drawing of modified McLaughlin procedure: transfer of subscapularis (SS) and/or lesser tuberosity (LT) to McLaughlin lesion (ML). G, glenoid.

Reverse Putti-Platt procedure: 1953

The reverse Putti-Platt procedure was first described by Severin⁷⁴ in 1953. This procedure is a modification of the Putti-Platt procedure used to manage anterior shoulder instability.⁷⁴ The reverse Putti-Platt procedure involves sectioning of the infraspinatus tendon to imbricate the posterior rotator cuff–capsule complex in an effort to create a posterior block to dislocation. In 1984, Hawkins et al²⁷ reported that 6 of 9 patients who were treated with the reverse Putti-Platt procedure and biceps tendon transfer experienced recurrent posterior dislocation with a loss of internal rotation permanently to about 45°, limiting this procedure to historical relevance only.⁸⁰

Staple capsulorrhaphy: 1956

Du Toit and Roux,¹⁵ in 1956, introduced staple capsulorrhaphy, in which the detached capsule is secured to the glenoid using staples. Unfortunately, the first published case of surgical treatment of posterior shoulder dislocation was not promising. In 1981, Tibone et al⁸⁴ published the results of staple capsulorrhaphy in 10 athletes with posterior shoulder dislocation. They concluded that staple capsulorrhaphy is an ineffective procedure for posterior shoulder instability because of the high failure rate (no patients returned to their former throwing ability and 30% of patients experienced recurrent dislocation). Four years later, in 1985, Rao et al⁶⁴ performed Du Toit staple capsulorrhaphy in 65 patients followed up for an average period of 9 years. There was 1 dislocation, with 98% of surgical procedures rated excellent or good (94% excellent) with a 58% return-to-sport rate. In 1990, Tibone and Ting⁸² revisited staple capsulorrhaphy, now for recurrent posterior subluxation of the shoulder. Unfortunately, the results were again disappointing. They ultimately recommended against staple capsulorrhaphy for posterior subluxation owing to the high failure rate.

Glenoid osteotomy: 1967

Glenoid osteotomy was first performed by Scott⁷¹ in 1967 in a report of 3 patients with recurrent posterior dislocation. In 1984, Hawkins et al²⁹ advised against surgical reconstruction procedures, especially glenoid osteotomy, because of the high complication rates. In particular, they found a complication rate of 19% (5 of 26 shoulders) and a recurrence rate of 50% (13 of 26 shoulders) and noted that degenerative osteoarthritis was associated with posterior glenoid osteotomy. Since then, several reports have demonstrated the efficacy of glenoid osteotomy, although it is a technically demanding procedure.^7,23,63 Graichen et al²⁷ performed glenoid osteotomy in 32 patients with atraumatic posterior instability and found that 81% of the outcomes were rated good or excellent by the Constant-Murley and Rowe scores, with a 12.5% recurrence rate. Unfortunately, most published historical techniques using osteotomy procedures were performed prior to the routine use of computed tomography and magnetic resonance imaging and thus did not provide an assessment of glenoid morphology.

Capsular shift: 1980

In 1980, Neer and Foster⁵⁷ first described the inferior capsular shift procedure. This procedure aims to reduce capsular and ligamentous redundancy when Bankart repair has previously failed. In the original article, Neer and Foster treated 36 patients (40 shoulders) with only 1 instance of recurrence. This procedure has been performed and modified in numerous studies. Bigliani et al,⁴ in 1995, performed a superior shift of the posterior-inferior aspect of the capsule specifically for posterior glenohumeral subluxation and dislocation (Fig. 3). They found that 28 of 34 patients experienced good or excellent outcomes of the surgical procedure. Fuchs et al²² conducted a posterior-inferior capsular shift for recurrent posterior instability associated with voluntary subluxation in 26 shoulders. They found that the average relative score for shoulder function was 91% according to the system of Constant and Murley. Furthermore, more than half of all patients were able to perform all activities of the Simple Shoulder Test, although 8 patients still reported discomfort at night.

Figure 3.

Drawing of posterior-inferior capsular shift. The dashed line represents the initial incision into the deltoid (removed here for illustrative purposes) along a posterolateral raphe. The incision is limited to less than 5.0 centimeters to prevent damage to the underlying axillary nerve. The arrow is demonstrating the superior shift of the posteroinferior flap of the capsule in order to remove the inferior pouch and reinforce the repair. The capsule was initially split in a T-shaped fashion in the mid-glenoid region, which created two capsular flaps. The superior flap was shifted inferiorly and reattached to the lateral aspect of the humeral neck. A, acromion; HH, humeral head; PC, posterior-inferior capsule.

Humeral rotational osteotomy: 1985

In 1985, Vukov⁸⁷ was the first author to report a rotational osteotomy of the humerus in the English-language literature, which was used to treat chronic posterior dislocation. In 1994, Keppler et al³⁸ reported on 10 patients with locked posterior dislocation of the shoulder. They concluded that rotational osteotomy was an effective procedure at restoring glenohumeral congruity and restoring function in patients with locked posterior dislocation given 3 criteria: (1) healthy articular cartilage, (2) a humeral head defect involving less than 40% of the articular surface, and (3) a patient who is able to participate in an active rehabilitation program. Recently, Ziran and Nourbakhsh⁹⁷ performed proximal humeral de-rotational osteotomy for posterior shoulder dislocation in 4 children, following the procedure outlined by Keppler et al. They found that proximal de-rotational osteotomy for acute locked posterior dislocation of the shoulder can be viable for a younger age group since these patients did not have wound or neurologic complications or dislocations.

Other authors have reported complications with humeral rotational osteotomy procedures and 1 patient presented with avascular necrosis of the humeral head. Finally, Brooks-Hill et al⁸ reported a high complication rate after humeral rotational osteotomy, finding 25 complications in 19 shoulders, necessitating 9 reoperations in 7 shoulders. Some authors do not recommend this technique because of the degree of technical difficulty and high percentage of osteoarthritis progression.^66,88 Humeral rotational osteotomy remains an uncommon but powerful approach.⁸

Thermal capsulorrhaphy: 1995

In the early 1990s, thermal energy was pioneered to “shrink” rather than suture together elongated glenohumeral ligaments.¹⁸ This thermal energy comes in the form of laser or radiofrequency energy to heat the tissue to a specific temperature. During this procedure, tissue is heated to 65°C or higher to disrupt collagen cross-links and interfere with the triple-helix arrangement of collagen polypeptide chains, causing them to unwind and shorten.³³ Inflammation of the tissue results in synovial hyperplasia and fibroblast proliferation.¹

Thermal capsulorrhaphy (TCS) has been used for the treatment of shoulder instability since 1994 as an alternative to traditional open capsular shift procedures pioneered by Neer and Foster.⁵⁷ The first authors to report on the clinical results using thermal energy to treat shoulder instability were Thabit et al,⁸¹ in 1994. Prior to their report, little clinical information was known regarding the indications and outcomes of TCS.^56,72 Thabit et al used a holmium:YAG (yttrium-aluminum-garnet) laser-assisted capsular shift technique and achieved good or excellent results in the majority of patients (90% of 41 patients) at 6-month follow-up.

Despite this early success, TCS had higher long-term failure rates owing to rebound ligamentous stretching.⁶⁹ Furthermore, concerns were raised regarding its high initial maintenance costs and technical difficulties. To address the problems of laser-assisted TCS, monopolar-radiofrequency TCS was developed in 1996 and was promoted as having the advantages of the laser TCS technique but with more control.⁸⁵

Controversy remains regarding using TCS to treat the shoulder capsule, particularly with increasing reports of complications including higher-than-expected failure rates, axillary nerve injury, recurrent instability, iatrogenic cartilage injury, and capsular disruption.^{16,31,32,44,51,65,}89, 90, 91^,95

Labral repair: 1996

Labral detachment from the posterior glenoid (reverse Bankart lesion) was first associated with instability by Pappas et al⁵⁹ in 1983. In 1996, Hawkins and Janda²⁸ reported an open labral repair procedure for posterior shoulder subluxation. Of 14 patients, 13 were satisfied with the surgical procedures, and no patient had recurrence of posterior instability. Kim et al,³⁹ in 2003, described 27 cases of traumatic unidirectional recurrent posterior subluxation of the shoulder and performed arthroscopic labral repair and posterior capsular shift. They further pioneered the use of arthroscopic labral repair to treat posterior shoulder instability, which at the time was primarily treated using open labral repair.³⁸

One major advancement in the field of labral repair was the transition from using staples or bioabsorbable tacks to using suture anchors (Fig. 4). Arthroscopic labral repair using staples or bioabsorbable tacks led to complication rates as high as 30%, with hardware breakage and migration occurring frequently.^48,53 The rate of implant-related complications associated with staples and bioabsorbable tacks has declined dramatically since the transition to suture anchors.

Figure 4.

Arthroscopic posterior-inferior labral repair for posterior shoulder instability using 2 bioabsorbable knotless suture anchors and tape.

Bottoni et al⁵ performed arthroscopic stabilization of the posterior shoulder with bioabsorbable suture anchors in 19 patients and open repair in 14 patients with traumatic posterior shoulder instability due to collision and contact sports. They reported that the patients who received arthroscopic stabilization with bioabsorbable suture anchors had significantly better Western Ontario Shoulder Instability Index scores and Rowe scores than the patients in the open-procedure group. Furthermore, Bottoni et al noted that the arthroscopic technique using suture anchor repair with capsular plication led to the most favorable outcomes. Similar results were obtained in a meta-analysis performed by DeLong et al,¹³ in which arthroscopic stabilization procedures using suture anchors were found to result in fewer recurrences and revisions than anchorless repairs in young adults engaging in highly demanding physical activity. As a testament to the generalized success with arthroscopic labral repair and capsulorrhaphy, no known randomized controlled trials exist comparing these procedures with other surgical options (eg, open repair).

Intra-articular bone block: 2013

Intracapsular techniques for repairing posterior glenoid bone loss have been increasingly popularized in recent years. Glenoid bone loss is one of the most significant risk factors for recurrent injury after arthroscopic treatment of glenohumeral instability.^37,62 Despite the controversy surrounding the amount of bone loss that necessitates restoration, glenohumeral stability is compromised when bone loss exceeds 20% to 25%.^24,35 Currently, there is no consensus regarding the amount of posterior glenoid loss necessitating bony reconstruction, although it has been recommended that glenoid defects with greater than 25% bone loss of the width of the inferior glenoid (“inverted-pear glenoid”) be reconstructed to re-establish shoulder stability.^54,77

Unfortunately, bone block reconstruction fails to provide anatomic restoration of the glenoid articular surface; therefore, the articular surface of the glenohumeral joint remains incongruent.¹⁹ To address the development of early, symptomatic glenohumeral arthritis associated with extracapsular iliac crest bone graft as a posterior bone block, intracapsular techniques have been developed, such as the use of a distal tibial allograft, which provides an anatomic reconstruction of the glenoid cavity.¹⁹

In 2013, Millett et al⁵⁴ were the first authors to use a distal tibial osteoarticular allograft for the treatment of posterior shoulder instability. They performed an anatomic posterior glenoid reconstruction using a distal tibial allograft in 2 patients with a large posterior glenoid bone defect and concluded that this allograft could be used as a new treatment option for patients with recurrent posterior instability accompanied by significant posterior glenoid bone loss. Both patients returned to noncontact recreational sporting activities. In addition, in 2014, Frank et al¹⁹ found that using distal tibial allograft provided similar contact mechanisms to iliac crest bone graft at the time of surgery in cadaveric shoulders and supported posterior glenoid reconstruction with fresh distal tibial allograft as an alternative procedure to iliac crest bone graft.

Surgical stabilization of posterior shoulder instability due to sports injury with or without glenoid bone loss

The best outcomes in patients with posterior shoulder instability after sports injuries seem to occur with open or arthroscopic procedures to repair posterior labral pathology and capsulolabral reconstruction.⁶⁷ The current trend favors lesion-specific treatment, and this recent development has improved clinical results, especially when performed arthroscopically.⁶⁷ Arthroscopic repair of traumatic posterior shoulder instability is an effective way of eliminating symptoms of pain and instability in athletes.⁹³ The 1980s marked the advent of shoulder arthroscopy and assisted shoulder surgeons in identifying specific lesions that were associated with posterior shoulder instability. Although surgery can be performed through either an open or arthroscopic approach, the arthroscopic approach allows the surgeon to address intra-articular pathology in the same setting.² However, the first report of arthroscopic shoulder stabilization was not published until years later, in 1998.⁹⁴ Reported clinical outcomes after arthroscopic posterior shoulder stabilization are good to excellent, and to date, this approach has had the highest success rates for treating posterior shoulder instability after sports injury, at around 90%.^{13,42,46,49,60,61} In a study conducted by DiFelice et al,¹⁴ the results of arthroscopic capsulolabral reconstruction for the treatment of posterior shoulder instability were reported in 100 athletes and showed an 89% success rate, with 67% of patients being able to return to the same level of play postoperatively. Furthermore, in one of the largest prospective studies to date on posterior shoulder instability due to sports injury, Bradley et al⁶ performed arthroscopic capsulolabral reconstruction in 188 athletes and found that 94% of patients were satisfied with the results and 90% returned to contact sports, with 64% returning to the same level of play. Another study found that for traumatic posterior shoulder subluxation, surgical treatment with both open and arthroscopic procedures provided satisfactory results; however, the arthroscopic technique using suture anchor repair with capsular plication provided the most favorable outcomes.⁵

Conclusion

A wide array of both soft tissue–based and bone-based procedures have been developed for the treatment of posterior shoulder instability, ranging from procedures addressing the soft tissue alone (capsular shift, labral repair, reverse Putti-Platt) and bone-based procedures (glenoid and/or humeral osteotomy, glenoid bone block) to a combination of both bone and soft-tissue procedures (modified McLaughlin procedure). Each of the procedures should be considered in the correct historical perspective and chosen based on an individualized approach regarding patient selection. Although arthroscopic labral repair as well as capsulorrhaphy is the currently favored approach to posterior instability, shoulder surgeons should be aware of the individual treatment options for posterior shoulder instability and how those options have evolved over time. Over the past several centuries, a number of procedures have been developed to address posterior shoulder instability, particularly as this pathology has become better understood. More recently, the advent of arthroscopic repair has led to increased interest in treating posterior instability after sports injury with or without glenoid bone loss without the morbidity of open surgery. The current trend for treating posterior shoulder instability from sports injuries favors lesion-specific treatment, and improved clinical outcomes are seen especially with arthroscopic repair. Ultimately, future work is required not only to continue to advance these procedures but also to assess their outcomes.

Disclaimer

Brett Owens is a consultant for Mitek, ConMed, Musculoskeletal Transplant Foundation, and Vericel and receives royalties from ConMed.

The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.