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
Case 2
Recurrent instability
- non recognised bony defect
- revised with Latarjet
