Introduction: The biomechanics of the shoulder joint are complex. To allow a functional range of motion, stability is sacrificed. Glenohumeral joint stability is maintained by static and dynamic stabilizers. Static stabilizers are non-contractile structures including capsulolabral structures and bony glenoid while dynamic stabilizers are contractile structures including rotator cuff, conjoint tendon, and long head of the bicep. The objective of this review is to elaborate on multidirectional instability (MDI) of the shoulder joint and the management of this disorder. Review: Laxity can be affected by hereditary and genetic factors. This can be seen for example in generalized joint laxity which often manifests in the shoulder as MDI. Mutations in collagen genes can cause altered collagen structure, mostly in collagen Type I, resulting in smaller and longer collagen cells. Abnormalities could be found in mRNA synthesis or amino acid transcription for collagen protein, resulting in amino acid content variation. Alterations in fine-tuning mechanism, cleavage process, ionic interaction, cross-linking and metabolism could also result in collagen quality variation. Genetic factors could also cause elastin overproduction rate or amount. Elastin amino acid content alterations could also be affected genetically. These alterations produced a looser static stabilizer. Even so, shoulder joint have multiple static stabilizers and the individual having hereditary laxity does not always have problems related to joint laxity. If the laxity caused problems, it is usually in the form of pain, discomfort, or disruption in shoulder joint function. To compensate for the loose static stabilizer, rehabilitation should be optimized on the contractile, musculature structure of the glenohumeral joint. Besides rehabilitation, capsular shift procedure could also be performed as management of the affected joint by open surgery, arthroscopic capsular plication, or arthroscopic thermal capsulorrhaphy. Conclusion: Based on the review conducted, reoperation rates for open surgery, arthroscopic technique, and thermal technique were approximately 10%, 5%, and 15% subsequently. This should be considered when choosing the appropriate surgery method for MDI management if rehabilitation on contractile structures does not improve patients’ condition.
Introduction: Labrum is a static stabilitator of the glenohumeral joint. Tear to this fibrocartilaginous structure could cause shoulder instability. Lately, anterior detachment of labrum is known as a contributor to recurrent anterior instability. Anterior labrum detachments are the classic Bankart lesion. Bankart lesion involving avulsion fracture is known as bony Bankart lesion. Management for this lesion is done operatively by doing antomical repair to return rigidity to its original state. Bankart repairs were originally done openly with coracoid osteotomy and subscapularis tenotomy. Currently, arthroscopic Bankart repair is often used as the preferred surgical management. Variations of portal placements, suture placements, suture technique and other components of Bankart repair can be found today, giving options for surgeons to achieve optimal results. Surgical Technique: In athletes, bony Bankart lesion, as an intraarticular lesion with displaced labrum and avulsion causing instability, is an absolute indication for surgical intervention to ensure function return. Nonoperative treatments have been reported on small bony Bankart lesions, but outcome on follow-up showed 25% recurrent instability. We performed arthroscopic bony Brankart repair by implementing labral repair, intraosesus tunneling and double-row suture bridge techniques. First, landmarks of incisions and portals were made. Incisions for visualisation were then done. Anterior portal and posterior portal were established before identifying bony Bankart lesion. A 5 o’ clock, trans subscapularis portal was then created. We released the bony Bankart and curatage the margin. A 6 o’clock stitch was anchored through rigid suture passage (drilled bone tunnel) in 5 o’clock direction. A 4.30 o’clock stitch was anchored in a 4 o’clock suture passage. The last stitch was a 3 o’clock stitch anchored through a 3 o’clock passage. Soft tissue release was conducted until subscapularis fibers were exposed. In the remodelling process, we performed overcorrection repair. Modifications done to the Bankart repair in this paper were done to achieve excellent post-op anterior stabilization.
Introduction: Acromioclavicular (AC) joint separations account for 12% of all shoulder injuries. People doing high-energy physical activities such as athletes are at risk for AC joint separation. The mechanism of injury could be direct or indirect. Direct mechanism involves a direct blow to the AC and coracoclavicular (CC) ligaments. Indirect mechanism happens when the injury force hits the AC joint indirectly, involving axial compression, as seen in a fall with an extended arm, where caput humeri is pressed against the acromion. The purpose of this paper is to elaborate on AC joint problems in athletes by reviewing literatures. Review: Patients with AC joint injury will exert complaints of pain and be unwilling to lift the affected arm, implying mobility function impairment. Signs such as skin abrasions and bruises can be found during inspection. A prominent distal clavicle is a pathognomonic sign of dislocation of the AC joint. A well-known classification for AC joint separations, Rockwood classification, divides the separations into six types. The classification helps determine different managements and prognoses for each of the AC joint separation types. Athletes should be treated in consideration of their position in the sports season. For athletes in season, pain should be treated as the priority. Absolute indications for surgical management are then identified to help determine the athlete’s return-to-play capability. For out-of-season athletes with AC injury, look for absolute or relative indications for operative management. If there is no indication, plan for rehabilitation. But if there are some indications, either absolute or relative, plan for surgery immediately. Complaints of pain and functional disabilities such as motion should be carefully assessed and managed. To determine suitable management, the injury should be classified properly. Type I and II injuries are treated with nonsurgical management. For type IV and VI injuries, surgical intervention is needed. AC joint separation Rockwood type III and V both had complete AC and CC ligament tear but repair is adequate for acute type III AC injury while reconstruction is needed for type V AC injury. Conclusion: AC joint separations should be treated as joints, not as bones where compressions are applied therefore limiting movements. Repair and reconstruction indications should be properly assessed on patients to ensure functions returned to their pre-injury state which is important for athletes’ return to sports.
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