OKOJ, Volume 6, No. 10

Shoulder instability is a pathologic increase in translation of the humeral head on the glenoid fossa during shoulder range of motion, resulting in symptoms. In recurrent anterior shoulder instability, the underlying pathology typically involves compromise of the capsulolabral attachment of the inferior glenohumeral ligament. However, bone loss from either the glenoid rim or posterolateral humeral head can also occur, which can adversely affect traditional treatment. Even in the hands of experts, an unrecognized or neglected bony defect is the primary reason for failure after arthroscopic management of shoulder instability. Anatomic glenoid reconstruction with autogenous tricortical iliac crest bone graft is warranted when there is greater than 30% loss of inferior glenoid length. Latarjet reconstruction (coracoid transfer) is indicated for bone loss that involves 25% to 30% of inferior glenoid length, especially after failed stabilization, or for humeral Hill-Sachs lesions that engage the anterior glenoid rim when the arm is in a position of abduction and external rotation. Arthroscopic repair can be performed for patients with small osseous lesions (less than 20% bone loss).

Multidirectional shoulder instability (MDI) is a challenging entity for the clinician to treat. The presenting complaint may range from pain to episodes of subluxation or dislocation in the affected shoulder. There is often no history of major trauma or only minor trauma. Athletes involved in repetitive overhead activities are often affected, as are patients with generalized ligamentous laxity. The mainstay of treatment of MDI is conservative, with a focus on physical therapy. Patients whose symptoms are refractory to conservative measures may benefit from surgical treatment. Traditionally, MDI has been treated with an open capsular shift. More recent reports have described successful arthroscopic capsular plication techniques. This article reviews the diagnosis and treatment options for MDI, and the technique of arthroscopic capsular plication is reviewed in detail.

Vacuum-assisted closure (VAC) is a therapy that involves the application of controlled levels of negative pressure to a specialized wound dressing to promote or assist wound healing. Its mode of action is thought to derive from mechanical strain imposed on the cells and mechanisms analogous to Ilizarovian distraction and/or by the active evacuation of excess interstitial edema and its contained proinflammatory cytokines, particulate debris, and bacteria. In addition, it has recently been shown that VAC therapy can be used to accelerate and improve the extent of incorporation of native cells into bioartificial dermal matrices, such as Integra. This approach has shown some promising results in early reports and may prompt the future development of new strategies for wound coverage with unique advantages for patients.