Injury, Int. J. Care Injured 44 (2013) 406–408

Editorial

First time traumatic anterior shoulder dislocation: A review of currentmanagement

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Injury

jo ur n al ho m epag e: ww w.els evier . c om / lo cat e/ in ju r y

The glenohumeral joint is the most frequently dislocated jointaccounting for 45% of all dislocations with an estimated annualincidence of 1.1 per 1000.1–3 The majority of patients are male intheir second or third decade, sustaining the injury during contactsports.4–6 Overall, 47% of dislocations occur in patients between 15and 25 years of age with a second peak of incidence occurring inthe elderly with low velocity falls.4 Despite its frequency, thetreatment of first-time (FT) anterior shoulder dislocation remainscontroversial both in the method and length of immobilisationafter reduction and also in the role of early surgical stabilisation.Currently in the United Kingdom 90% of cases are treated withimmobilisation in a sling in internal rotation (IR) for an average of 5weeks, however amongst enthusiasts there is a trend towardsoffering early arthroscopic stabilisation.7,8

Anterior shoulder dislocations usually occur with the arm in anabducted and externally rotated position and lead to predictablepatterns of injury to the labrum, capsuloligamentous structures,glenoid and humeral head. The Bankart lesion, an avulsion injury ofthe labrum with or without capsular injury inferior to the equatorof the glenoid, is the most common but other pathologies are seen.9

A lesion in which the anterior band of the inferior glenohumeralligament (IGHL), the labrum and the anterior scapular periosteumare displaced as a sleeve from the anterior scapular neck (anteriorlabral periosteal sleeve avulsion, the ALPSA lesion) was describedby Neviasier.10 Less commonly a humeral avulsion of theglenohumeral ligament (HAGL lesion) can occur.11 Completemid-substance tears of the capsule and IGHL also occur.12,13 ABankart lesion in itself is not sufficient to lead to recurrentinstability in pathological studies.14 Plastic deformation of theIGHL occurs either at the time of initial injury or during subsequentinstability episodes and it is the combination of the two that causesrecurrent instability.15–17 Glenoid rim fractures are reported in 4–22% of FT anterior dislocations, are generally small (<10% of the APdiameter of the glenoid) and may represent either a shear fractureor an avulsion fracture of the IGHL attachment.12,13,18–20 Loss ofbone from the anteroinferior glenoid decreases the arc of thearticular surface (therefore diminishing the distance that thehumeral head must translate prior to recurrent dislocation),decreases the articular surface area (thereby increasing contactpressures) and reduces the depth of the glenoid socket (thereforereducing the effectiveness of the concavity compression mecha-nism).21,22 The Hill–Sachs impression fracture of the poster-osuperolateral humeral head is reported to occur in 54–100% of FTanterior dislocations when the soft posterosuperolateral bone ofthe dislocated humeral head impacts on the hard anterior glenoid

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rim.12,13,18–20,23–26 These lesions have been classified according totheir size, depth and volume but more recently it has beensuggested that it is the orientation of the lesion and itscombination with glenoid bone loss that is more signifi-cant.25,27–29 Greater tuberosity fractures are seen in 16% of FTanterior dislocations and in contrast to capsulolabral injury areassociated with an older group of patients (mean age 60).30 In thesame series all fractures were displaced >1 cm prior to reduction.After reduction 42% were reduced, 58% were displaced <1 cm andnone were displaced >1 cm. Multiple authors have demonstratedthat greater tuberosity fractures are associated with a lower risk ofrecurrent instability.31–34 Therefore the indication for internalfixation of these fractures is based on the avoidance of cuffdysfunction and impingement, with residual displacement of 1 cmgenerally considered an indication for surgical intervention.35,36

Rotator cuff tears occur in 10% of FT anterior dislocations and,similarly to greater tuberosity fractures, occur in an older subgroupof patients.30 The size of the lesion is variable (14% <1 cm, 48% 1–3 cm, 25% 3–5 cm, 12% >5 cm). In the initial phase it can be difficultto clinically diagnose a rotator cuff tear due to pain. In patients over40 years of age, ongoing pain or weakness 3 weeks after adislocation has a 100% correlation with a full thickness tear,although 15% may be chronic or acute-on-chronic.30,37 If treatednon-operatively 100% will continue to be weak but only 33% haveongoing pain.37 Surgical intervention can be considered in thosepatients with an acute tear although this has no bearing onrecurrent instability rates. It may be reasonable to treat small tearsnon-operatively.38

Management after reduction traditionally involves immobilisa-tion in internal rotation (IR).

The typical length of immobilisation is 3–6 weeks but there is atrend towards shorter periods or no immobilisation atall.3,5,8,34,39,40 The safe position of IR avoids the typical instabilityposition of abduction and external rotation (ER) while conve-niently resting the arm close to the torso. There is mixed evidenceboth for and against immobilisation. Rowe and Kivoluto showedsome benefit from immobilisation up to 3 weeks after disloca-tion.34,41 In contrast, Hovelius did not show any reduction inrecurrent instability rates in a group randomised to immobilisationin a sling for 3–4 weeks compared to a group randomised tosymptomatic immobilisation only.31,39,42 Similarly other authorshave not demonstrated any positive effect.32,43,44 Analysingstudies in patients under 30 years of age it was concluded thatthere was no benefit to immobilisation for more than one week.45

It is recommended that older patients in particular should be

Editorial / Injury, Int. J. Care Injured 44 (2013) 406–408 407

immobilised for a short time to prevent stiffness.33,41 There isdebate whether the arm is immobilised in IR or ER. Cadavericstudies have suggested that ER keeps the capsule in contact withunderlying bone and this effect has since been documented withMR arthrography.46–48 A Cochrane review (2006) suggested therewas no difference in clinical outcome while more recent clinicalstudies have shown mixed results.49–52 Whatever the methodchosen there is a reported non-compliance rate of 20–47%.50,53

The risk of recurrent instability is 26–95% after non-operativetreatment.13,19,20,23,24,31,32,38,39,42,54,55 The wide range reflectspopulation differences between series and different lengths offollow up. Those studies with the highest recurrence rates haveincluded highly selected groups such as military cadets and contactathletes.13,19 The definition of recurrent instability varies withsome authors including symptomatic instability, clinical anteriorapprehension, subluxation, dislocation or multiple dislocations.Risk of recurrence is strongly correlated with age and sex, beinghighest amongst males in their early twenties or youn-ger.30,31,33,34,39,42 The sex difference is significant, with theprobability of redislocation within the first 2 years falling below50% in males age 27 and females at age 17.6 Recurrence rates alsocorrelate with time after the original injury. Hovelius showed arecurrence rate of 30% at 2 years rising to 49% at 25 years andRobinson reported 56% at 2 years increasing to 67% at 5 years (87%recurring in the first 2 years).6,31,39,42,56 Participation in contactsports and forced overhead activity increases the risk.6,57 As aresult of the high recurrence rate after non-operative treatmentnumerous authors have recommended surgical intervention.18–

20,23,24,26,57

It was postulated that arthroscopic lavage might decreasecapsular volume and allow better coaptation of the capsulolabralcomplex with the glenoid rim.18 Wintzell compared the results ofarthroscopic lavage with that of non-operative treatment. Recur-rence rates were significantly reduced at 2 years in those treatedwith lavage (20 vs 60%). Other authors have not shown such afavourable outcome with recurrence rates of 38–55% at 2 and 5years respectively.20,38

The typical Bankart lesion is usually treated by arthroscopicstabilisation using several anchors, which are inserted into theglenoid rim. The aim of soft tissue stabilisation is to restore thenative capsulolabral anatomy. Originally the emphasis was placedon creating a soft tissue bumper effect. However, since it has beenrecognised that plastic deformation of the IGHL occurs withdislocation, a re-tensioning of the inferior capsule has beenconsidered an essential step – which is performed by an inferior tosuperior and lateral to medial capsular shift. Several studies haveassessed the effect of arthroscopic surgery after FT anteriordislocation. Two prospective randomised controlled trials in youngpatients employing arthroscopic techniques have demonstrated alower recurrence rate with operative stabilisation (47–75%ongoing instability after nonoperative treatment vs 10–11% afterarthroscopic stabilisation).23,24 A Cochrane review concluded thatthere was a significantly decreased dislocation rate in young adultstreated by arthroscopic stabilisation.58 In a study of 88 patientsaged 15–35 randomised to arthroscopic washout alone orarthroscopic stabilisation, there was a significantly lower recur-rence rate in those treated by stabilisation (7% vs 38% at 2 years).20

Using the results of their own series, Robinson demonstratedthe need to treat 4.7 patients to eliminate one dislocation and 3.2for symptomatic instability; but in the high-risk group of males<28 years and females <17 years this falls to 2.6.20 Hoveliusestimated that if all FT dislocators of <25 years undergo surgerythen 30% will undergo unnecessary operations.56 It is difficult tocompare the relative costs of the two treatment options. Eachepisode of redislocation entails time off work or education andattendance at an emergency department with radiographs and

reduction under sedation. Functional outcomes are better inpatients treated operatively yet a full health economic analysis hasyet to be undertaken.6,20 Despite the potential benefits 19–56% ofpatients elect to pursue a wait-and-see policy.6,20,30,39,42,54,56

From the evidence reviewed, there is little benefit inimmobilisation of young patients in IR other than for symptomaticbenefit as redislocation rates remain high. Older patients should bemobilised early to avoid stiffness in the knowledge thatredislocation rates are low. They should be examined carefullyfor evidence of a rotator cuff tear once the acute pain has settled.The evidence for bracing in ER to reduce recurrent instability ratesis limited. The recurrence rate of instability can be reduced byarthroscopic stabilisation of the FT dislocator and early surgery,particularly in the younger patient who wishes to continue withhigh-risk activities such as contact, overhead and water-basedsports, should be considered. Patients should be counselled as totheir recurrence rates without surgery allowing them to make aninformed decision.6 It should be acknowledged that there is apossibility of spontaneous stabilisation even in those withrecurrent dislocations.6,56 Routine plain radiographs in threeplanes are recommended after reduction, and axial imaging eitherin form of CT or MRI arthrography if there is suspicion of glenoid orhumeral bone loss or rotator cuff tear.

Arthroscopic soft tissue stabilisation is performed in theabsence of major bone loss. When bone loss has occurred, defectson the humeral and glenoid sides are considered individually andin combination. A final decision on treatment may not be madeuntil the time of arthroscopic assessment. Loss of 15–20% of theanteroposterior diameter of the inferior glenoid is considered asignificant risk factor for recurrence 59,60,61. Rarely a large anteriorglenoid fragment may be fixed directly but it is more common thatglenoid rim fragments are of insufficient size to allow this. Optionsin this situation include a Latarjet procedure or other bone graftingtechniques.62–64 As evidence increases, the management of the FTdislocator should involve assessment by those with experience ofthe available operative techniques.

References

1. Saha AK. Dynamic stability of the glenohumeral joint. Acta Orthop Scand1971;42(6):491–505.

2. Kazar B, Relovszky E. Prognosis of primary dislocation of the shoulder. ActaOrthop Scand 1969;40(2):216–24.

3. Simonet WT, Melton 3rd LJ, Cofield RH, Ilstrup DM. Incidence of anteriorshoulder dislocation in Olmsted county, Minnesota. Clin Orthop Relat Res1984;186(186):186–91.

4. Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting toemergency departments in the United States. J Bone Joint Surg Am2010;92(3):542–9.

5. Robinson CM, Dobson RJ. Anterior instability of the shoulder after trauma. J BoneJoint Surg Br 2004;86(4):469–79.

6. Robinson CM, Howes J, Murdoch H, Will E, Graham C. Functional outcome andrisk of recurrent instability after primary traumatic anterior shoulder disloca-tion in young patients. J Bone Joint Surg Am 2006;88(11):2326–36.

7. Chong M, Karataglis D, Learmonth D. Survey of the management of acutetraumatic first-time anterior shoulder dislocation among trauma cliniciansin the UK. Ann R Coll Surg Engl 2006;88(5):454–8.

8. Malhotra A, Freudmann MS, Hay SM. Management of traumatic anteriorshoulder dislocation in the 17- to 25-year age group: a dramatic evolutionof practice. J Shoulder Elbow Surg 2012;21(4):545–53.

9. Bankart AS. Recurrent or habitual dislocation of the shoulder-joint. Br Med J1923;2(3285):1132–3.

10. Neviaser TJ. The anterior labroligamentous periosteal sleeve avulsion lesion: acause of anterior instability of the shoulder. Arthroscopy 1993;9(1):17–21.

11. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of the glenohumeral ligamentsas a cause of anterior shoulder instability. Arthroscopy 1995;11:600–7.

12. Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anteriorshoulder dislocations. Am J Sports Med 1990;18(1):25–8.

13. Taylor DC, Arciero RA. Pathologic changes associated with shoulder disloca-tions. Arthroscopic and physical examination findings in first-time, traumaticanterior dislocations. Am J Sports Med 1997;25(3):306–11.

14. Speer KP, Deng X, Borrero S, Torzilli PA, Altchek DA, Warren RF. Biomechanicalevaluation of a simulated bankart lesion. J Bone Joint Surg Am1994;76(12):1819–26.

Editorial / Injury, Int. J. Care Injured 44 (2013) 406–408408

15. Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC. Tensileproperties of the inferior glenohumeral ligament. J Orthop Res 1992;10(2):187–97.

16. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligamentcomplex in posttraumatic anterior shoulder instability: a prospective study. JShoulder Elbow Surg 1999;8(1):66–74.

17. Urayama M, Itoi E, Sashi R, Minagawa H, Sato K. Capsular elongation inshoulders with recurrent anterior dislocation. Quantitative assessment withmagnetic resonance arthrography. Am J Sports Med 2003;31(1):64–7.

18. Wintzell G, Haglund-Akerlind Y, Ekelund A, Sandstrom B, Hovelius L, Larsson S.Arthroscopic lavage reduced the recurrence rate following primary anteriorshoulder dislocation. A randomised multicentre study with 1-year follow-up.Knee Surg Sports Traumatol Arthrosc 1999;7(3):192–6.

19. Larrain MV, Montenegro HJ, Mauas DM, Collazo CC, Pavon F. Arthroscopicmanagement of traumatic anterior shoulder instability in collision athletes:analysis of 204 cases with a 4- to 9-year follow-up and results with the sutureanchor technique. Arthroscopy 2006;22(12):1283–9.

20. Robinson CM, Jenkins PJ, White TO, Ker A, Will E. Primary arthroscopic stabili-zation for a first-time anterior dislocation of the shoulder. A randomized,double-blind trial. J Bone Joint Surg Am 2008;90(4):708–21.

21. Beran MC, Donaldson CT, Bishop JY. Treatment of chronic glenoid defects in thesetting of recurrent anterior shoulder instability: a systematic review. J Shoul-der Elbow Surg 2010;19(5):769–80.

22. Piasecki DP, Verma NN, Romeo AA, Levine WN, Bach Jr BR, Provencher MT.Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosisand management. J Am Acad Orthop Surg 2009;17(8):482–93.

23. Kirkley A, Griffin S, Richards C, Miniaci A, Mohtadi N. Prospective randomizedclinical trial comparing the effectiveness of immediate arthroscopic stabiliza-tion versus immobilization and rehabilitation in first traumatic anterior dis-locations of the shoulder. Arthroscopy 1999;15(5):507–14.

24. Bottoni CR, Wilckens JH, DeBerardino TM, D’Alleyrand J-CG, Rooney RC, Harp-strite JK, Arciero RA, et al. A prospective, randomized evaluation of arthroscopicstabilization versus nonoperative treatment in patients with acute, traumatic,first-time shoulder dislocations. Am J Sports Med 2002;30(4):576–80.

25. Calandra J, Baker C, Uribe J. The incidence of Hill–Sachs lesions in initial anteriorshoulder dislocations. Arthroscopy 1989;5:254–7.

26. DeBerardino TM, Arciero RA, Taylor DC, Uhorchak JM. Prospective evaluation ofarthroscopic stabilization of acute, initial anterior shoulder dislocations inyoung athletes. Two- to five-year follow-up. Am J Sports Med2001;29(5):586–92.

27. Provencher MT, Frank RM, Leclere LE, Metzger PD, Ryu JJ, Bernardson A, RomeoAA, et al. The Hill–Sachs lesion: diagnosis, classification, and management. J AmAcad Orthop Surg 2012;20(4):242–52.

28. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and theirrelationship to failure of arthroscopic bankart repairs: significance of theinverted-pear glenoid and the humeral engaging Hill–Sachs lesion. Arthroscopy2000;16(7):677–94.

29. Yamamoto N, Itoi E, Abe H, Minagawa H, Seki N, Shimada Y, Okada K, et al.Contact between the glenoid and the humeral head in abduction, externalrotation, and horizontal extension: a new concept of glenoid track. J ShoulderElbow Surg 2007;16(5):649–56.

30. Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with traumaticanterior glenohumeral dislocations. J Bone Joint Surg Am 2012;94(1):18–26.

31. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primaryanterior dislocation of the shoulder in young patients. A ten-year prospectivestudy. J Bone Joint Surg Am 1996;78(11):1677–84.

32. Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G. Predictingrecurrence after primary anterior shoulder dislocation. Am J Sports Med2002;30(1):116–20.

33. McLaughlin HL, MacLellan DI. Recurrent anterior dislocation of the shoulder. II.A comparative study. J Trauma 1967;7(2):191–201.

34. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am 1956;38-

A:957–77.35. Flatow E, Cuomo F, Maday M, Miller SR, McIlveen SJ, Bigliani LU. Open reduction

and internal fixation of two-part displaced fractures of the greater tuberosity ofthe proximal part of the humerus. J Bone Joint Surg Am 1991;73-A:1213–8.

36. George MS. Fractures of the greater tuberosity of the humerus. J Am Acad OrthopSurg 2007;15(10):607–13.

37. Sonnabend DH. Treatment of primary anterior shoulder dislocation in patientsolder than 40 years of age. Conservative versus operative. Clin Orthop Relat Res1994;304:74–7.

38. te Slaa RL, Brand R, Marti RK. A prospective arthroscopic study of acute first-time anterior shoulder dislocation in the young: a five-year follow-up study. JShoulder Elbow Surg 2003;12(6):529–34.

39. Hovelius L. Anterior dislocation of the shoulder in teen-agers and young adults.Five-year prognosis. J Bone Joint Surg Am 1987;69(3):393–9.

40. Smith TO. Immobilisation following traumatic anterior glenohumeral jointdislocation: a literature review. Injury 2006;37(3):228–37.

41. Kiviluoto O, Pasila M, Jaroma H, Sundholm A. Immobilization after primarydislocation of the shoulder. Acta Orthop Scand 1980;51(6):915–9.

42. Hovelius L, Eriksson K, Fredin H, Hagberg G, Hussenius A, Lind B, Thorling J,Weckstrom J, et al. Recurrences after initial dislocation of the shoulder. Resultsof a prospective study of treatment. J Bone Joint Surg Am 1983;65(3):343–9.

43. Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anteriordislocation of the shoulder in children. J Bone Joint Surg Am 1992;74(8):1242–4.

44. Henry JH, Genung JA. Natural history of glenohumeral dislocation – revisited.Am J Sports Med 1982;10(3):135–7.

45. Paterson WH, Throckmorton TW, Koester M, Azar FM, Kuhn JE. Position andduration of immobilization after primary anterior shoulder dislocation: asystematic review and meta-analysis of the literature. J Bone Joint Surg Am2010;92(18):2924–33.

46. Itoi E, Hatakeyama Y, Urayama M, Pradhan RL, Kido T, Sato K. Position ofimmobilization after dislocation of the shoulder. A cadaveric study. J Bone JointSurg Am 1999;81(3):385–90.

47. Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I, Sato K. Position ofimmobilization after dislocation of the glenohumeral joint. A study with useof magnetic resonance imaging. J Bone Joint Surg Am 2001;83-A(5):661–7.

48. Miller BS, Sonnabend DH, Hatrick C, O’Leary S, Goldberg J, Harper W, Walsh WR,et al. Should acute anterior dislocations of the shoulder be immobilized inexternal rotation? A cadaveric study. J Shoulder Elbow Surg 2004;13(6):589–92.

49. Handoll HH, Hanchard NC, Goodchild L, Feary J. Conservative managementfollowing closed reduction of traumatic anterior dislocation of the shoulder.Cochrane Database Syst Rev 2006;(1):CD004962.

50. Itoi E, Hatakeyama Y, Sato T, Kido T, Minagawa H, Yamamoto N, Wakabayashi I,et al. Immobilization in external rotation after shoulder dislocation reduces therisk of recurrence. A randomized controlled trial. J Bone Joint Surg Am2007;89(10):2124–31.

51. Liavaag S, Brox JI, Pripp AH, Enger M, Soldal LA, Svenningsen S. Immobilizationin external rotation after primary shoulder dislocation did not reduce the risk ofrecurrence: a randomized controlled trial. J Bone Joint Surg Am2011;93(10):897–904.

52. Finestone A, Milgrom C, Radeva-Petrova DR, Rath E, Barchilon V, Beyth S, JaberS, Safran O, et al. Bracing in external rotation for traumatic anterior dislocationof the shoulder. J Bone Joint Surg Br 2009;91(7):918–21.

53. Itoi E, Hatakeyama Y, Kido T, Minagawa H, Wakabayashi I, Kobayashi M,et al. A new method of immobilization after traumatic anterior dislocationof the shoulder: a preliminary study. J Shoulder Elbow Surg 2003;12(5):413–5.

54. Sachs RA, Lin D, Stone ML, Paxton E, Kuney M. Can the need for future surgeryfor acute traumatic anterior shoulder dislocation be predicted? J Bone Joint SurgAm 2007;89(8):1665–74.

55. Jakobsen BW, Johannsen HV, Suder P, Sojbjerg JO. Primary repair versusconservative treatment of first-time traumatic anterior dislocation of theshoulder: a randomized study with 10-year follow-up. Arthroscopy2007;23(2):118–23.

56. Hovelius L, Olofsson A, Sandstrom B, Augustini B-G, Krantz L, Fredin H, TillanderB, Skoglund U, Salomonsson B, Nowak J, Sennerby U, et al. Nonoperativetreatment of primary anterior shoulder dislocation in patients forty years ofage and younger. A prospective twenty-five-year follow-up. J Bone Joint Surg Am2008;90(5):945–52.

57. Gooding BWT, Geoghegan JM, Manning PA. The management of acute trau-matic primary anterior shoulder dislocation in young adults. Shoulder Elbow2010;2:141–6.

58. Handoll HHG, Al-Maiyah MA. Surgical versus non-surgical treatment for acuteanterior shoulder dislocation. Cochrane Database Syst Rev 2010;(1):CD004325.

59. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect onanteroinferior stability of the shoulder after bankart repair: a cadaveric study. JBone Joint Surg Am 2000;82(1):35–46.

60. Bigliani LU, Newton PM, Steinmann SP, Connor PM, Mcllveen SJ. Glenoid rimlesions associated with recurrent anterior dislocation of the shoulder. Am JSports Med 1998;26(1):41–5.

61. Calvo E, Granizo JJ, Fernandez-Yruegas D. Criteria for arthroscopic treatment ofanterior instability of the shoulder: a prospective study. J Bone Joint Surg Br2005;87(5):677–83.

62. Sugaya H, Kon Y, Tsuchiya A. Arthroscopic repair of glenoid fractures usingsuture anchors. Arthroscopy 2005;21(5):635.

63. Millett PJ, Braun S. The ‘‘bony bankart bridge’’ procedure: a new arthroscopictechnique for reduction and internal fixation of a bony bankart lesion. Arthros-copy 2009;25(1):102–5.

64. Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C, Richards DP, et al.Results of modified Latarjet reconstruction in patients with anteroinferiorinstability and significant bone loss. Arthroscopy 2007;23:1033–41.

G.C.S. SmithT.J.S. Chesser*

I.N. PackhamM.A.A. Crowther

Frenchay Hospital, North Bristol NHS Trust, Bristol BS16 1LE, UK

*Corresponding authorE-mail address: tim.chesser@nbt.nhs.uk (T.J.S. Chesser)