Clinical significance of the arthroscopic drive-through sign in shoulder surgery

doi:10.1053/jars.2001.19967

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 17, Issue 1, January 2001, Pages 38-43

https://doi.org/10.1053/jars.2001.19967 Get rights and content

Abstract

Purpose: During arthroscopy of the shoulder, the ability to pass the arthroscope easily between the humeral head and the glenoid at the level of the anterior band of the inferior glenohumeral ligament is considered a positive drive-through sign. The drive-through sign has been considered diagnostic of shoulder instability and has been associated with shoulder laxity and with SLAP lesions. The goal of this study was to examine the prevalence of the drive-through sign in patients undergoing shoulder arthroscopy and to determine its relationship to shoulder instability, shoulder laxity, and to SLAP lesions. Type of Study: Case series. Methods: We prospectively studied 339 patients undergoing arthroscopy of the shoulder for a variety of diagnosis from 1992 to 1998. The drive-through sign was performed with the patients in a lateral decubitus position and under general anesthesia. The drive-through sign was correlated with preoperative physical findings, intraoperative laxity testing, and with intra-articular pathology at the time of arthroscopy. Results: The arthroscopic evaluation showed that drive-through sign was positive in 234 (69%) shoulders. For the diagnosis of instability, the drive-through sign had a sensitivity of 92%, a specificity of 37.6%, a positive predictive value of 29.9%, a negative predictive value of 94.2%, and an overall accuracy of 49%. There was an association between the drive-through sign and increasing shoulder laxity, but not with SLAP lesions. Conclusions: This study shows that a positive drive-through sign is not specific for shoulder instability but is associated with shoulder laxity. This arthroscopic sign should be incorporated with other factors when considering the diagnosis of instability.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 38–43

Section snippets

Methods

Between 1992 and 1998, 349 patients who underwent diagnostic arthroscopy of the shoulder were prospectively entered into this study. There were 10 patients in whom the drive-through sign was not documented or not performed, so 339 patients were included in the analysis. In all patients, a thorough preoperative physical examination was performed that included range of motion of the affected and unaffected shoulders, instability tests, impingement signs, and a neurologic examination.

All patients

Results

There were 186 male patients (53%) and 163 female patients (47%) with a average age of 43 years (range, 12 to 86 years). The final diagnosis was instability in 76, impingement or partial rotator cuff tear in 91, full-thickness rotator cuff tear in 80, frozen shoulder or adhesive capsulitis in 27, and “other” in 65 patients (acromioclavicular pathology, synovial cysts, osteoarthritis, rheumatoid arthritis, and avascular necrosis). In patients with more than 1 diagnosis, the more symptomatic

Discussion

This study shows that the drive-through sign is associated with shoulder laxity but not with SLAP lesions. Although most shoulders with instability had a positive drive-through sign, the presence of a positive sign did not rule in that diagnosis. The drive-through sign is very sensitive for the diagnosis of instability and it rarely will be absent if instability is present. However, the lack of specificity of the sign does not allow one to conclude that the presence of a drive-through sign

Acknowledgements

Acknowledgment: The authors thank Mrs. Carie Johnson for invaluable assistance with this project.

References (19)

AA. Answorth
Clinical evaluation of the unstable shoulder
JH Hawkins et al.
Clinical evaluation of shoulder problems
WJ Mallon et al.
Multidirectional instability: Current Concepts
J Shoulder Elbow Surg
(1995)
EG McFarland et al.
Clinical and diagnostic evaluation of anterior shoulder instability, impingement and rotator cuff tears
CS Neer
Dislocations.
CS Neer et al.
Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A Preliminary report
J Bone Joint Surg Am
(1980)
JF Silliman et al.
Classification and physical diagnosis of instability of the shoulder
Clin Orthop
(1993)
FA Cordasco et al.
Management of multidirectional instability
Oper Tech Sports Med
(1993)
R. Foster
Multidirectional instability of the shoulder in the athlete
Clin Sports Med
(1983)

There are more references available in the full text version of this article.

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Citation Excerpt :
The anterior capsule appears patulous, and there is a positive drive-through sign, meaning that the arthroscope can easily pass between the humeral head and the glenoid at the level of the anterior band of the IGHL. This sign has a 92% sensitivity and 38% specificity for instability, though the increased anterior humeral head translation and posterosuperior impingement can also usually be directly visualized during the diagnostic arthroscopy.12 Most athletes with microinstability undergo a trial of nonoperative treatment, consisting of targeted exercises to rebalance and stabilize the glenohumeral joint.
Throwers, particularly baseball players, are dependent on a delicate balance of shoulder mobility and stability to excel at their sport. Disruptions to this balance can lead to a number of different types of anterior shoulder instability: microinstability, acute atraumatic instability and traumatic instability. Pathologic microinstability can develop over time in a pitcher, as repetative throwing (ie extreme external rotation in abduction) causes stretch to the joint capsule anteriorly and impingement posteriorly. The resultant anterior or posterior shoulder pain can affect pitch velocity and control. Over time, the anterior capsule and ligaments can also become attenuated. They can tear abruptly during routine pitching, resulting in acute atraumatic instability. While microinstability and acute atraumatic instability typically occur in pitchers, position players are at a higher risk of traumatic shoulder instability. Diving for a ball or sliding into a base with an arm outstretched can cause the shoulder to sublux or frankly dislocate. These traumatic instability events often lead to injury of the anterior labrum and can result in recurrent instability. Treatment of instability in these throwing athletes includes physical therapy to restore the strength and coordination of the periscapular muscles, rotator cuff, deltoid and biceps. When nonoperative treatments fail, a number of arthroscopic and open procedures are available, with the type of procedure depending on the type of instability. While these techniques can adequately restore stability to the shoulder and many throwers do return to play, throwers do so at lower rates and often at lower levels than athletes of other sports.
Surgical Management of Capsulolabral and Rotator Cuff Injuries in Throwing Athletes
2018, Shoulder and Elbow Injuries in Athletes: Prevention, Treatment and Return to Sport
Surgical management of the throwing shoulder has unique challenges specific to the high demands of the overhead throwing motion. This chapter reviews the various rotator cuff and SLAP (superior labrum anterior and posterior) repair and instability and posterior release techniques used to return these athletes to the field. Successful return to competitive throwing after shoulder surgery requires a combination of thoughtful preoperative planning, meticulous surgical technique, and a comprehensive goal-oriented postsurgical rehabilitation program.
Intra- and inter-observer reproducibility of shoulder laxity tests: Comparison of the drawer, modified drawer and load and shift tests
2018, Journal of Orthopaedic Science
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We utilized Carter's criteria to analyse the right and left side separately. The advantage of the modified over the original Hawkins scale was verified prior to the statistical analyses of the objectives, although numerous studies have indicated its benefit [6,18]. Shoulder laxity examination has been commonly practiced under anaesthesia as it relaxes the surrounding muscles and facilitates the assessment of GH joint translation [4,5,17], but the same manoeuvres also have been applied in the clinic setting.
Conventional tests of shoulder laxity have been shown to have poor reliability due to the difficulty in palpating the subtle movements of the shoulder joint beneath the musculature. Modified drawer test that is performed while the soft tissues surrounding the shoulder are loosened has been proposed to facilitate glenohumeral joint movement and improve reliability. We hypothesised that the modified drawer test would have an improved intra- and inter-observer reproducibility in comparison to the drawer and load and shift tests. Correlation of shoulder laxity measured by these tests with generalized joint laxity was also assessed.
Forty healthy volunteers underwent bilateral shoulder examination in the clinic using the three tests for anterior and posterior laxity assessment by a consultant shoulder surgeon and a resident. The examination was repeated three months later by the same examiners in the same cohort. Intra- and inter- observer reproducibility was calculated using Kappa values. The correlation of shoulder with generalized joint laxity was also investigated.
The modified drawer test showed significantly improved intra-observer reproducibility compared to the drawer test, but not to the load and shift (κ = 0.173, −0.042, and 0.009, respectively). There were no significant differences in the inter-observer reproducibility between the three tests (κ = 0.054, 0.055, and 0.056, respectively). Moderate correlation was noted between shoulder and generalized joint laxity when modified drawer test was used (r = 0.417).
The modified drawer test improves intra- but not inter- observer reproducibility compared to the drawer test. Shoulder laxity assessed by the modified test correlated to generalized joint laxity. The modified drawer test has an improved reproducibility and correlation to generalized joint laxity over the conventional tests.
Surgical management of capsulolabral and rotator cuff injuries in throwing athletes
2017, Shoulder and Elbow Injuries in Athletes: Prevention, Treatment and Return to Sport
Surgical management of the throwing shoulder has unique challenges specific to the high demands of the overhead throwing motion. This chapter reviews the various rotator cuff and SLAP (superior labrum anterior and posterior) repair and instability and posterior release techniques used to return these athletes to the field. Successful return to competitive throwing after shoulder surgery requires a combination of thoughtful preoperative planning, meticulous surgical technique, and a comprehensive goal-oriented postsurgical rehabilitation program.
Arthroscopic Revision Surgery for Failure of Open Latarjet Technique
2017, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Under arthroscopic examination, an inferior humeral displacement was observed in relation to the lower border of the glenoid (Fig 1).28 The drive-through sign was studied to diagnose a capsular laxity.29 When the distance between the glenoid rim and the capsule or an inferior humeral displacement in relation to the lower border of the glenoid was >10 mm, then the capsule was considered as elongated (Grade I).28
To evaluate the efficacy in treating pain, limited range of motion, and continued instability of the Latarjet open technique via the use of arthroscopy.
A retrospective review of patients who underwent arthroscopic capsule plication after failure of an open Latarjet technique was performed. Revision surgery was indicated in cases of recurrent instability and associated pain. Only patients with a glenoid defect <25% were considered. The Constant and Rowe scores were administered, whereas pain was assessed with a visual analog scale before the reoperation and at 24 months after operation. Radiographs, computed tomography, and CT arthrography scans were performed.
Twelve patients met the inclusion criteria. All patients had capsular distension and consequently were subjected to a capsuloplasty. Shoulder function, stability, and pain had all improved significantly at 24 months after arthroscopic revision (P < .0001). In particular, the Constant score increased from 44.9 (standard deviation [SD] 7.10) to 89.3 (SD 12.6) points, the Rowe score improved from 49.5 (SD 10.1) to 80.9 (SD 10.9), whereas the visual analog scale pain score decreased from 6.75 (SD 1.17) to 1.38 (SD 1.06).
Primary open Latarjet with a glenoid bone defect <25% that failed due to capsular redundancy is amenable to successful treatment with arthroscopic capsuloplasty.
Arthroscopic approaches can offer a good solution for treating previously failed open Latarjet procedures.
Level IV, therapeutic case series.
Arthroscopically Assisted Open Reduction-Internal Fixation of Ankle Fractures: Significance of the Arthroscopic Ankle Drive-through Sign
2016, Arthroscopy Techniques
Standalone open reduction–internal fixation (ORIF) of unstable ankle fractures is the current standard of care. Intraoperative stress radiographs are useful for assessing the extent of ligamentous disruption, but arthroscopic visualization has been shown to be more accurate. Concomitant arthroscopy at the time of ankle fracture ORIF is useful for accurately diagnosing and managing syndesmotic and deltoid ligament injuries. The arthroscopic ankle drive-through sign is characterized by the ability to pass a 2.9-mm shaver (Smith & Nephew, Andover, MA) easily through the medial ankle gutter during arthroscopy, which is not usually possible with both an intact deltoid ligament and syndesmosis. This arthroscopic maneuver indicates instability after ankle reduction and fixation and is predictive of the need for further stabilization. Furthermore, when this sign remains positive after fracture fixation, it may guide the surgeon to further evaluate the adequacy of fixation for the possible need for further fixation of the syndesmosis or deltoid. We present the case of an ankle fracture managed with arthroscopy-assisted ORIF and describe the clinical utility of the arthroscopic ankle drive-through sign.

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^*: Address correspondence and reprint requests to Edward G. McFarland, M.D., 10753 Falls Rd, Suite 215, Lutherville, MD 21093, U.S.A. E-mail: [email protected]

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Original ArticlesClinical significance of the arthroscopic drive-through sign in shoulder surgery*

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

Clinical evaluation of the unstable shoulder

Clinical evaluation of shoulder problems

Multidirectional instability: Current Concepts

J Shoulder Elbow Surg

Clinical and diagnostic evaluation of anterior shoulder instability, impingement and rotator cuff tears

Dislocations.

Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A Preliminary report

J Bone Joint Surg Am

Classification and physical diagnosis of instability of the shoulder

Clin Orthop

Management of multidirectional instability

Oper Tech Sports Med

Multidirectional instability of the shoulder in the athlete

Clin Sports Med

Original Articles
Clinical significance of the arthroscopic drive-through sign in shoulder surgery*