Transcript Arthroscopic Findings and Treatment of Shoulder Instability Emmanuel Antonogiannakis,M.D. Center For Shoulder arthroscopy IASO gen.

Arthroscopic Findings and Treatment of
Shoulder Instability
Emmanuel Antonogiannakis,M.D.
Center For Shoulder arthroscopy
IASO gen. hospital
Athens Greece
The Shoulder
 Greatest Range of Motion in the Body
 Motion in all 3 planes of movement
 Prone to injuries
 8-20% of all sports injuries
How common is shoulder dislocation;
 2% of the general population
 90% anterior
Classification Schemes
• Mechanism
– Traumatic
– Atraumatic
– Congenital
– Neuromuscular
• Direction
– Anterior (and inferior)
– Posterior (and inferior)
– Superior?
– Multidirectional
• Frequency
– Acute
– Chronic
– Recurrent
– Involuntary
– Voluntary
• Extent
– Subluxation
– Dislocation
What is Traumatic Shoulder Instability ?
TRAUMA
Instability Profiles
T.U.B.S.
Traumatic
Unidirectional
Bankart lesion
Surgery
A.M.B.R.I.
Atraumatic
Multidirectional
Bilateral
Rehabilitation
Inferior capsular shift
A.I.O.S.
Acquired
Instability
Overstress
Surgery
TUBS
AIOS
AMBRI
The Spectrum of Instability Lesions
– Minor instability with
activity related pain
– Recurrent subluxation
– Recurrent dislocation
– Locked dislocation with
loss of motion
The Most Important Factors In Treating Instability Are
Recognizing It And Defining It.
Instability
 Biomechanical Dysfunction
 Failure of static and dynamic stabilizers
 Ranges from mild subluxation to
traumatic dislocation
Direction of the Instability
Anterior
 Unidirectional
Posterior
 Bidirectional
 Multidirectional
Mechanisms of Glenohumeral Stability
• Static
Labrum (50% of Glenoid depth)
Capsule
LigamentsGlenohumeral- Superior, Middle & Inferior
(stability & proprioception)
• Dynamic
Rotator cuff tension
• Negative Intra- articular pressure
Glenohumeral Ligament
Variations
 66% - Well defined SGHL, MGHL & IGHL
 7% - Confluent MGHL & IGHL
 19% - Cordlike MGHL with a high riding
attachment
 8% - No discernable MGHL – IGHL but one
confluent anterior capsular sheath
Loose Shoulder
Pathology of Anterior Instability
• Lax Capsule
• Bankart’s lesion
• # glenoid rim
• Shape of Glenoid
• Posterolateral head defect
Bankart Lesion
the essential lesion
 Avulsion of the IGHL from the glenoid rim
from 2 o’clock to 6 o’clock
 Primary restraint to anterior translation
at 90o of abduction
 85% in traumatic anterior dislocations
 Not enough to induce symptomatic instability
Bankart Lesion
Anterior Shoulder Instability
Bankart Lesion
ALPSA lesion
ALPSA lesion
Bankart Lesion Equivalent
 Recurrent dislocations also can cause
stretching of the glenohumeral capsule
and ligaments
 This plastic deformation occurs
from repetitive loading
Associated Lesions
BONY LESIONS
• Humeral Head
• Glenoid rim
BICEPS LESIONS
LABRAL - LIGAMENTOUS INJURY
• Bankart lesion
• A.L.P.S.A.
• H.A.G.L.
• Capsular Tear
ROTATOR CUFF TEARS
• Partial thickness
• Full thickness
INCREASED CAPSULAR VOLUME
• Atraumatic elongation
• Traumatic stretch
ROTATOR INTERVAL
PATHOLOGY
• Widening
• Synovitis
• Rupture
Hill-Sachs
humerus
glenoid
 Indentation fracture
 Present in 85% of recurrent dislocations
SLAP II
SLAP III
SLAP IV
Posterior Capsular Stretching
Arthroscopic Shoulder Stabilization
Patient Selection
 Patients of all ages and all activity levels with
recurrent anterior instability who are impaired
functionally and in whom nonoperative treatment
has failed
 Revision stabilization
 First-time, acute shoulder dislocations
Arthroscopic Shoulder Reconstruction
Goal of the Operation:
 Restoration of the Labrum to
its anatomic attachment
 Reestablishment of the appropriate tension
in the GH ligaments and capsule
Goal of arthroscopic shoulder reconstruction
Proximal Shift and Restoration of Capsular Tension
Examination Under Anaesthesia
 In various degrees of abduction and ER
 Side-to-side comparisons
 Sulcus sign
Lateral Decubitus Position
Abduction 70o
Traction 3-5 kg
Beach Chair Position
Portals: Left Shoulder
posterior
anterior
HEAD
Surgical Technique
Arthroscopic Reconstruction: Technique
1. Define Pathology
2. Debride damaged tissue
3. Release capsule to/past 6 o’clock
4. Free off subscapularis
5. Abrade glenoid
6. Repair capsulolabral complex
7. Associated Injuries (Posterior
capsule, Rotator Interval, SLAP)
1. Identify and Define Pathology
humerus
Bankart lesion
glenoid
2. Mobilize Bankart Lesion and
Abrade Glenoid Rim
anterior
labrum
glenoid
rim
3. Anchor Insertion
1st anchor
5 o’clock
2nd anchor
3 o’clock
3rd anchor
2 o’clock
3-4 mm on the articular rim
from inferior to superior
anchor insertion
capsule penetration
4. Suture Passing
humerus
labrum
5. Knot Tying
humerus
labrum
Completed repair
Capsular shift
6. Assessment of the Final Repair
humerus
labrum
completed repair
completed repair
7. Associated Pathology
 RI laxity
 Posterior Capsule
 Ant. Capsular Stretch
 HAGL
 SLAP
 Hill-Sachs
SLAP repair
How to Reduce Capsule Redundancy
 the capsular “pinch-tuck” technique
 adjunctive thermal treatment
 rotator interval closure
Rotator Interval Closure
humerus
rotator
interval
in external rotation
Posterior capsule reefing
Posterior Instability
Posterior Instability
Posterior Instability
Bankart Lesion Healing
A second-look arthroscopic study
Case 1
Humeral head
labrum
Avulsed
labrum
before
glenoid
10 months later
Postoperative Rehabilitation
supervised and individualized
 Sling for 4/52
 Isometrics and pendulum exercises immediately
 Active forward elevation may begin after 3/52
 External rotation to 30° to 40° at 4/52
 Progressive strengthening at 8/52
 Return to sport at 18 to 36 weeks
Limitations of the
Arthroscopic Techniques
 Glenoid Bone Loss > 30%
 Engaging Hill-Sachs
 HAGL lesions
Normal Glenoid
pear
Bony Bankart
inverted
pear
Compression
Bankart
loss of
anterior rim
The normal glenoid shape
Inverted pear glenoid
Engaging Hill-Sachs Lesion
anterior capsule
humeral
head
glenoid
Articular Arc Deficit
Arthroscopic vs Open Shoulder Reconstruction
 Less trauma
 Better cosmesis
 Addresses associated pathology
 Less postoperative pain
 On an outpatient basis
 Faster surgery
 Better ROM
 Return to sports
 Similar recurrence rate
 Patient Demand
 Insurance Policy (Less cost)
 Equipment dependent
Open Shoulder Reconstruction
 familiar to most orthopaedic surgeons
 requires little special equipment
 reasonably reproducible recurrence rate
 addresses large glenoid bone defects
Neither technique is "easy"
Both techniques are equivalent in terms of “success”
The operation should be tailored to the patient
and not the patient to the operation.
Arthroscopic Techniques are suitable
for almost every instability problem
Arthroscopic stabilization is the technique of choice
when confronted with the patient exhibiting
unilateral anterior shoulder instability
Keys to Success
• Mobilization of capsule
• South to north transfer
• Anchors on the glenoid
• At least 3 double suture loaded anchors
• Address secondary lesions
• Address capsular laxity
• Individualized and supervised
rehabilitation
Conclusions
• Arthroscopic instability repair gained wider
acceptance
• Results are equivalent to open repairs
• It is technically demanding but feasible
• With experience most of the instability
problems can be treated arthroscopic