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