arthroscopic findings and treatment of shoulder instability emmanuel antonogiannakis, 2 nd...
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Arthroscopic Findings and Treatment of Shoulder Instability
Emmanuel Antonogiannakis,
2nd Orthopaedic Department,
Athens Army Hospital
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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
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Instability
Biomechanical Dysfunction
Failure of static and dynamic stabilizers
Ranges from mild subluxation to
traumatic dislocation
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Direction of the Instability
Unidirectional
Bidirectional
Multidirectional
Anterior
Posterior
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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
Instability Profiles
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Glenohumeral LigamentGlenohumeral LigamentVariationsVariations
66% - Well defined SGHL, MGHL & 66% - Well defined SGHL, MGHL & IGHLIGHL
7% - Confluent MGHL & IGHL7% - Confluent MGHL & IGHL 19% - Cordlike MGHL with a high 19% - Cordlike MGHL with a high
riding attachmentriding attachment 8% - No discernable MGHL – IGHL but 8% - No discernable MGHL – IGHL but
one confluent anterior capsular sheathone confluent anterior capsular sheath
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Loose Shoulder
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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
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Bankart Lesion
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Bankart Lesion
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ALPSA lesion
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ALPSA lesion
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ALPSA lesion
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Recurrent dislocations also can cause
stretching of the glenohumeral capsule and
ligaments
This plastic deformation occurs
from repetitive loading
Bankart Lesion Equivalent
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BONY LESIONS• Humeral Head• Glenoid rim
LABRAL - LIGAMENTOUS INJURY • Bankart lesion• A.L.P.S.A.• H.A.G.L. • Capsular Tear
INCREASED CAPSULAR VOLUME • Atraumatic elongation• Traumatic stretch
Associated Lesions
BICEPS LESIONS
ROTATOR CUFF TEARS • Partial thickness • Full thickness
ROTATOR INTERVAL PATHOLOGY• Widening• Synovitis• Rupture
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Hill-Sachs
humerus
glenoid
Indentation fracture
Present in 85% of recurrent dislocations
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SLAP II
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SLAP III
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SLAP IV
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Posterior Capsular Stretching
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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 Stabilization
Patient Selection
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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
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Goal of arthroscopic shoulder reconstruction
Proximal Shift and Restoration of Capsular Tension
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Lateral Decubitus Position
Abduction 70o
Traction 3-5 kg WWW.SHOULDER.GWWW.SHOULDER.GRR
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Portals: Left Shoulder
HEAD
anteriorposterior
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Surgical TechniqueSurgical Technique
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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)
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humerus
Bankart lesion
glenoid
1. Identify and Define Pathology
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glenoid rim
anterior labrum
2. Mobilize Bankart Lesion and Abrade Glenoid Rim
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1st anchor 5 o’clock
2nd anchor 3 o’clock
3rd anchor 2 o’clock
3. Anchor Insertion
3-4 mm on the articular rim
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anchor insertion
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capsule penetration
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humerus
labrum
4. Suture Passing
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humerus
labrum
Completed repair
Capsular shift
5. Knot Tying
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humerus
labrum
completed repair
6. Assessment of the Final Repair
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completed repair
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7. Associated Pathology
RI laxity
Posterior Capsule
Ant. Capsular Stretch
HAGL
SLAP
Hill-Sachs
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humerus
rotator interval
Rotator Interval Closure
in external rotation
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SLAP repair
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Posterior capsule reefing
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Posterior Instability
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Posterior Instability
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Posterior Instability
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Postoperative Rehabilitation
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
supervised and individualized
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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 dependentWWW.SHOULDER.GWWW.SHOULDER.GRR
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Glenoid Bone Loss > 30%
Engaging Hill-Sachs
HAGL lesions
Limitations of theArthroscopic Techniques
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Normal Glenoid
inverted pear
Bony Bankart
pear
Compression Bankart
loss of anterior rim
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Engaging Hill-Sachs Lesion
Articular Arc Deficit
glenoid
humeral head
anterior capsule
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Recognition of normal variants and pathologic lesions
Cord like MGHL
Sublabral hole
Bare area
♣ ALPSA♣ PASTA♣ HAGL, RHAGL, BHAGL♣ SLAP♣ Hill-Sachs♣ Bankart-Perthes♣ Patulous capsule♣ Rotator interval lesions
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Cord like MGHL
Anterior Band IGHL
Subscapularis
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ALPSA lesion
glenoidglenoid
labrum
capsule
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