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 SchemesClassification Schemes

• Mechanism– Traumatic– Atraumatic– Congenital– Neuromuscular

• Frequency– Acute– Chronic– Recurrent– Involuntary– Voluntary

• Mechanism– Traumatic– Atraumatic– Congenital– Neuromuscular

• Frequency– Acute– Chronic– Recurrent– Involuntary– Voluntary

• Direction– Anterior (and inferior)– Posterior (and inferior)– Superior?– Multidirectional

• Extent– Subluxation– Dislocation

• Direction– Anterior (and inferior)– Posterior (and inferior)– Superior?– Multidirectional

• Extent– Subluxation– Dislocation

TRAUMA

What is Traumatic Shoulder Instability ?

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

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

Unidirectional

Bidirectional

Multidirectional

Anterior

Posterior

Mechanisms of Glenohumeral Stability

• Static

• Dynamic

• Negative Intra- articular pressure

Labrum (50% of Glenoid depth)CapsuleLigaments- Glenohumeral- Superior, Middle & Inferior

(stability & proprioception) Rotator cuff tension

Glenohumeral LigamentVariations

66% - Well defined SGHL, MGHL & IGHL

7% - Confluent MGHL & IGHL19% - Cordlike MGHL with a high

riding attachment8% - 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

Recurrent dislocations also can cause

stretching of the glenohumeral capsule and

ligaments

This plastic deformation occurs

from repetitive loading

Bankart Lesion Equivalent

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

Hill-Sachs

humerus

glenoid

Indentation fracture

Present in 85% of recurrent dislocations

SLAP II

SLAP III

SLAP IV

Posterior Capsular Stretching

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

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

HEAD

anteriorposterior

Surgical TechniqueSurgical 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)

humerus

Bankart lesion

glenoid

1. Identify and Define Pathology

glenoid rim

anterior labrum

2. Mobilize Bankart Lesion and Abrade Glenoid Rim

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

from inferior to superior

anchor insertion

capsule penetration

humerus

labrum

4. Suture Passing

humerus

labrum

Completed repair

Capsular shift

5. Knot Tying

humerus

labrum

completed repair

6. Assessment of the Final Repair

completed repair

7. Associated Pathology

RI laxity

Posterior Capsule

Ant. Capsular Stretch

HAGL

SLAP

Hill-Sachs

SLAP repair

the capsular “pinch-tuck” technique

adjunctive thermal treatment

rotator interval closure

How to Reduce Capsule Redundancy

humerus

rotator interval

Rotator Interval Closure

in external rotation

Posterior capsule reefing

Posterior Instability

Posterior Instability

Posterior Instability

Bankart Lesion Healing

A second-look arthroscopic study

Case 1

labrum

Humeral head

glenoid10 months later

before

Avulsed labrum

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

Glenoid Bone Loss > 30%

Engaging Hill-Sachs

HAGL lesions

Limitations of theArthroscopic Techniques

Normal Glenoid

inverted pear

Bony Bankart

pear

Compression Bankart

loss of anterior rim

The normal glenoid shape

Inverted pear glenoid

Engaging Hill-Sachs Lesion

Articular Arc Deficit

glenoid

humeral head

anterior capsule

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"

The operation should be tailored to the patient and not the patient to the operation.

Both techniques are equivalent in terms of “success”

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