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Arthroscopic Findings and Treatment of Shoulder Instability Emmanuel Antonogiannakis,M.D. Center For Shoulder arthroscopy IASO gen. hospital Athens Greece
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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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How common is shoulder dislocation; 2% of the general population 90% anterior
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Classification 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
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TRAUMA What is Traumatic Shoulder Instability ?
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T.U.B.S. T.U.B.S. Traumatic Unidirectional Bankart lesion Surgery A.M.B.R.I. A.M.B.R.I. Atraumatic Multidirectional Bilateral Rehabilitation Inferior capsular shift A.I.O.S. A.I.O.S. Acquired Instability Overstress Surgery Instability Profiles
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TUBS AIOS AMBRI
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The Spectrum of Instability Lesions –Minor instability with activity related pain –Recurrent subluxation –Recurrent dislocation –Locked dislocation with loss of motion
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The Most Important Factors In Treating Instability Are Recognizing It And Defining It.
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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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Mechanisms of Glenohumeral Stability Static Dynamic Negative Intra- articular pressure Labrum (50% of Glenoid depth) Capsule Ligaments- Glenohumeral- Superior, Middle & Inferior (stability & proprioception) Rotator cuff tension
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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
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Loose Shoulder
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Pathology of Anterior Instability Lax Capsule Bankart’s lesion # glenoid rim Shape of Glenoid Posterolateral head defect
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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 90 o of abduction 85% in traumatic anterior dislocations Not enough to induce symptomatic instability
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Bankart Lesion
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Anterior Shoulder Instability
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Bankart 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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Examination Under Anaesthesia In various degrees of abduction and ER Side-to-side comparisons Sulcus sign
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Lateral Decubitus Position Abduction 70 o Traction 3-5 kg
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Beach Chair Position
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Portals: Left Shoulder HEAD anteriorposterior
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Surgical 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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1 st anchor 5 o’clock 2 nd anchor3 o’clock 3 rd anchor2 o’clock 3. Anchor Insertion 3-4 mm on the articular rim from inferior to superior
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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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SLAP repair
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the capsular “pinch-tuck” technique adjunctive thermal treatment rotator interval closure How to Reduce Capsule Redundancy
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humerus rotator interval Rotator Interval Closure in external rotation
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Posterior capsule reefing
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Posterior Instability
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Bankart Lesion Healing A second-look arthroscopic study
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Case 1 labrum Humeral head glenoid 10 months later before Avulsed labrum
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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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Glenoid Bone Loss > 30% Engaging Hill-Sachs HAGL lesions Limitations of the Arthroscopic Techniques
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Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim
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The normal glenoid shape
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Inverted pear glenoid
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Engaging Hill-Sachs Lesion Articular Arc Deficit glenoid humeral head anterior capsule
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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 dependent
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Open Shoulder Reconstruction familiar to most orthopaedic surgeons requires little special equipment reasonably reproducible recurrence rate addresses large glenoid bone defects
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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”
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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
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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
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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
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