Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Instability of the Shoulder: Complex Problems and Failed Repairs. Part I.

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Presentation transcript:

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Instability of the Shoulder: Complex Problems and Failed Repairs. Part I. Relevant Biomechanics, Multidirectional Instability, and Severe Loss of Glenoid and Humeral Bone*† by EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am Volume 80(1): January 1, 1998 ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 1 Drawing of the glenohumeral joint. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 2 Drawing showing the glenoid labrum, which extends around the perimeter of the glenoid and increases the surface area (arrows) and depth of the glenoid socket. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 3 Drawing of the capsuloligamentous anatomy, viewed from the side with the anterior aspect (A) to the right and the posterior aspect (P) to the left. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 4-A Drawing of the hammock-like anatomy of the inferior glenohumeral ligament complex, which allows for reciprocal tightening of its anterior and posterior portions when the arm moves from neutral rotation in abduction (a) to external rotation (b) and... EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 4-B Drawing showing changes in the orientation of the anterior band (aa) and the posterior band (pp) during neutral (NR), internal (IR), and external rotation (ER). EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Figs. 5-A and 5-B: Photographs of patients demonstrating generalized ligamentous laxity. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 5-B Laxity of the elbow is demonstrated by this patient who can hyperextend the elbow. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Figs. 6-A, 6-B, and 6-C: Preoperative photographs of a twenty-two-year-old woman who had multidirectional instability. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 6-B: The shoulder subluxated anteriorly when the arm was extended and externally rotated. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 6-C: The shoulder dislocated posteriorly when the arm was flexed and internally rotated. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Figs. 6-D through 6-H: Photographs made seven years after treatment with an inferior capsular shift from a posterior approach. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 6-E External rotation. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 6-F: Slight loss of internal rotation. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 6-G: The shoulder had no anterior subluxation when the arm was extended and externally rotated. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 6-H: The shoulder did not dislocate posteriorly when the arm was flexed and internally rotated. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Figs. 7-A, 7-B, and 7-C: Drawings showing an inferior capsular shift performed from an anterior approach. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 7-B: The inferior flap of the laterally-based T-capsulorrhaphy is brought anteriorly and superiorly. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 7-C: The rotator interval is closed, and the superior flap is brought down and across the inferior flap. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 8-A: Radiograph showing a chronic unreduced anterior dislocation in an elderly patient. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 8-B: An enormous humeral impression fracture was seen at the open reconstruction. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Figs. 9-A through 9-D: An active young female patient who had recurrent anterior instability of the shoulder. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 9-B Computerized tomographic scans showing the large size of the defect (arrows). EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 9-C Radiographs made after ligament reconstruction, which was accompanied by reconstruction of the humeral head defect with a segment of an allograft humeral head. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 9-D Photograph of the patient, showing a good functional result. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Figs. 10-A through 10-J: A young patient who had recurrent anterior dislocation of the shoulder. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 10-B Axillary radiograph showing loss of bone from the anteroinferior aspect of the glenoid, which was confirmed by a computerized tomographic scan (not shown). EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 10-C Photograph made intraoperatively, showing loss of 30 per cent of the anteroinferior aspect of the glenoid. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Figs. 10-D, 10-E, and 10-F: Postoperative radiographs. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 10-E: Lateral radiograph showing anteroinferior placement of the graft. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 10-F Axillary radiograph showing placement of the graft to reconstruct the anterior aspect of the glenoid rim. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Figs. 10-G through 10-J: Photographs made one year postoperatively. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 10-H Full external rotation. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 10-I: Full external rotation at 90 degrees of elevation. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.

Fig. 10-J: Full internal rotation. EVAN L. FLATOW, and JON J. P. WARNER J Bone Joint Surg Am 1998;80: ©1998 by The Journal of Bone and Joint Surgery, Inc.