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ANTERIOR GLENOHUMERAL INSTABILITY Jason Phillips

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Anterior Glenohumeral Instability. Jason Phillips. Normal Anatomy:. Labrum increases depth of glenoid IGHL 1 0 static check to A/P and inf @ 45-90 0 SGHL and MGHL play stabilizing roles in lower ranges of abduction. Inferior Glenohumeral Ligament Complex. Hunt et al. JAAOS 2007. - PowerPoint PPT Presentation

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Anterior Glenohumeral Instability

Anterior Glenohumeral InstabilityJason PhillipsNormal Anatomy:

Labrum increases depth of glenoidIGHL 10 static check to A/P and inf @ 45-900 SGHL and MGHL play stabilizing roles in lower ranges of abductionInferior Glenohumeral Ligament ComplexHunt et al. JAAOS 2007Normal Anatomy:

IGHL complex forms HammockAnterior band resists anterior translation in Abd/ER

Glenoid bare spot is centralHistory:Arm in Abducted/ER positonWas an ER reduction required?Age?Contact athlete/Military?Position?Ultimate goals?End/Beginning of Season?

Physical Exam:Apprehension-Relocation (Instability)AbER reproduces symptomsPosterior force relievesLoad & Shift (Laxity)Grade I Up face Grade II To Rim w/ immediate reductionGrade III Over Rim

Bahk et al. AJSM 2007Laxity or Excessive TranslationDoes Not Equal Instability

EUA is Critical: Compare translation of BOTH shoulders for any increase in anterior translation

7How should we treat the primary event?Risks for recurrent instabilityPosition of immobiliztionLength of immobilizationMeeting patients goals and expectationsRisks for Recurrent InstabilityRowe 1980 140yo = 14%Arciero 1989 2Ave age 18yo (17-22)3wks of immobilization (position not specified)92% recurrence if treated nonoperatively

Rowe CR. Acute and recurrent anterior dislocations of the shoulder. Ortho Clin North Am 1980;11:253-70.Wheeler JH, et al. Arthroscopic vs. Nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy 1989;5:213-217.Risks for Recurrent Instability

Arciero et al. Arthroscopic bankart vs nonoperative treatment for acute, initial anterior shoulder dislocations. AJSM 1994;22:589-594.Risks for Recurrent Instability

Group 1 = immobilized IR for 3-4 weeksGroup 2 = immobilized IR until patient felt comfortableGroup 3 = immobilization less than 3 weeksHovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.Risks for Recurrent Instability

Hovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.Risks for Recurrent Instability

Hovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.13

KeysPrimary dislocation4wks immobilized IRRobinson CM, et al. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. JBJS AM 2006;88:2326-2336.

Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477.16

Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477.

Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477.

Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477.Glenoid Bone Loss: Biomechanical EvidenceOsseous defect at least 21% of glenoid length may cause instabilityItoi E et al. JBJS(A) 2000 Jan

Anteroinferior glenoid defect diminished stability by almost 50%Bone grafting increased stability by 150% to 230%Montgomery WH et al. JBJS (A) 2005 Sept.

Risk Factors for Failure194 consecutive arthroscopic Bankart repairs; 101 contact athletes Recurrence in Contact Athletes: Without significant bony defects: 6.5%With significant bony defects: 89%Engaging Hill-SachsGlenoid bone loss 25%

Burkhart SS, DeBeer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic bankart repairs: significance of the inverted-pear glenoid and the humeral engaging hill-sachs lesion. Arthroscopy 2000;16:677-694.

Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

Burkhart SS, DeBeer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic bankart repairs: significance of the inverted-pear glenoid and the humeral engaging hill-sachs lesion. Arthroscopy 2000;16:677-694.

Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.24Quantifying the Risk FactorCadaveric study : Quantify glenoid bone loss by arthroscopic meansThe bare spot of the glenoidconsistent reference point from which to determine glenoid bone loss

Burkhart SS, De Beer JF et al. Arthroscopy, 2002 May

Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46. Risks for Recurrent Instability

3B EffectLabral repair (Bumper effect)Increased bony contact via coracoid transfer (Bony effect)Sling effect of conjoined tendon and lowered subscap (Belt or sling effect)Boileau et al. Orthop Clin N Am 2010;41:381-392.Position/Length of Immobilization

Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.Position/Length of Immobilization

Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.Position/Length of Immobilization

Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.36Position/Length of Immobilization

Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.Position/Length of Immobilization

Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.Position/Length of Immobilization

Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.Itoi, JBJS 2007RCT, Level II, 2yr f/u198pts sling vs 100ER x 3wks (ER group more compliant (68% vs 80%)ER group w/ reduced recurrence (38% Rel. Risk)

Itoi, JBJS, 2007Immobilize 100 ERMust initiate tx earlyMost effective if