Arthroscopicmanagementofanteriorshoulderinstability

AaronVenouziouOrthopaedic SurgeonSt.Luke’sHospital

Thessaloniki

AnteriorShoulderInstability

MostdetailedearlydescriptionstemsfromHippocratesaround400B.C.

Surgery consisted of burning the soft

tissues around the shoulder with a

red-hot iron, resulting in the

formation of stabilizing scars.

AnteriorShoulderInstability

AnteriorShoulderInstability

Bankart described the detachment of the anterior

capsulo-labral complex from the glenoid as the

“Essential Lesion” of chronic shoulder instability

3.5%recurrencerate

AnteriorShoulderInstability

EarlyArthroscopicStabilization

Metalstaples3-33%recurrencerate

Johnson,WilsonTransglenoid sutures0-49%recurrencerate

Caspari,MorganPGAtags0-21%recurrencerate

Warner,Cole

CurrentArthroscopicStabilization

SutureAnchorRepairRecurrence• 8% Savoie etal,1999• 4% Burkhart&DeBeer,2000• 0% Romeoetal,2000• 4% Kimetal,2003• 4.8% Sugaya etal,2005

Whatarethekeyfactorsforasuccessfularthroscopicstabilization?

Howwesucceeded?

Successfuloutcomedependson:

üΑssociated copathologies

üPatientprofile

üStableanatomicfixation

Anatomy

Labrumdeepens

theglenoidsocket

Anatomy

IGHL+Capsule=Hammock

Pathoanatomy – Labrum

Detachmentofthehammockontheglenoidside

Lossofchockblock

Presentin > 90%ofalltraumaticanterior shoulderdislocations

BANKARTlesion

Pathoanatomy – Labrum

AnteriorLabrumPeriostealSleeveAvulsion

Labroligamentous complexmustbemobilizedfromtheglenoidandreattachedanatomically

ALPSAlesion

Pathoanatomy – Labrum

Inthe settingofshoulderinstability,superiorlabrumtearsshould alwaysberepaired

Bankart andSLAPlesion(TypeVSLAPlesion)

40% inpatientswithchronicanteriorinstability

Hantes,AJSM2009

Pathoanatomy – Ligaments

Plasticdeformationoftheglenohumeral ligamentsisaprominentfactorinrecurrentinstability

CapsularDistension

Pathoanatomy – Ligaments

HumeralAvulsionofGlenohumeral Ligament

Surgicaltechniqueisbasedonthesurgeon’sexperience

HAGLlesion

Pathoanatomy – RotatorCuff

ü RepairBankart +RCinyounghighdemandingpts

ü RepairRConlyinolderlowdemandingpts

ü 30%ofpatients>40yearsofage

ü 80%ofpatients>60yearsofage

Pathoanatomy – Bone

GlenoidErosion(invertedpear)

5%-56%ofchronictraumaticanteriorinstabilitycases

Fujii, JSES2008Tauber,JSES2007

Lossoftheanteriorglenoidconcavityreducestheeffectivenessoftheconcavity–compressionmechanism

Lessforceisrequiredtodislocatetheshoulder

Pathoanatomy – Bone

>25%ofbonelossisacontraindicationforarthroscopicrepair

Pathoanatomy – Bone

Hill-SachsLesion

Pathoanatomy – Bone

Hill-SachsLesion

PatientSelection

PatientSelection

AllthepatientsareNOT candidatesforanarthroscopicBankart repair

PatientSelection

Riskfactorsforrecurrence:

ü Youngage

ü Malesex

ü Competitivelevelofsports

ü Contactsports

ü Excessivecapsularlaxity

ü Largegleno-humeralbonedefects

Randelli,KSSTA2012

2006

ISIS<3• <5%recurrence• arthroscopic repair

ISIS3– 6• 5- 10%recurrence• ???repair

ISIS>6• 70%recurrence• openrepair

ArthroscopicBankart Repair

GeneralPrinciples:

ü Reattachment oftheanteroinferior labrum

meticulousanatomicrepair

ü Reestablishmentofpropertensionintheinferior

glenohumeral ligamentcomplex

LateralDecubitusPosition

Doubletractionsystem

Providesbetteraccesstothecapsuleandtheaxillarypouch

ArthroscopicPortals

StandardposteriorportalBonyLandamarks

ArthroscopicPortals

AnteriorSuperiorAnteriorInferior

working working- viewing

DiagnosticArthroscopy

Lookforadditionalpathology

smallbonyBankart loosebody

SLAP

HAGL

Assessthelesion

Anterosuperior portalprovidesthebestview

Measureglenoidboneloss

Preparethelesion

• Dissectthecapsulolabralsleevefromtheanteriorglenoidneck

• Rasptheanteriorglenoidtocreateableedingbonesurface

• Correctmediallydisplacedlabrum(ALPSAlesion)

• Freecapsuletotallyand“float”thelabrumuptotheleveloftheglenoid

Placea5o’clockanchor

Theholesaredrilledatthemarginofthearticularsurfacetoallowrecreationoftheglenoidconcavity

Distal-to-proximalcapsuleshift

Passthesuturesthroughthecapsuledistaltotheanchor,accomplishingadistal-to-proximalshift

Createananteriorcapsulolabral “bumper”

Atleast3sutureanchorsshouldbeplaced

End-pointAssessment

Thehumeralheadiscenteredontheglenoid

Nodrivethroughsign

ConcomitantSLAPlesion

PortofWilmingtonforSLAPIIrepair

ü No/smallbonedefect(<25%)=>arthroscopicBankart repair

ü LargeacutebonyBankart =>earlyfixation

ü LargechronicbonyBankart =>Latarjet

ü Normalglenoidw/largeHill-Sachs=>arthroscopicBankartrepair+remplissage

ü Bordeline largebonelossoneitherside=>arthroscopicBankart repair+remplissage

Recommendations

ü Alwayslookforconcomitantpathologies

ü Patientprofileisveryimportantinthedecisionmaking

üGlenoidandhumeralbonelossarecommonsequelaoftraumaticanteriorshoulderinstability

üGlenoiddefectsaremoreimportantinshoulderinstability

Conclusions