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Anterior shoulder instability st4-6

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Lennard Funk
Lennard Funk

Management of anterior shoulder instability for surgical trainees

Health & Medicine
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Lennard Funk Shoulder Instability lenfunk@shoulderdoc.co.uk
www.wrightington.com Evolution of Instability Surgery 1. Hippocrates cautery – 460 BC 2. Putti-Platt 3. Bristow 4. Open Bankart repair 5. Thermal Shrinkage 6. Arthroscopic Bankart 7. Tailored Approach – Arthroscopic / Open / Combined
www.wrightington.com Plan Classification Pathological Lesions Management Decisions Procedure Principles Arthroscopic & Open Soft Tissue & Bony
www.wrightington.com Classification TUBS AMBRI Range
Stanmore Classification (Bayley Triangle) Lewis, Kitamura & Bayley Current Orthopaedics. 18:97-108. 2004 Less Muscle Patterning Less Trauma Polar Type III Muscle Patterning Non-Structural Polar Type I Traumatic Structural Polar Type II Atraumatic Structural
www.wrightington.com Pathology of Shoulder Instability Polar Type 1 (Traumatic) 1. Soft Tissue Lesions: Soft Tissue Bankart SLAP Tears Capsular Tears (HAGL) 2. Bony Lesions: Bony Bankart (acute) Glenoid bone loss Hill-Sachs Polar Type 2 (Atraumatic) Capsular insufficiency Polar Type 3 (Muscle Patterning) Motor control & patterns Proprioception Scapula stability Kinetic chain
www.wrightington.com Pathological Lesions Bankart Tear Bony Bankart SLAP Tear Rotator Cuff Tear
www.wrightington.com Soft tissue Bankart tears Bankart ALPSA
Bankart ALPSA
Bankart ALPSA
www.wrightington.com Bony Bankart
Bony Bankart
www.wrightington.com Glenoid Deficiency Inverted pear
www.wrightington.com Bony Bankart vs. Deficiency
www.wrightington.com Capsular Tears (HAGL)
www.wrightington.com Capsular Laxity
www.wrightington.com Hill-Sachs Lesion
www.wrightington.com ‘Large’ Hill-Sachs Lesion > 12.5% of the humeral head diameter Engaging in a functional position of abduction and external rotation
www.wrightington.com Decisions … Soft tissue lesions: Soft tissue surgery Arthroscopic / Open Large Bony lesions: Consider bony procedures Arthroscopic / Open
www.wrightington.com Open / Arthroscopic ? Depends on: ! Experience ! Expertise ! Facilities ! Preference Shall I phone a friend?
www.wrightington.com Outcomes Recurrence Rates: 4% - no bony defects 67% - with bony defects Burkhart, 2001 More Recent: 4.8% - with bony defects (>25%) Mologne et al, JSEM, 2007
www.wrightington.com Bankart Repair Principles: 1. Mobilise capsulolabral tissues 2. Prepare the bone surfaces 3. Repair slightly on to the face of the glenoid 4. Obtain knot security and loop security 5. Repair coexisting lesions
www.wrightington.com Arthroscopic Bankart repair
www.wrightington.com Capsular Plication – How much? Symptoms – direction of instability EUA – Cofield & Gagey From: Copeland, Operative Shoulder Surgery
www.wrightington.com Capsular Shift / Plication
www.wrightington.com Glenoid Deficiency – Modified Latarjet
www.wrightington.com
www.wrightington.com Glenoid Deficiency - Eden Hybinette
www.wrightington.com
www.wrightington.com Large Hill-Sachs - Remplissage
www.wrightington.com Remplissage
www.wrightington.com Large Hill-Sachs - Allograft
www.wrightington.com Summary Polar Type I traumatic structural Polar Type II Atraumatic Structural Polar Type III Muscle patterning Non-structural Large Bankart Lesion Bony Bankart Large Hill-Sachs Associated Lesions Consider Bony Procedure Repair all coexisting lesions Capsular Laxity Small Bankart Tear Small Hill-Sachs Address capsular laxity
Clinical (Classification) MR Arthrogram Glenoid Bankart Repair (scope / open) Deficiency Latarjet / Eden-Hybinette Humeral Head Large Hill-Sachs Remplissage / Allograft Capsule HAGL Repair (open / Scope) Hyperlax Shift / Plication
35

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Anterior shoulder instability st4-6