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Arthroscopic management of anterior shoulder instability larissa 2016

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Arthroscopic management of anterior shoulder instability larissa 2016

  1. 1. Arthroscopic management of anterior shoulder instability Aaron Venouziou Orthopaedic Surgeon St. Luke’s Hospital Thessaloniki
  2. 2. Anterior Shoulder Instability Most detailed early description stems from Hippocrates around 400 B.C. Surgery consisted of burning the soft tissues around the shoulder with a red-hot iron, resulting in the formation of stabilizing scars.
  3. 3. Anterior Shoulder Instability
  4. 4. Anterior Shoulder Instability Bankart described the detachment of the anterior capsulo-labral complex from the glenoid as the “Essential Lesion” of chronic shoulder instability
  5. 5. 3.5% recurrence rate Anterior Shoulder Instability
  6. 6. Early Arthroscopic Stabilization Metal staples 3-33% recurrence rate Johnson, Wilson Transglenoid sutures 0-49 % recurrence rate Caspari, Morgan PGA tags 0-21 % recurrence rate Warner, Cole
  7. 7. Current Arthroscopic Stabilization Suture Anchor Repair Recurrence • 8% Savoie et al, 1999 • 4% Burkhart & DeBeer, 2000 • 0% Romeo et al, 2000 • 4% Kim et al, 2003 • 4.8% Sugaya et al, 2005
  8. 8. What are the key factors for a successful arthroscopic stabilization? How we succeeded?
  9. 9. Successful outcome depends on: üΑssociated copathologies üPatient profile üStable anatomic fixation
  10. 10. Anatomy Labrum deepens the glenoid socket
  11. 11. Anatomy IGHL + Capsule = Hammock
  12. 12. Pathoanatomy – Labrum Detachment of the hammock on the glenoid side Loss of chock block Present in > 90% of all traumatic anterior shoulder dislocations BANKART lesion
  13. 13. Pathoanatomy – Labrum Anterior Labrum Periosteal Sleeve Avulsion Labroligamentous complex must be mobilized from the glenoid and reattached anatomically ALPSA lesion
  14. 14. Pathoanatomy – Labrum In the setting of shoulder instability, superior labrum tears should always be repaired Bankart and SLAP lesion (Type V SLAP lesion) 40% in patients with chronic anterior instability Hantes, AJSM 2009
  15. 15. Pathoanatomy – Ligaments Plastic deformation of the glenohumeral ligaments is a prominent factor in recurrent instability Capsular Distension
  16. 16. Pathoanatomy – Ligaments Humeral Avulsion of Glenohumeral Ligament Surgical technique is based on the surgeon’s experience HAGL lesion
  17. 17. Pathoanatomy – Rotator Cuff ü Repair Bankart + RC in young high demanding pts ü Repair RC only in older low demanding pts ü 30% of patients > 40 years of age ü 80% of patients > 60 years of age
  18. 18. Pathoanatomy – Bone Glenoid Erosion (inverted pear) 5%-56% of chronic traumatic anterior instability cases Fujii, JSES 2008 Tauber, JSES 2007 Loss of the anterior glenoid concavity reduces the effectiveness of the concavity – compression mechanism Less force is required to dislocate the shoulder
  19. 19. Pathoanatomy – Bone > 25% of bone loss is a contraindication for arthroscopic repair
  20. 20. Pathoanatomy – Bone Hill-Sachs Lesion
  21. 21. Pathoanatomy – Bone Hill-Sachs Lesion
  22. 22. Patient Selection
  23. 23. Patient Selection All the patients are NOT candidates for an arthroscopic Bankart repair
  24. 24. Patient Selection Risk factors for recurrence: ü Young age ü Male sex ü Competitive level of sports ü Contact sports ü Excessive capsular laxity ü Large gleno-humeral bone defects Randelli, KSSTA 2012
  25. 25. 2006 ISIS < 3 • < 5% recurrence • arthroscopic repair ISIS 3 – 6 • 5- 10% recurrence • ??? repair ISIS > 6 • 70% recurrence • open repair
  26. 26. Arthroscopic Bankart Repair General Principles : ü Reattachment of the anteroinferior labrum meticulous anatomic repair ü Reestablishment of proper tension in the inferior glenohumeral ligament complex
  27. 27. Lateral Decubitus Position Double traction system Provides better access to the capsule and the axillary pouch
  28. 28. Arthroscopic Portals Standard posterior portalBony Landamarks
  29. 29. Arthroscopic Portals Anterior SuperiorAnterior Inferior working working - viewing
  30. 30. Diagnostic Arthroscopy Look for additional pathology small bony Bankart loose body SLAP HAGL
  31. 31. Assess the lesion Anterosuperior portal provides the best view
  32. 32. Measure glenoid bone loss
  33. 33. Prepare the lesion • Dissect the capsulolabral sleeve from the anterior glenoid neck • Rasp the anterior glenoid to create a bleeding bone surface • Correct medially displaced labrum (ALPSA lesion) • Free capsule totally and “float” the labrum up to the level of the glenoid
  34. 34. Place a 5 o’clock anchor The holes are drilled at the margin of the articular surface to allow recreation of the glenoid concavity
  35. 35. Distal-to-proximal capsule shift Pass the sutures through the capsule distal to the anchor, accomplishing a distal-to-proximal shift
  36. 36. Create an anterior capsulolabral “bumper” At least 3 suture anchors should be placed
  37. 37. End-point Assessment The humeral head is centered on the glenoid No drive through sign
  38. 38. Concomitant SLAP lesion Port of Wilmington for SLAP II repair
  39. 39. ü No/small bone defect (<25%) => arthroscopic Bankart repair ü Large acute bony Bankart => early fixation ü Large chronic bony Bankart => Latarjet ü Normal glenoid w/ large Hill-Sachs => arthroscopic Bankart repair + remplissage ü Bordelinelarge bone loss on either side => arthroscopic Bankart repair + remplissage Recommendations
  40. 40. ü Always look for concomitant pathologies ü Patient profile is very important in the decision making ü Glenoid and humeral bone loss are common sequela of traumatic anterior shoulder instability ü Glenoid defects are more important in shoulder instability Conclusions