Current concepts in the management of shoulder instability

1. Current Concepts in the
Management of Shoulder Instability
By Dr.PONNILAVAN
ORTHO RESIDENT
PIMS
PONDICHERRY

2. Introduction
Shoulder
joint
stability
Static soft
tissue
dynamic
muscular
stabilizers
-ve
pressure
with
“suction
cup mech”
bony
anatomy

3. SI causes pain and dysfunction in young active
pts, more so in athletes.
Optimal Mx of SI is challenging in young adult as
well as the professional sportsperson.
Increase in the no. of shoulder D/L being
identified & managed in the last 2 to 3 decades.

4. Etiopathogenesis
Incidence in
India –
Unknown

5. Stages of evolution of pathological
lesion in post traumatic AI
• Habermeyer et al Staging :

6. Classification
STANMORE triangle spectrum
TUBS
AMBRI
PHYSIO

7. Radiographs- AP view

8. Transcapular Y view of GH jt

10. AXILLARY VIEW

11. STRYKER NOTCH VIEW

13. CT & MR arthrogram
Give details of soft tissue
& bony pathology
Help to decide b/w
arthroscopic & open
procedures
Recurrent
shoulder d/l
Larribe et al
MRI – SENSITIVITY –
91 -100%

14. Mx
• Non - operative – PHYSIOTHERAPY
• Operative Mx
- a} Anterior instability-
key factors- < 20yrs
- activity of the person
[sports person , active military
personal,climbers]
- pts expectations

15. Decision making in chronic SI
2 key question –
- what is the
problem ? – soft
tissue, bony or
both
-if bony – where
is the problem ?(
glenoid or
humerus or both
)
If in doubt abt the quality of soft tissue &
bony defect & based on intraoperative
assessement , a latarjet procedure described
by him in 1954 would more reliably stabilize
the jt esp. in contact sportsmen.

16. Coracoid osteotomy Transferred anterior
to glenoid rim
Done for instability due
to glenoid bone loss

17. • Latarjet - > 25% glenoid osseous defect
• Modified congruent arc latarjet procedure
developed by de Beer in atheletes with
recurrent anterior instability .
• Colegate et al found that complication rate –
7% & 89% pts return to sports activity in a
mean of 3.2 mts

18. • Current std of care for
bankart lesion is
arthroscopic bankart repair
named after the person
who 1st described open
anterior stabilization in
1923.

19. Bessiere et
al
Arthroscopic
bankart
Open latarjet
Incidence of recurrent instability favored latarjet group
No diff. b/w reoperation rate & return to sports

20. The bipolar bone loss has emerged
the concept of taking Hills Sachs
lesion into consideration
Bankart & Hill- Sachs lesions should
be considered in combination as a
continuum of the spectrum.

22. Yamamoto
et al
CONCEPT OF
GLENOID
TRACKING
This takes into account the
glenoid width +/- bone loss & the
amt of glenoid articulation with
capsule & humeral head

23. • In instability due to large Hill- Sachs lesion,
there is a role for arthroscopic reimplissage
procedure [ French to fill up]
• This involves using the capsule & infraspinatus
to fill up a large engaging Hill- Sachs defect
usually in combination with anterior bankart
repair.
• It makes the defect extrarticular so that it
does not engage against glenoid edge

24. • The Instability severity index score[ ISIS] < 6pts
meant an acceptably rate of 10% instability
recurrence & potentially good candidates for
bankart procedure.
• Phandnis et al study with 141 pts, found a 7-%
risk of failure of arthroscopic ant. Stabilization
if ISIS >4 vs 4% risk if score < 4

25. Multidirectional instability
Rx of choice is open
or arthroscopic
plication and capsular
shift if conservative
management fails.

26. - no diff. in open or arthroscopic
management -based on 24 studies
with a mean age of 24 yrs & mean FU
of 4 yrs in a 790pt with 861 shoulders
Longo et al - systematic
review

27. Posterior instability
Patients often do not present with typical history and
could describe the posterior joint pain and/or clicking.
They are also likely to be missed on scans unless
specifically looked for.
Principles of Mx & Sx stabilization are same as anterior
instability, i.e., if there is posterior soft tissue injury, then
capsular shift and posterior labral repair is indicated.

28. Antoniou and Harryman reported successful
achievement of stability for PI instability using their
techniques of arthroscopic posterior capsulolabral
repair and shift.
For bony injuries, McLaughlin procedure has been
described historically.
The posterior bone block could be considered in very
carefully selected cases

29. Rehabilitation
Rehabilitation aims are to return the
patient to the previous level of functional
status before injury.
Healing and recovery of sportspersons
may be much quicker due to better muscle
conditioning, motivation, facilities with
therapy input and compliance, as
compared to nonathletes.

30. Conventionally, a time-based approach has been used by
most surgeons in the postoperative rehabilitation phase.
Protect the repair with the arm in a sling, for 3 weeks avoid
rotations, especially external rotation and taking the arm
backwards. After 3 weeks, progressive mobilization is started
till 6 weeks when sling comes off and active mobilization
along with strengthening commences.

31. Summary
Shoulder instability
requires a
meticulous and
systematic
management plan.
All aspects of
instability should be
sought for and
thoroughly assessed.
Investigations (MRA,
CT scan) are adjuncts
to a comprehensive
history, examination,
and good diagnostic
arthroscopy

32. Thank u