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Unstable Shoulder


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Unstable Shoulder. A more detailed definition of these slides and concepts can be found at:

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Unstable Shoulder

  1. 1. Unstable Shoulder:Current ConceptsVivek Agrawal, MDThe Shoulder Center12188A North MeridianCarmel, Indiana
  2. 2. Unstable Shoulder
  3. 3. Why is an Unstable Shoulder socommon?• Flat socket(glenoid) meansthat soft tissues(labrum, capsule,ligaments,muscles) providemost of the support
  4. 4. Unstable Shoulder• A delicate balance ofall these tissueskeeps the shoulderbalanced and stable• Injury, overuse, orcompensation candisrupt this balance.
  5. 5. Circle Concept
  6. 6. Unstable ShoulderBumper Cushion Circle Concept
  7. 7. What is Shoulder Instability?• Wide variation in diagnosticand treatment criteria evenamong shoulder surgeons.– Chahal, J., Clin. J. Sports Med• With the advances in modernarthroscopic diagnosis andtreatment this may reflect agradual transition from anetiology based diagnosis andtreatment methodology to onethat is based on the anatomicsites of pathology.
  8. 8. What is posterior instability?• Spectrum of disorders and pathology– Acute only 5% of all dislocations• Trauma, Seizure, ElectricalShock• Nearly 50% missed initially– Voluntary• Psychogenic• Learned Behavior– Acquired• Largest group includesmultiple etiologies• Circle Concept of Instability• Multiple sites of concurrentpathology– Glenoid Dysplasia
  9. 9. Diagnosis• Difficult– Pain often the only complaint• Primarily with activity or positional• Flexion, adduction, internal rotation– Instability and Neurological Complaints• More common with underlying laxity/MDI– Spectrum of anatomic lesions• Historically articles have focused on a small subsetof this spectrum.
  10. 10. Diagnosis• No single test reliable– Jerk– Load and Shift– Sulcus– Biceps/SLAP relatedTests– Rotator Cuff– Anterior InstabilityTests
  11. 11. DiagnosisPosterior Instability Inferior Labrum Tear
  12. 12. DiagnosisPosterior Instability Posterior Instability
  13. 13. DiagnosisBrachial Plexus Shoulder Girdle Nerves
  14. 14. Suprascapular Nerve
  15. 15. Suprascapular NerveArthroscopic Decompression of a BonySuprascapular Foramen. Arthroscopy2009
  16. 16. Why Arthroscopic Repair?• Allows globalevaluation, treatment,and flexibility• Instability is aSpectrum• Broad array ofcoexistent pathology• Modern techniquesoffer excellent results
  17. 17. Complications• Catastrophic Chondrolysis– Intraarticular pain pumps• Local anesthetic toxic to cartilage– Knotless Suture Anchors• Five fold failure rate for instability (4.9% vs. 23.8%)• Windshield wiper phenomenon shears cartilage– Thermal Shrinkage• High failure rates• Nerve, Capsule, and Cartilage Injury/Damage
  18. 18. Acromioplasty
  19. 19. Acromioplasty
  20. 20. Subscapularis RepairPresent in 27-35% of cases. Frequently missed.
  21. 21. Arthroscopic Repair• The best repairsare much morethan just a labrumrepair.• Balance to theentire shouldermust be restored.Restore Bumper Cushion
  22. 22. Arthroscopic Repair• State of the ArtRepair requiressutures and tyingknots• Avoid thermalprobes andknotless anchors• 5:1 failure rateknotless:knot
  23. 23. Biceps/SLAP37% Revision Rate Reported for Type II SLAP. Provencher. AAOS 2012
  24. 24. Buford Complex
  25. 25. Unstable ShoulderBony Bankart Lesion Bony Bankart Lesion
  26. 26. Unstable ShoulderBony Bankart Reduced Bony Bankart Repaired
  27. 27. Unstable Shoulder
  28. 28. Unstable ShoulderWispy (Thin) Capsule No Bumper Cushion
  29. 29. Unstable Shoulder
  30. 30. Unstable ShoulderAcute Postop Injury Percutaneous Technique
  31. 31. Unstable ShoulderReverse HAGL Lesion Reverse HAGL Lesion
  32. 32. Unstable ShoulderReverse HAGL Lesion Reverse HAGL Repair
  33. 33. Unstable ShoulderRepaired Reverse HAGL Repaired Reverse HAGL
  34. 34. Unstable ShoulderHill Sachs Lesion Hill Sachs Lesion
  35. 35. Unstable Shoulder(Remplissage)
  36. 36. Unstable Shoulder(Remplissage)
  37. 37. Unstable ShoulderHill Sachs Healed Hill Sachs Healed
  38. 38. Bone Void From Metal Anchor
  39. 39. Metal ArtifactKnotless Metal Anchor Knotless Metal Anchor
  40. 40. Metal ArtifactAnterior Inferior Tear Posterior Tear
  41. 41. Resorbable Anchor Osteolysis
  42. 42. Unstable Shoulder2 Year MRI Healed Tunnel 2 Year MRI Healed Tunnel
  43. 43. Unstable Shoulder2 Year MRI 2 Year MRI
  44. 44. Unstable Shoulder• Spectrum ofPathology– Labrum– Biceps– Capsule– Rotator Cuff– Bone– Circle Concept• Get a Second Opinion– Acromioplasty– ImpingementDiagnosis– Biceps Tenodesis– Knotless Anchors– Single Anchor Repair– Failed ShoulderSurgery
  45. 45. Learn More at:The Shoulder CenterThank You!