Management of anterior shoulder instability for surgical trainees

1. Lennard Funk
Shoulder Instability
lenfunk@shoulderdoc.co.uk

2. 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

3. www.wrightington.com
Plan
Classification
Pathological Lesions
Management Decisions
Procedure Principles
Arthroscopic & Open
Soft Tissue & Bony

4. www.wrightington.com
Classification
TUBS AMBRI
Range

5. 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

6. 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

7. www.wrightington.com
Pathological Lesions
Bankart Tear
Bony Bankart
SLAP Tear Rotator Cuff Tear

8. www.wrightington.com
Soft tissue Bankart tears
Bankart ALPSA

9. Bankart ALPSA

10. Bankart ALPSA

11. www.wrightington.com
Bony Bankart

12. Bony Bankart

13. www.wrightington.com
Glenoid Deficiency
Inverted pear

14. www.wrightington.com
Bony Bankart vs. Deficiency

15. www.wrightington.com
Capsular Tears (HAGL)

16. www.wrightington.com
Capsular Laxity

17. www.wrightington.com
Hill-Sachs Lesion

18. www.wrightington.com
‘Large’ Hill-Sachs Lesion
> 12.5% of the humeral head diameter
Engaging in a functional position of abduction and external
rotation

19. www.wrightington.com
Decisions …
Soft tissue lesions:
Soft tissue surgery
Arthroscopic / Open
Large Bony lesions:
Consider bony procedures
Arthroscopic / Open

20. www.wrightington.com
Open / Arthroscopic ?
Depends on:
! Experience
! Expertise
! Facilities
! Preference
Shall I phone
a friend?

21. 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

22. 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

23. www.wrightington.com
Arthroscopic Bankart repair

24. www.wrightington.com
Capsular Plication – How much?
Symptoms – direction of instability
EUA – Cofield & Gagey
From: Copeland, Operative Shoulder Surgery

25. www.wrightington.com
Capsular Shift / Plication

26. www.wrightington.com
Glenoid Deficiency – Modified Latarjet

27. www.wrightington.com

28. www.wrightington.com
Glenoid Deficiency - Eden Hybinette

29. www.wrightington.com

30. www.wrightington.com
Large Hill-Sachs - Remplissage

31. www.wrightington.com
Remplissage

32. www.wrightington.com
Large Hill-Sachs - Allograft

33. 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

34. 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. 35