This document provides an overview of recurrent shoulder dislocation and operative intervention. It begins with a brief history of shoulder dislocation documentation and treatment. It then discusses the pathoanatomy, risk factors, classifications, and open vs arthroscopic surgical procedures for recurrent shoulder dislocation. Key open surgical techniques discussed include the Bankart procedure, capsular shift procedure, Putti-Platt procedure, Magnuson-Stack procedure, Bristow procedure, and Latarjet procedure. The document examines factors in determining the optimal treatment approach and whether open or arthroscopic stabilization is superior.

1. Recurrent shoulder dislocation
with emphasis on operative
intervention
engaging Hill-Sachs lesio
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2. Outline
• History and introduction
• Pathoanatomy
• Risk factors
• Classification
• Open vs arthroscopic procedures
• Landmark procedures
• Rehabilitation protocol
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3. Introduction
• Documented in Egyptian tombs
as early as 3000 BC, with reduction
maneuver resembling Kocher technique
• Hippocrates detailed the oldest
known reduction method (Hippocratic Method)
• Most common joint dislocation
• Most mobile joint in the human body
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4. Introduction
• Most commonly dislocated joint
 50 % of all dislocations
 2 % incidence in general population
• Acute dislocation - emergency and demands urgent relocation.
• Failure to reduce within the first 24 hours risk that it will be
impossible to achieve a stable closed reduction#
#Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective
study. J Bone Joint Surg Am 1996; 78: 1677–84.
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5. Introduction
• In the younger-age group, the risk of
recurrence correlates strongly to
 the violence of the initial injury
 the age of the patient at the time of presentation
 return to contact or collision sports
 hyper laxity
• 16–30- year-old group being at particularly
high risk
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6. Introduction
• Hovelius et al. found that the risk of re-
dislocation varied inversely with the age at the
time of primary dislocation
• Simonet et al in 1984, described a similar
recurrence rate. Both age and athletic activity
were shown to be important to the risk of
recurrence.#
#Simonet WT, Cofield RH. Prognosis in anterior shoulder dislocation. Am J Sports Med 1984; 12: 19–24.
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7. Functional anatomy
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8. Functional anatomy
• Shoulder joint is a complex
anatomical and biomechanical
structure which functions in a manner
that several stabilizers play role in
a special harmony in different stages of motion
Stability of the shoulder is established
by the glenohumeral articulation, labrum,
glenohumeral ligaments, rotator cuff, and
• deltoid muscle
Contact surface of the humeral head with the glenoid is about 30%, which means
that the joint has a limited osseous constraint so that the primary stability is due to
other soft tissue components rather than the osseous contact
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9. Stabilizers
• Glenohumeral Stability
• Static restraints
– glenohumeral ligaments (below)
– glenoid labrum (below)
– articular congruity and version
– negative intraarticular pressure
• if release head will sublux inferiorly
• Dynamic restraints
– rotator cuff muscles
• the primary biomechanical role of the rotator cuff is stabilizing the
glenohumeral joint by compressing the humeral head against the glenoid
– rotator interval
– biceps long head
– periscapular muscles
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10. Gleno-humeral ligaments
• Superior gleno humeral ligament -
attaches to the glenoid rim near the
apex of the labrum conjoined with
the long head of the biceps . On the
humerus, it is attached to the
anterior aspect of the anatomical
neck .
• restraint to inferior, anterior and
posterior stress at 0 degrees of
abduction
• Tightening of the rotator interval
(which includes the superior
glenohumeral ligament) decreases
posterior and inferior translation;
external rotation also may be
decreased DPS

11. • Middle gleno humeral ligament
–
has wide attachment
extending from the superior
glenohumeral ligament along the
anterior margin of the glenoid
down as far as the junction of the
middle and inferior thirds of the
glenoid rim.
On the humerus, it also is
attached to the anterior aspect of
the anatomical neck.
limits external rotation
when the arm is in the lower and
middle ranges of abduction but
has little effect when the arm is in
90 degrees of abduction DPS

12. • Inferior glenohumeral ligament –
glenoid margin from the 2- to 3-o’clock positions
anteriorly to the 8- to 9-o’clock positions posteriorly
humeral attachment is below the level of the
horizontally oriented physis into the inferior aspect of the
anatomical and surgical neck .
anterosuperior edge of this ligament usually is quite
thickened. There is a less thick and distinct posterior part
and thin axillary recess which create hammock type model.
external rotation, the hammock slides anteriorly and
superiorly. The anterior band tightens, and the posterior
band fans out. With internal rotation, the opposite occurs
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13. “Circle Stability Concept”
• “Circle Stability Concept”
• For a full dislocation to occur, both
sides of the capsule and ligaments must be damaged.
The capsule preventing the direction of location
would be considered the primary restraint and the
opposite side would be considered the secondary restraint.
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14. Mechanism of Injury
– Anterior (Abduction, ER, Extension)95% of all dislocations
– Posterior (Adduction, IR, Flexion, Axial Load)4% of all dislocations
– Epilepsy (Seizures), Electric Shock
– If seizure, look for bilateral
– Inferior (Luxatio Erecta)0.5% of all dislocations
– Hyperabduction or Axial force on overhead arm
• Superior (Rare)
• Intrathoracic (Rare)
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15. Mechanism of Injury
Violent external rotation in abduction levers the
head of the humerus out of the glenoid socket,
avulsing anterior bony and soft tissue structures
in the process (Bankart lesion) *
• posterior part of the humeral head exits
the joint, it often collides with the anterior rim
of the glenoid, creating a bony indentation
at the back of the humeral head ( Hill Sachs lesion).#
*Bankart ASB. The pathology and treatment of recurrent dislocations of the shoulder joint. Br J Surg 1938: 26: 23–9.
# Bost FC, Inman VC. The pathological changes in recurrent dislocation of the shoulder: a report of Bankart’s operative procedure. J Bone
Joint Surg Am
1942; 23: 596–613.
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16. Historical previews
• During the 1930s, many workers pursued what
was believed to be the essential lesion in
recurrent shoulder dislocation
• In a landmark paper in 1938, the British surgeon
Bankart described the lesion that still bears his
name.
• Bankart’s ‘essential lesion’ is an avulsion of
labrum from the anterior inferior glenoid with an
associated tear in the Labrum.
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17. • capsular laxity in the absence of a Bankart
lesion is also well recognised #
• biomechanical studies have demonstrated that
the creation of a Bankart lesion in itself is
insufficient to permit shoulder dislocation.
• More recent cadaveric, arthroscopic and MRI
studies have shown that many patients have
sustained injury to several structures in the
shoulder.
#Hintermann B, Gachter A. Arthroscopic findings after shoulder dislocation. J Sports Med 1995; 23: 545–51.on
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18. Classification
• According to direction of instability –
unidirectional
bidirectional
multidirectional
• Degree of instability –
sublaxation
dislocation
• Duration of instability –
acute
sub acute
chronic > 6 weeks
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19. • Type of trauma –
macro trauma
micro trauma
secondary trauma
• Age of initial dislocation –
< 20 year - 90% recurrence
20 – 40 year
> 40 year - 10% recurrence
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20. • Matsen’s simplified classification system -
1 - TUBS (Traumatic Unidirectional Bankart Surgery )
2 - AMBRII (Atraumatic, Multidirectional, Bilateral,
Rehabilitation, Inferior capsular shift, and Internal closure)
Micro traumatic or developmental lesions fall between the
extremes of macro traumatic and atraumatic lesions and
can overlap these extreme lesions
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21. Clinico radiological evaluation
• A detailed history and a careful physical examination
of the patient are the primary steps of the clinical
assessment.
Mechanism of the first incident
time period from the first dislocation to recurrent
instability
activities leading to recurrence or apprehension
number of dislocations
history of reducibility without emergency visit
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22. Clinico radiological evaluation
• Apprehension and relocation tests as provocative
examination are the fundamentals of clinical evaluation
• Anterior apprehension test is performed with the shoulder in 90 degrees of abduction and the elbow in 90 degrees of flexion, with forced external
rota- tion applied to the extremity as anterior stress is applied to the humerus. Relocation test is performed while the patient is supine and the shoulder in 90
degrees of abduction and external rotation.
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23. Clinico radiological evaluation
• Anteroposterior, axillary lateral and scapular Y-
view images are the primary routine radiographic
evaluation along with West point axillary view
(glenoid rim fracture) or Stryker notch view (Hill-
Sachs lesion)
• 3D CT is gold-standard technique to detect
osseous pathologies as well as quantifying the
degree of bone loss
• Magnetic resonance imaging (MRI) is a very
useful tool in detecting soft tissue pathologies
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24. Who is at risk
• young age
• participation in high demand contact sports activities
• previous history of ipsilateral traumatic dislocation
• presence of
Hill-Sachs
osseous Bankart lesion
ipsilateral rotator cuff
deltoid muscle insufficiency
underlying ligamentous laxity
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25. Treatment
• common surgical interventions address the labral tears as
well as the capsular laxity which are generally the basic
underlying pathologies.
• Surgical repair of any accompanying rotator cuff tear should
also be included in the treatment process
• Although many different surgical techniques have been
described to treat traumatic recurrent anterior instability of
the shoulder, the best method still remains controversial.
• A successful clinical outcome basically requires an accurate
surgical technique applied via adequate exposure.
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26. DPS

27. • The main objective of the treatment should be
considered as the most anatomical repair of the well
defined pathological condition leading to recurrent
instability.
• Achieving the best result for any particular patient
depends on the procedure which allows :
 observation of the joint surfaces
 provides the anatomical repair
 maintains range of motion
 with low rates of complications and recurrence
• Open and arthroscopic procedures are treatment options
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28. DPS

29. DPS

30. History of anterior shoulder
stabilization surgery
• Open procedures
• Open anatomic repair
• Sutures (Bankart)
• Staples
• Soft-tissue reconstruction
• Fascia lata autograft (Gallie)
• Muscular transposition of subscapularis
• (Magnusson-Stack)
• Shortening of subscapularis and anterior capsule
• (Putti-Platt)
• Osseous glenoid reconstruction
• Bristow
• Latarjet
• Iliac crest autograft (Eden-Hybbinette)
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31. History of anterior shoulder
stabilization surgery
• Distal tibia allograft
• Corrective osteotomy
• Proximal humerus (Weber)
• Glenoid (Meyer-Burgdorff)
• Open capsular imbrication
• Laterally based inferior capsular shift (Neer and Foster)
• Medially based inferior capsular shift (Altchek)
• Vertical capsulotomy
• Horizontal capsulotomy
• Arthroscopic procedures
• Arthroscopic anatomic repair
• Staples
• Transosseous sutures
• Metallic rivet
• Bioabsorbable tack
• Suture anchors
• Arthroscopic capsular imbrication
• Thermal capsulorrhaphy
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32. History of anterior shoulder
stabilization surgery
• Split and shift
• Multi-pleated capsular plication
• Posteroinferior capsular plication
• Rotator interval closure
• Arthroscopic Latarjet
• Targeted management of Hill-Sachs lesions
• Humeral head or femoral head allograft
• Disimpaction
• Partial resurfacing arthroplasty
• Hemiarthroplasty
• Arthroscopic remplissage
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33. Which one is superior
• Although open stabilization was reported as more effective
than arthroscopic stabilization in the aspect of post-operative
recurrence rates in 1990s, clinical outcomes have become
similar in time.
• Technological improvements in arthroscopic
instrumentation as well as the development of the innovative
surgical techniques as a result of the cumulative experience
with improved understanding of the factors leading failure in
such patients have played the key role#
# Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic
Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy
2000; 16: 677-694 [PMID: 11027751]
Porcellini G, Campi F, Pegreffi F, Castagna A, Paladini P. Predisposing factors for recurrent shoulder dislocation
after arthroscopic treatment. J Bone Joint Surg Am 2009; 91: 2537-2542 [PMID: 19884424 DOI:
10.2106/JBJS.H.01126]
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34. • According to the results of prospective randomized clinical trial
comparing open and arthroscopic techniques, the difference in
quality of life between the patients in the two groups was neither
significant nor clinically important at two years follow-up; however
significantly lower risk of recurrence was obtained in patients for
whom open repair was preferred@
• Rhee et al compared the results of arthroscopic and open
stabilization in young contact athletes and reported recurrent
instability as 25% in the arthroscopic group and 13% in the open
stabilization group *
• Some authors mentioned that athletic activity plays a greater role in
postoperative recurrence than the surgical method used for
stabilization#
@Mohtadi NG, Chan DS, Hollinshead RM, Boorman RS, Hiemstra LA, Lo IK, Hannaford HN, Fredine J, SasyniukTM, Paolucci EO. A randomized
clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability: two-year follow-up with
disease-specific quality-of-life outcomes. J Bone Joint Surg Am 2014; 96: 353-360 [PMID: 24599195 DOI: 10.2106/JBJS.L.01656]
* Rhee YG, Ha JH, Cho NS. Anterior shoulder stabilization in collision athletes: arthroscopic versus open Bankart repair. Am J Sports Med
2006; 34: 979-985 [PMID: 16436537]
# Cole BJ, L’Insalata J, Irrgang J, Warner JJ. Comparison of arthroscopic and open anterior shoulder stabilization. A two to six-year follow-
up study. J Bone Joint Surg Am 2000; 82-A:
1108-1114 [PMID: 10954100]
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35. Open Surgical Techniques
• Two basic types of surgical approaches :
 Anatomic repairs the goal is to restore the labrum to its
normal position and to reestablish the appropriate tension in
the shoulder capsule and ligaments
• Depending on the pathoanatomy
 the classic Bankart procedure that was popularized by
Rowe
 the capsular shift procedure which was popularized by
Neer
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36. • Non-anatomic repairs :
The goal is to stabilize the shoulder by compensating for the capsulolabral and
osseous injury with an osseous or soft-tissue checkrein that blocks excessive translation
and restores stability.
 The Putti-Platt procedure, which is an imbrication and shortening of the subscapularis
demonstrated excellent outcomes with non-anatomic stabilizations, but the reported
complications, such as loss of motion, recurrent instability, and premature arthritis#
 The Magnuson-Stack procedure, which is an advancement of the subscapularis that
was popularized by De-Palma
 The Bristow procedure
 The Latarjet procedure which are transfers of the coracoid to the glenoid
• #Fredriksson AS, Tegner Y. Results of the Putti-Platt operation for recurrent anterior dislocation of the shoulder.
Int Orthop. 1991;15:185-8.
• Young DC, Rockwood CA Jr. Complications of a failed Bristow procedure and their management. J Bone Joint Surg
Am. 1991;73:969-81.
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37. Patient selection
• an apprehension sign that is relieved by a relocation maneuver can be
virtually diagnostic of anterior shoulder instability and a Bankart lesion#.
• The anteroposterior laxity of the shoulder should be assessed with load
and shift testing, and the inferior laxity should be assessed with inferior
translation (sulcus testing).
• A large sulcus sign that recreates symptoms of instability is
Pathognomonic for multidirectional instability.
• a large sulcus sign in the adducted arm that does not decrease when the
arm is placed in external rotation indicates an insufficiency of the rotator
interval*
• #Speer KP, Hannafin JA, Altchek DW, Warren RF. An evaluation of the shoulder relocation test. Am J Sports Med.
1994;22:177-83.
• *Neer CS 2nd. Involuntary inferior and multidirectional instability of the shoulder:etiology, recognition, and treatment. Instr
Course Lect. 1985;34:232-8.
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38. Indications
• Absolute indications :
substantial glenoid or humeral bone loss
capsular deficiency
irreparable rotator cuff deficiency
humeral avulsions of the glenohumeral ligaments and
capsular ruptures as these two injuries are extremely
difficult to address arthroscopically
• a previous failed arthroscopic or open repair because it
is easier to address the causes of the instability (which
may be multiple) with an open procedure
a prior failed thermal capsulorrhaphy
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39. Contra indications
• Absolute contraindications: voluntary or
psychogenic instability and active infection.
• patients with concomitant severe arthritis.
• Paralysis
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40. Open bankart repair
• Classically, the subscapularis tendon
is incised vertically at its lateral
insertion and sharply dissected
medially from the anterior capsule
• Make a vertical capsulotomy
approximately 0.5 cm lateral to the
glenoid
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41. Open bankart repair…
Prepare this area with a curet to expose
bleeding bone and drill three holes; one at the
2-o' clock, one at the 4-o' clock, and one at the
6-o' clock positions for right shoulders (10-, 8-,
and 6-o' clock positions for left shoulders
Pass sutures through the holes and the lateral
capsular flap
Tie the flap down to the glenoid rim, and pass
these same sutures through the small medial
capsular flap, reinforcing the repair
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42. Coracoid transfer procedures
• Latarjet 1958
• Later on popularized and modified
by Helfet, who named it for
his mentor Rowley Bristow.
• The aim of these procedures is
to stabilize the shoulder with the
static action of the transferred bone
block and the attached
coracobrachialis tendon
Only the tip of the coracoid process is transferred
in the Bristow procedure, whereas, in the Latarjet procedure,
the transfer includes a portion of the coracoacromial
osteotomy with the conjoined tendon left attached
transferred to the anterior glenoid, and fixed
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43. Coracoid transfer procedures :Pit falls
• May fail to address :
 essential lesion (i.e., theBankart lesion)
 associated pathology (SLAP lesion)
• Recurrence rates have ranged from 0% (Allain et
al) to 6% (Hovelius et al.)
Loss of ROM: greater than that after an open
Bankart procedure
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44. Glenoid Reconstruction with Iliac
Crest Bone Graft
• Bodey and Denham: first report 1983
• Glenoid grafting restores bone to recreate the
arc of the glenoid
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45. Humeral Bone Deficiency
• Hill-Sachs lesions
• “engaging Hill-Sachs lesions.”-Burkhart and De
Beer described
• long axis of the humeral head defect aligns
parallel to the anterior glenoid rim, when the
shoulder is in a position of abduction and external rotation.
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46. Humeral Bone Deficiency
• Surgical options :
Reconstruction of the humerus with an allograft
Restore the humeral articular arc
reconstruction of the glenoid with an anterior bone graft to lengthen
the glenoid articular arc and prevent the humeral defect from engaging
the glenoid rim
Rotation of the humeral head with an osteotomy to move the defect so
that it does not come into contact with the anterior aspect of the
glenoid
Burkhart S, Danaceau S. Articular arc length mismatch as a cause of failed Bankart repair. Arthroscopy. 2000;16:740-4.
Yagishita K, Thomas BJ. Use of allograft for large Hill-Sachs lesion associated with anterior glenohumeral dislocation. A case report.
Injury. 2002;33:791-4.
Weber BG, Simpson LA, Hardegger F. Rotational humeral osteotomy for recurrent anterior dislocation of the shoulder associated with a
large Hill-Sachs lesion. J Bone Joint Surg Am. 1984;66:1443-50.
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47. Capsular Deficiency
• Capsular deficiency is more common in revision settings and after thermal capsulorrhaphy.
• Lazarus and Harryman described a method of using hamstring tendons for repair of such
deficiencies*
• . The long head of the biceps can be combined with the autograft for additional support.
• Gallie and Le Mesurier described the use of the iliotibial band for capsular reconstruction to treat
glenohumeral instability associated with an irreparable capsule#
• Moeckel et al. described the use of Achilles tendon allograft in ten patients who had persistent
anterior instability
• *Lazarus MD, Harryman DT 2nd. Open repair for anterior instability. In: Warner JJP, Iannotti JP, Gerber C, editors. Complex
and revision problems in shoulder surgery. Philadelphia: Lippincott-Raven; 1997. p 47-64.
• #Gallie WE, Le Mesurier AB. Recurring dislocation of the shoulder. J Bone Joint Surg Br. 1948;30:9-18.
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48. Revision and Complex Problems
surgeon should be prepared to face:
 distorted anatomic tissue planes
 severe scarring
 capsular deficiencies
 osseous deficiencies due to erosion or
fracture, and subscapularis deficiencies
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49. Open repairs: Complications and
Pitfalls
• Recurrence of Instability
• Stiffness
• Subscapularis Deficiency
• Arthrosis
• Hardware Problems
• Neurovascular Injuries
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50. Arthroscopic Procedures
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51. Arthroscopic Stapling
• In 1982, Detrisac and Johnson performed the first
arthroscopic shoulder stabilization procedure, using a
capsular stapling technique.*
• Abandoned because of hardware problems and an inability to
address capsular laxity.
• Lane and colleagues retrospectively reported 33% recurrence rate,
with 18.5% requiring a subsequent open reconstructive procedure.
Fifteen percent developed loose staples on follow-up radiographs#
• *Detrisac DA, Johnson LL: Arthroscopic shoulder capsulorraphy using metal staples. Orthop Clin North Am24(1):71-88, 1993.
• # Lane JG, Sachs RA, Riehl B: Arthroscopic staple capsulorraphy: A long-term follow-up. Arthroscopy 9(2):190-194, 1993.
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52. Transglenoid Suture Technique
Morgan and associates first described the transglenoid suture technique in
1987*
• Failures were attributed to #
• plastic deformation in the capsular tissue
• component of the instability still existed. Seventy-
• immobilization periods of less than one week
• Caspari, in 1988, described a technique that allowed the surgeon to
advance and adjust tension in the capsuloligamentous structures$
• Caspari technique have experienced similar recurrence rates
• *Morgan CD, Bodenstab AB: Arthroscopic Bankart suture repair: Technique and early results. Arthroscopy 3:111-122, 1987.
• #Grana WA, Buckley PD, Yates CK: Arthroscopic Bankart suture repair. Am J Sports Med 21(3):348-353, 1993.
• $Green MR, Christensen KP: Arthroscopic Bankart procedure:Two- to five-year follow-up with clinical correlationto severity of glenoid labral lesion. Am J Sports Med
• 23(3):276-281, 1995.
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53. Suture Anchors
• Weber and associates
• modified by both Wolf and Snyder who used
absorbable and non-absorbable sutures,
respectively.
• This technique has the advantage of allowing the
capsuloligamentous structures to be shifted
superiorly and be properly tensioned.
• Complications:
• intra-articular migration of a suture anchor
• articular damage
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54. Arthroscopic Latarjet Procedure
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55. Arthroscopic Latarjet Procedure
• First Stage: Achieving Exposure
• Second Stage: Coracoid Preparation
• Third Stage: Coracoid Drilling and Osteotomy
• Fourth Stage: Coracoid Transfer
• Fifth Stage: Fixation of Bone Graft
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56. Arthroscopic Latarjet Procedure
• Advantageous in those cases in which the preoperative
assessment fails to reveal an HAGL lesion or a large
bony avulsion from the anterior rim
• Allows surgeon to modify his or her plan
intraoperatively
• With regard to graft placement and fixation: provides
superior visualization for positioning the coracoid
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57. ARTHROSCOPIC BANKART REPAIR
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58. ARTHROSCOPIC BANKART REPAIR
• Place the arm in 45 degrees abduction and 20 degrees
• forward flexion using 10 to 12 lb of traction.
• Place the posterior portal 2 cm inferior to the
• posterolateral edge of the acromion
• Thoroughly evaluate the glenohumeral joint for bony loss
• After identifying the quadrant or quadrants of injury
• to the labrum, create the planned portals shoulder
• just posterior to the biceps tendon and anterior to the
• leading edge of the supraspinatus tendon
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59. Posterior Instability
– Indications:
– Failed non operative
– Irreducible dislocation
– Open dislocation
– Unstable reduction
– Surgical Options:
– Arthroscopic
– Open Anterior Procedure
– Open Posterior Procedure
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60. Posterior Instability
– Arthroscopic
 Capsular repair/capsulorrhaphy, Labral repair
 86-96% success, 0-7% recurrent instability
• Open Anterior Procedure
 Deltopectoral approach
 Capsular release and transfer to remove
redundancy + imbrication
• RCT repair
– McLaughlin Procedure
– Neer Modification (reverse Hill-Sachs repair)
Transfer of subscap tendon into lesion
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61. Multidirectional Instability
• Indications:
• Failed nonoperative
– Pain + Disability (>6 months) despite rehab protocol
– Unstable reduction
Surgical Options:
• ArthroscopicThermal/Suture Capsulorrhaphy
• 88-94% success, 2-12% recurrent instability
• Open Anterior/Posterior ProcedureCapsulolabral
Reconstruction (Inferior/Anterior/Posterior)
• 85-97% success, 3-26% recurrent instability
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62. THANK YOU
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