Arthroscopicmanagementofanteriorshoulderinstability
AaronVenouziouOrthopaedic SurgeonSt.Luke’sHospital
Thessaloniki
AnteriorShoulderInstability
MostdetailedearlydescriptionstemsfromHippocratesaround400B.C.
Surgery consisted of burning the soft
tissues around the shoulder with a
red-hot iron, resulting in the
formation of stabilizing scars.
AnteriorShoulderInstability
AnteriorShoulderInstability
Bankart described the detachment of the anterior
capsulo-labral complex from the glenoid as the
“Essential Lesion” of chronic shoulder instability
3.5%recurrencerate
AnteriorShoulderInstability
EarlyArthroscopicStabilization
Metalstaples3-33%recurrencerate
Johnson,WilsonTransglenoid sutures0-49%recurrencerate
Caspari,MorganPGAtags0-21%recurrencerate
Warner,Cole
CurrentArthroscopicStabilization
SutureAnchorRepairRecurrence• 8% Savoie etal,1999• 4% Burkhart&DeBeer,2000• 0% Romeoetal,2000• 4% Kimetal,2003• 4.8% Sugaya etal,2005
Whatarethekeyfactorsforasuccessfularthroscopicstabilization?
Howwesucceeded?
Successfuloutcomedependson:
üΑssociated copathologies
üPatientprofile
üStableanatomicfixation
Anatomy
Labrumdeepens
theglenoidsocket
Anatomy
IGHL+Capsule=Hammock
Pathoanatomy – Labrum
Detachmentofthehammockontheglenoidside
Lossofchockblock
Presentin > 90%ofalltraumaticanterior shoulderdislocations
BANKARTlesion
Pathoanatomy – Labrum
AnteriorLabrumPeriostealSleeveAvulsion
Labroligamentous complexmustbemobilizedfromtheglenoidandreattachedanatomically
ALPSAlesion
Pathoanatomy – Labrum
Inthe settingofshoulderinstability,superiorlabrumtearsshould alwaysberepaired
Bankart andSLAPlesion(TypeVSLAPlesion)
40% inpatientswithchronicanteriorinstability
Hantes,AJSM2009
Pathoanatomy – Ligaments
Plasticdeformationoftheglenohumeral ligamentsisaprominentfactorinrecurrentinstability
CapsularDistension
Pathoanatomy – Ligaments
HumeralAvulsionofGlenohumeral Ligament
Surgicaltechniqueisbasedonthesurgeon’sexperience
HAGLlesion
Pathoanatomy – RotatorCuff
ü RepairBankart +RCinyounghighdemandingpts
ü RepairRConlyinolderlowdemandingpts
ü 30%ofpatients>40yearsofage
ü 80%ofpatients>60yearsofage
Pathoanatomy – Bone
GlenoidErosion(invertedpear)
5%-56%ofchronictraumaticanteriorinstabilitycases
Fujii, JSES2008Tauber,JSES2007
Lossoftheanteriorglenoidconcavityreducestheeffectivenessoftheconcavity–compressionmechanism
Lessforceisrequiredtodislocatetheshoulder
Pathoanatomy – Bone
>25%ofbonelossisacontraindicationforarthroscopicrepair
Pathoanatomy – Bone
Hill-SachsLesion
Pathoanatomy – Bone
Hill-SachsLesion
PatientSelection
PatientSelection
AllthepatientsareNOT candidatesforanarthroscopicBankart repair
PatientSelection
Riskfactorsforrecurrence:
ü Youngage
ü Malesex
ü Competitivelevelofsports
ü Contactsports
ü Excessivecapsularlaxity
ü Largegleno-humeralbonedefects
Randelli,KSSTA2012
2006
ISIS<3• <5%recurrence• arthroscopic repair
ISIS3– 6• 5- 10%recurrence• ???repair
ISIS>6• 70%recurrence• openrepair
ArthroscopicBankart Repair
GeneralPrinciples:
ü Reattachment oftheanteroinferior labrum
meticulousanatomicrepair
ü Reestablishmentofpropertensionintheinferior
glenohumeral ligamentcomplex
LateralDecubitusPosition
Doubletractionsystem
Providesbetteraccesstothecapsuleandtheaxillarypouch
ArthroscopicPortals
StandardposteriorportalBonyLandamarks
ArthroscopicPortals
AnteriorSuperiorAnteriorInferior
working working- viewing
DiagnosticArthroscopy
Lookforadditionalpathology
smallbonyBankart loosebody
SLAP
HAGL
Assessthelesion
Anterosuperior portalprovidesthebestview
Measureglenoidboneloss
Preparethelesion
• Dissectthecapsulolabralsleevefromtheanteriorglenoidneck
• Rasptheanteriorglenoidtocreateableedingbonesurface
• Correctmediallydisplacedlabrum(ALPSAlesion)
• Freecapsuletotallyand“float”thelabrumuptotheleveloftheglenoid
Placea5o’clockanchor
Theholesaredrilledatthemarginofthearticularsurfacetoallowrecreationoftheglenoidconcavity
Distal-to-proximalcapsuleshift
Passthesuturesthroughthecapsuledistaltotheanchor,accomplishingadistal-to-proximalshift
Createananteriorcapsulolabral “bumper”
Atleast3sutureanchorsshouldbeplaced
End-pointAssessment
Thehumeralheadiscenteredontheglenoid
Nodrivethroughsign
ConcomitantSLAPlesion
PortofWilmingtonforSLAPIIrepair
ü No/smallbonedefect(<25%)=>arthroscopicBankart repair
ü LargeacutebonyBankart =>earlyfixation
ü LargechronicbonyBankart =>Latarjet
ü Normalglenoidw/largeHill-Sachs=>arthroscopicBankartrepair+remplissage
ü Bordeline largebonelossoneitherside=>arthroscopicBankart repair+remplissage
Recommendations
ü Alwayslookforconcomitantpathologies
ü Patientprofileisveryimportantinthedecisionmaking
üGlenoidandhumeralbonelossarecommonsequelaoftraumaticanteriorshoulderinstability
üGlenoiddefectsaremoreimportantinshoulderinstability
Conclusions