Arthroscopic management of anterior shoulder instability larissa 2016
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Transcript of Arthroscopic management of anterior shoulder instability larissa 2016
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Arthroscopicmanagementofanteriorshoulderinstability
AaronVenouziouOrthopaedic SurgeonSt.Luke’sHospital
Thessaloniki
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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.
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AnteriorShoulderInstability
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AnteriorShoulderInstability
Bankart described the detachment of the anterior
capsulo-labral complex from the glenoid as the
“Essential Lesion” of chronic shoulder instability
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3.5%recurrencerate
AnteriorShoulderInstability
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EarlyArthroscopicStabilization
Metalstaples3-33%recurrencerate
Johnson,WilsonTransglenoid sutures0-49%recurrencerate
Caspari,MorganPGAtags0-21%recurrencerate
Warner,Cole
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CurrentArthroscopicStabilization
SutureAnchorRepairRecurrence• 8% Savoie etal,1999• 4% Burkhart&DeBeer,2000• 0% Romeoetal,2000• 4% Kimetal,2003• 4.8% Sugaya etal,2005
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Whatarethekeyfactorsforasuccessfularthroscopicstabilization?
Howwesucceeded?
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Successfuloutcomedependson:
üΑssociated copathologies
üPatientprofile
üStableanatomicfixation
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Anatomy
Labrumdeepens
theglenoidsocket
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Anatomy
IGHL+Capsule=Hammock
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Pathoanatomy – Labrum
Detachmentofthehammockontheglenoidside
Lossofchockblock
Presentin > 90%ofalltraumaticanterior shoulderdislocations
BANKARTlesion
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Pathoanatomy – Labrum
AnteriorLabrumPeriostealSleeveAvulsion
Labroligamentous complexmustbemobilizedfromtheglenoidandreattachedanatomically
ALPSAlesion
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Pathoanatomy – Labrum
Inthe settingofshoulderinstability,superiorlabrumtearsshould alwaysberepaired
Bankart andSLAPlesion(TypeVSLAPlesion)
40% inpatientswithchronicanteriorinstability
Hantes,AJSM2009
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Pathoanatomy – Ligaments
Plasticdeformationoftheglenohumeral ligamentsisaprominentfactorinrecurrentinstability
CapsularDistension
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Pathoanatomy – Ligaments
HumeralAvulsionofGlenohumeral Ligament
Surgicaltechniqueisbasedonthesurgeon’sexperience
HAGLlesion
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Pathoanatomy – RotatorCuff
ü RepairBankart +RCinyounghighdemandingpts
ü RepairRConlyinolderlowdemandingpts
ü 30%ofpatients>40yearsofage
ü 80%ofpatients>60yearsofage
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Pathoanatomy – Bone
GlenoidErosion(invertedpear)
5%-56%ofchronictraumaticanteriorinstabilitycases
Fujii, JSES2008Tauber,JSES2007
Lossoftheanteriorglenoidconcavityreducestheeffectivenessoftheconcavity–compressionmechanism
Lessforceisrequiredtodislocatetheshoulder
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Pathoanatomy – Bone
>25%ofbonelossisacontraindicationforarthroscopicrepair
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Pathoanatomy – Bone
Hill-SachsLesion
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Pathoanatomy – Bone
Hill-SachsLesion
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PatientSelection
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PatientSelection
AllthepatientsareNOT candidatesforanarthroscopicBankart repair
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PatientSelection
Riskfactorsforrecurrence:
ü Youngage
ü Malesex
ü Competitivelevelofsports
ü Contactsports
ü Excessivecapsularlaxity
ü Largegleno-humeralbonedefects
Randelli,KSSTA2012
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2006
ISIS<3• <5%recurrence• arthroscopic repair
ISIS3– 6• 5- 10%recurrence• ???repair
ISIS>6• 70%recurrence• openrepair
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ArthroscopicBankart Repair
GeneralPrinciples:
ü Reattachment oftheanteroinferior labrum
meticulousanatomicrepair
ü Reestablishmentofpropertensionintheinferior
glenohumeral ligamentcomplex
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LateralDecubitusPosition
Doubletractionsystem
Providesbetteraccesstothecapsuleandtheaxillarypouch
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ArthroscopicPortals
StandardposteriorportalBonyLandamarks
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ArthroscopicPortals
AnteriorSuperiorAnteriorInferior
working working- viewing
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DiagnosticArthroscopy
Lookforadditionalpathology
smallbonyBankart loosebody
SLAP
HAGL
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Assessthelesion
Anterosuperior portalprovidesthebestview
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Measureglenoidboneloss
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Preparethelesion
• Dissectthecapsulolabralsleevefromtheanteriorglenoidneck
• Rasptheanteriorglenoidtocreateableedingbonesurface
• Correctmediallydisplacedlabrum(ALPSAlesion)
• Freecapsuletotallyand“float”thelabrumuptotheleveloftheglenoid
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Placea5o’clockanchor
Theholesaredrilledatthemarginofthearticularsurfacetoallowrecreationoftheglenoidconcavity
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Distal-to-proximalcapsuleshift
Passthesuturesthroughthecapsuledistaltotheanchor,accomplishingadistal-to-proximalshift
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Createananteriorcapsulolabral “bumper”
Atleast3sutureanchorsshouldbeplaced
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End-pointAssessment
Thehumeralheadiscenteredontheglenoid
Nodrivethroughsign
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ConcomitantSLAPlesion
PortofWilmingtonforSLAPIIrepair
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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
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ü Alwayslookforconcomitantpathologies
ü Patientprofileisveryimportantinthedecisionmaking
üGlenoidandhumeralbonelossarecommonsequelaoftraumaticanteriorshoulderinstability
üGlenoiddefectsaremoreimportantinshoulderinstability
Conclusions
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