Anterior Glenohumeral Instability

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Presentation transcript:

Anterior Glenohumeral Instability John W. Sperling, MD

Anterior Glenohumeral Instability

Anterior Glenohumeral Instability Introduction Rockwood and Green: 1400 references Clinics in Sports Medicine x 2 Common 1.7% [Sweden; Hovelis] 8.2/100,000 [Rochester, MN] Males 2x> Females Surgeons and Primary Care physicians Emerging areas of treatment

Anterior Glenohumeral Instability Overview Classification Anatomy/Biomechanics Mechanisms of Injury Patient Presentation/Evaluation Treatment Reduction Rehabilitation Surgery: Open vs Arthroscopic

Anterior Glenohumeral Instability Classification Voluntary vs Involuntary Direction Traumatic vs Atraumatic overuse vs hyperlaxity Acute vs Chronic Subluxation vs Dislocation

Anterior Glenohumeral Instability Classification

Anterior Glenohumeral Instability Classification Instability Spectrum TUBS AMBRI Atraumatic Multi-directional Bilateral Responds to Rehab Inferior Capsular Shift Traumatic Unilateral Bankart Surgery

Anterior Glenohumeral Instability Anatomy Built for Mobility not Stability Important neurovascular structures Complex: Movers vs Stabilizers

Anterior Glenohumeral Instability Shoulder Anatomy

Anterior Glenohumeral Instability Shoulder Anatomy: Anterior

Anterior Glenohumeral Instability Shoulder Anatomy: Posterior

Anterior Glenohumeral Instability Anatomy Glenoid Labrum Glenohumeral Ligaments

Anterior Glenohumeral Instability Glenohumeral Ligament Complex Biceps Tendon Rotator Cuff Sup. GH Lig Subscapularis Humeral Head

Anterior Glenohumeral Instability Biomechanics: Static Congruity of articular surface of glenoid Labrum: increases contact area by 50% Negative intra-articular pressure

Anterior Glenohumeral Instability Labral Anatomy

Anterior Glenohumeral Instability Biomechanics: Dynamic Glenohumeral ligaments: different roles in different positions Rotator cuff: dynamic compression/steering effect Biceps tendon active stabilizer

Anterior Glenohumeral Instability IGHL Anterior Slip

Anterior Glenohumeral Instability Mechanism of injury Outstretched/Abducted/Externally Rotated Young: athletic Older: fall

Anterior Glenohumeral Instability Mechanism of Injury

Anterior Glenohumeral Instability Patient Presentation Anterior shoulder deformity Holds arm abducted/externally rotated Unable to adduct/internally rotate arm

Anterior Glenohumeral Instability Patient Presentation

Anterior Glenohumeral Instability Patient Evaluation Complete neurovascular exam: 30-60% will have neurologic injury (axillary/brachial plexus) vascular injuries are rare Radiographs A/P Axillary Scapular Y/Neer view

Anterior Glenohumeral Instability Treatment Adequate analgesia Various reduction maneuvers Repeat neurovascular exam Post-reduction x-rays

Anterior Glenohumeral Instability Reduction Techniques Rockwood and Green’s Fractures in Adults, 4th Ed; 1996

Anterior Glenohumeral Instability Hippocratic Technique Modified Hippocratic Technique Skeletal Trauma, 2nd Ed., 1998

Anterior Glenohumeral Instability Stimson Technique Scapular Rotation Maneuver Skeletal Trauma, 2nd Ed., 1998

Anterior Glenohumeral Instability Kocher Technique Milch Technique Skeletal Trauma, 2nd Ed., 1998

Anterior Glenohumeral Instability Aronen Self -Reduction Technique

Anterior Glenohumeral Instability Radiographs True A/P x-ray Internal Rotation External Rotation

Anterior Glenohumeral Instability Radiographs Axillary x-ray

Anterior Glenohumeral Instability Radiographs Stryker-Notch View

Anterior Glenohumeral Instability Associated Injuries Bankart Lesion: (85-90%) Hill-Sachs: up to 70% Rotator Cuff: age dependent; 65% of patients >50: Ribbans et al. JBJS 1990 Greater tuberosity fractures: 10-33% Glenoid rim fractures: 5% SLAP lesions: 5% Coracoid process fractures

Anterior Glenohumeral Instability Bankart Lesion Bankart Lesion Classification

Anterior Glenohumeral Instability Labral Tear

Anterior Glenohumeral Instability Normal Labrum

Anterior Glenohumeral Instability Associated Injuries Bankart Lesion: (85-90%) Hill-Sachs: up to 70% Rotator Cuff: age dependent; 65% of patients >50: Ribbans et al. JBJS 1990 Greater tuberosity fractures: 10-33% Glenoid rim fractures: 5% SLAP lesions: 5% Coracoid process fractures:

Anterior Glenohumeral Instability Hill-Sachs Lesion Normal Humeral Cartilage

Anterior Glenohumeral Instability Associated Injuries Bankart Lesion: (85-90%) Hill-Sachs: up to 70% Rotator Cuff: age dependent; 65% of patients >50: Ribbans et al. JBJS 1990 Greater tuberosity fractures: 10-33% Glenoid rim fractures: 5% SLAP lesions: 5% Coracoid process fractures:

Anterior Glenohumeral Instability Post Reduction Care Immobilization and Rehabilitation Surgery

Anterior Glenohumeral Instability

Anterior Glenohumeral Instability Natural History

Anterior Glenohumeral Instability Natural History McLaughlin and Cavallaro: Am J Surg, 1950 Rowe: Orth Clin NA, 1980 Simonet and Cofield: AJSM, 1984 Hovelius et al: JBJS, 1983 96% of recurrent dislocators have initial episode younger than 30

Anterior Glenohumeral Instability Immobilization Watson Jones: 4 weeks, 0 redislocation: JBJS, 1948 Rowe: 3 weeks maximum: Clin Ortho, 1961 Kiviluota et all: higher rate < 30 y/o: 1 week vs 3 weeks: Acta Ortho Scand, 1980 Hovelius: no difference < 40 y/o: 3-4 weeks vs early mobilization: ASES, 1994 Aronen and Regan: 25% re-dislocation rate with aggressive program: AJSM, 1984

Anterior Glenohumeral Instability Rehabilitation Immobilization Age dependent Early passive range of motion Strengthening in scapular plane of motion Restore dynamic stability of rotator cuff Sport specific activities

Anterior Glenohumeral Instability Recurrent Instability Essential Lesion ?: Bankart Capsular tear Injury to subscapularis Cadaveric Studies Apreleva et al: JBJS,1998: Speer et al: JBJS, 1994 Bigliani et al: J Ortho Res, 1992 Clinical Experience

Anterior Glenohumeral Instability Dr. Bankart British Medical Journal 2:1132, 1923

Anterior Glenohumeral Instability Repair of Recurrent Instability Open: History Hippocrates Perthes, 1906 Bankart, 1923: Capsulolabral repair 250 Different procedures described Induce scarring: Putti-Platt, Magnusun-Stack Bony Block: Bristow Osteotomies to change orientation of Glenoid/Humerus Anatomic Reconstruction: Bankart

Anterior Glenohumeral Instability Apprehension Sign

Anterior Glenohumeral Instability Open Bankart Repair

Anterior Glenohumeral Instability Open Bankart Repair

Anterior Glenohumeral Instability Open Bankart Repair

Anterior Glenohumeral Instability Open Bankart Repair

Anterior Glenohumeral Instability Open Repair of Recurrent Instability Very successful: Less than 5% recurrence rate One problem for another: O’Driscoll: JBJS, 1993 Subjective 50% altered quality of life 30% gave up physical activities 24% abnormal sensations 51% pain with certain positions 6% changed jobs 33% perceived they were weaker

Anterior Glenohumeral Instability Open Repair of Recurrent Instability Functional outcomes Loss of motion Loss of strength Complications wound infection neural injuries arthritis

Anterior Glenohumeral Instability Arthroscopic Repair of Recurrent Instability Staples Sutures Suture Anchors Absorbable Tacks Recurrence Rates 0 to 49% (Average 22% of 388 cases reported) Acute arthroscopic repair: 13% (all traumatic) Arciero et al: Clin Sports Med, 1995

Anterior Glenohumeral Instability Suture Arthroscopic Suture Repair

Anterior Glenohumeral Instability Arthroscopic Bankart Repair: Suture

Anterior Glenohumeral Instability Arthroscopic Bankart Repair: Suture

Anterior Glenohumeral Instability Arthroscopic Bankart Repair: Suture

Anterior Glenohumeral Instability Arthroscopic Bankart Repair: Tacks

Anterior Glenohumeral Instability Arthroscopic Bankart Repair: Tacks

Anterior Glenohumeral Instability Arthroscopic Bankart Repair: Tacks

Anterior Glenohumeral Instability Arthroscopic vs Open Repair

Anterior Glenohumeral Instability Arthroscopic vs Open Repair

Anterior Glenohumeral Instability Arthroscopic vs Open Repair

Anterior Glenohumeral Instability Summary Traumatic anterior glenohumeral dislocations are common Complete physical and radiographic examination is imperative Adequate analgesia for reduction Immobilization according to age

Anterior Glenohumeral Instability Summary Rehabilitation is effective in older, less active patients Consider early arthroscopic repair in young, high demand athletes Patient selection is key to success in Open versus Arthroscopic repair in recurrent dislocations

Anterior Glenohumeral Instability