What are the limits of arthroscopic shoulder instability repair Emmanuel Antonogiannakis Director Of “Center for Shoulder Arthroscopy” ΙΑΣΩ General Hospital, Athens

The Shoulder Greatest Range of Motion in the Body Motion in all 3 planes of movement Prone to injuries 8-20% of all sports injuries

Instability Biomechanical Dysfunction Failure of static and dynamic stabilizers Ranges from mild subluxation to traumatic dislocation

T.U.B.S. T.U.B.S. Traumatic Unidirectional Bankart lesion Surgery A.M.B.R.I. A.M.B.R.I. Atraumatic Multidirectional Bilateral Rehabilitation Inferior capsular shift A.I.O.S. A.I.O.S. Acquired Instability Overstress Surgery Instability Profiles

Types of instability Not a black or white issue

Patients of all ages and all activity levels with recurrent anterior instability who are impaired functionally and in whom nonoperative treatment has failed Revision stabilization First-time, acute shoulder dislocations Arthroscopic Shoulder Stabilization Patient Selection

Arthroscopic Reconstruction Success rate %

High Initial Failure Rate of Arthroscopic Techniques Technical factors (medial repair) Failure to treat other lesions (RI, capsular laxity) Failure to recognize the importance of the dynamic stabilizers and the rehabilitation program

Unidirectional, traumatic instability Bankart lesion First dislocation Robust labroligamentous tissue Low activity level no athletes Experienced surgeon The Ideal Patient

As Dr Rockwood proposed following all the above limitations probably no-one should be treated arthroscopic

What have we learned ?

Bankart Lesion the essential lesion Avulsion of the IGHL from the glenoid rim from 2 o’clock to 6 o’clock Primary restraint to anterior translation at 90 o of abduction 85% in traumatic anterior dislocations Not enough to induce symptomatic instability

Bankart Lesion

Recurrent dislocations also can cause stretching of the glenohumeral capsule and ligaments This plastic deformation occurs from repetitive loading Bankart Lesion Equivalent

BONY LESIONS Humeral Head Glenoid rim LABRAL - LIGAMENTOUS INJURY Bankart lesion A.L.P.S.A. H.A.G.L. Capsular Tear INCREASED CAPSULAR VOLUME Atraumatic elongation Traumatic stretch Associated Lesions BICEPS LESIONS ROTATOR CUFF TEARS Partial thickness Full thickness ROTATOR INTERVAL PATHOLOGY Widening Synovitis Rupture

Hill-Sachs humerus glenoid Indentation fracture Present in 85% of recurrent dislocations

SLAP II SLAP IV

Arthroscopic Shoulder Reconstruction Goal of the Operation: Restoration of the Labrum to its anatomic attachment Reestablishment of the appropriate tension in the GH ligaments and capsule

Goal of arthroscopic shoulder reconstruction Proximal Shift of the Capsule

Arthroscopic Reconstruction: Technique 1. Define Pathology 2. Debride damaged tissue 3. Release capsule to/past 6 o’clock 4. Abrade glenoid 5. Repair capsulolabral complex 6. Associated Injuries (Posterior capsule, Rotator Interval, SLAP)

1. Identify and Define Pathology

Scope in Anterior-Superior Portal Change portals

Mobilization of Anterior Labrum

Anchor Placement

1 st suture passage

Knot Tying

Evaluation of Repair

Postoperative Rehabilitation Sling for 4/52 Isometrics and pendulum exercises immediately Active forward elevation may begin after 3/52 External rotation to 30° to 40° at 4/52 Progressive strengthening at 8/52 Return to sport at 18 to 36 weeks supervised and individualized

Arthroscopic Stabilization of the Shoulder: A Prospective Randomized Study of Absorbable Versus Nonabsorbable Suture Anchors Frostick, et all Arthroscopy, July, patients mean follow-up: 2.6 years Lost to follow-up 5%. Redislocation rate 6%.

The “Purse-String” Technique: An Arthroscopic Technique for Stabilization of the anteroinferior instability of the Shoulder. Early and Medium-Term Results Ofer Levy et all Arthroscopy January, pt (37 shoulders). Follow up : 36 months (range, 27 to 87 months). 2 recurences (5.4%) 97% returned to the same sport that they had played before injury. 66% of patients returned to their preinjury level of sports

Arthroscopic anterior stabilization and posterior capsular plication for anterior glenohumeral Instability: A Report of 71 Cases J. Snyder, M.D. et all Arthroscopy, May patients (follow-up m.a months) 5 redislocations 7% 97% of patients reported they were able to return to their normal activity level, 90% of patients reported that they were able to return to their previous level of athletics

Glenoid Bone Loss > 30% Limitations of the Arthroscopic Techniques

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 S.S. Burkhart and J. F. De Beer, M.D. Arthroscopy,October 2000

  Total group: 194 patients   173 pt without significant bone defects : 7 pt sustained a recurrence (4%)   21 pt with significant bone defects: 14 pt developed recurrent instability(67%)

Arthroscopy December 2006 Arthroscopic Management of Traumatic Anterior Shoulder Instability in Collision Athletes: Analysis of 204 Cases With a 4- to 9-Year Follow-Up and Results With the Suture Anchor Technique Larrain et all

204 rugby players with acute or recurrent traumatic anterior instability   mean follow-up 5.9 years   39 cases of acute instability : arthroscopic stabilization : 2 redislocations (5.1%)   158 cases of recurrent instability : 121 arthroscopic stabilization: 10 recurences(8.3%)

The level of athletic activity after arthroscopic stabilization probably is not a factor of recurence,the presence of bone defects is!!

Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim

Engaging Hill-Sachs Lesion Articular Arc Deficit glenoid humeral head anterior capsule

Limitations of the Arthroscopic Techniques   Glenoid Bone Loss > 30% Open Latarjet procedure

  Glenoid Bone Loss > 30% Arthroscopic Latarjet procedure L. Lafosse Arthroscopic shoulder stabilization with a bone block E. Taverna et all Nice shoulder course 2006 Limitations of the Arthroscopic Techniques

Engaging Hill-Sachs

  Engaging Hill-Sachs-glenoid bone loss Limitations of the Arthroscopic Techniques Hill- Sachs Remplisage: An arthroscopic surgical solution for the engaging Hill-Sachs E.M. Wolf Nice shoulder course 2006

Hill- Sachs Remplisage

HAGL lesions Limitations of the Arthroscopic Techniques

  HAGL lesions Limitations of the Arthroscopic Techniques Arthroscopic repair of HAGL and reverse HAGL lesions A Cowboy’s guide to advanced shoulder arthroscopy Burkhart’s view of the shoulder

 Absent destroyed capsule i.e.Thermal shrinkage i.e.Thermal shrinkage Allograft reconstruction Allograft reconstruction Limitations of the Arthroscopic Techniques

Chronic Locked dislocation Irreducible dislocations

Large Hill-Sachs lesion Large Hill-Sachs lesion Allograft reconstruction Allograft reconstruction or prosthetic replacement or prosthetic replacement Limitations of the Arthroscopic Techniques

Conclusions  Arthroscopic shoulder stabilization gained wider acceptance  Repair of all the lesions found is essential for long term good results  Restoration of the dynamic stabilizers i.e. a supervised rehabilitation program is essential  the athroscopic treatment of bone defects and soft tissue loss is the next chalenge  The experience of the surgeon and the ability to recognize the anatomic structures sets the limits of arthroscopic shoulder stabilization