1. Anterior Glenohumeral Instability
John W. Sperling, MD

2. Anterior Glenohumeral Instability

3. 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

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

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

6. Anterior Glenohumeral Instability Classification

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

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

9. Anterior Glenohumeral Instability
Shoulder Anatomy

10. Anterior Glenohumeral Instability
Shoulder Anatomy: Anterior

11. Anterior Glenohumeral Instability
Shoulder Anatomy: Posterior

12. Anterior Glenohumeral Instability Anatomy
Glenoid
Labrum
Glenohumeral Ligaments

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

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

15. Anterior Glenohumeral Instability
Labral Anatomy

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

17. Anterior Glenohumeral Instability
IGHL
Anterior Slip

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

19. Anterior Glenohumeral Instability
Mechanism of Injury

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

21. Anterior Glenohumeral Instability
Patient Presentation

22. 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

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

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

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

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

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

28. Anterior Glenohumeral Instability
Aronen Self -Reduction Technique

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

30. Anterior Glenohumeral Instability Radiographs
Axillary x-ray

31. Anterior Glenohumeral Instability Radiographs
Stryker-Notch View

32. 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

33. Anterior Glenohumeral Instability
Bankart Lesion
Bankart Lesion Classification

34. Anterior Glenohumeral Instability
Labral Tear

35. Anterior Glenohumeral Instability
Normal Labrum

36. 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:

37. Anterior Glenohumeral Instability
Hill-Sachs Lesion
Normal Humeral Cartilage

38. 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:

39. Anterior Glenohumeral Instability Post Reduction Care
Immobilization and Rehabilitation
Surgery

40. Anterior Glenohumeral Instability

41. Anterior Glenohumeral Instability Natural History

42. 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

43. 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

44. 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

45. 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

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

47. 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

48. Anterior Glenohumeral Instability
Apprehension Sign

49. Anterior Glenohumeral Instability
Open
Bankart
Repair

50. Anterior Glenohumeral Instability
Open
Bankart
Repair

51. Anterior Glenohumeral Instability
Open
Bankart
Repair

52. Anterior Glenohumeral Instability
Open
Bankart
Repair

53. 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

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

55. 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

56. Anterior Glenohumeral Instability
Suture
Arthroscopic
Suture
Repair

57. Anterior Glenohumeral Instability
Arthroscopic Bankart Repair: Suture

58. Anterior Glenohumeral Instability
Arthroscopic Bankart Repair: Suture

59. Anterior Glenohumeral Instability
Arthroscopic Bankart Repair: Suture

60. Anterior Glenohumeral Instability
Arthroscopic Bankart Repair: Tacks

61. Anterior Glenohumeral Instability
Arthroscopic Bankart Repair: Tacks

62. Anterior Glenohumeral Instability
Arthroscopic Bankart Repair: Tacks

63. Anterior Glenohumeral Instability Arthroscopic vs Open Repair

64. Anterior Glenohumeral Instability Arthroscopic vs Open Repair

65. Anterior Glenohumeral Instability Arthroscopic vs Open Repair

66. 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

67. 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

68. Anterior Glenohumeral Instability