1. Arthroscopic Findings and Treatment of Shoulder Instability Emmanuel Antonogiannakis,M.D. Center For Shoulder arthroscopy IASO gen. hospital Athens Greece

2. 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

3. How common is shoulder dislocation; 2% of the general population 90% anterior

4. Classification Schemes Mechanism –Traumatic –Atraumatic –Congenital –Neuromuscular Frequency –Acute –Chronic –Recurrent –Involuntary –Voluntary Mechanism –Traumatic –Atraumatic –Congenital –Neuromuscular Frequency –Acute –Chronic –Recurrent –Involuntary –Voluntary Direction –Anterior (and inferior) –Posterior (and inferior) –Superior? –Multidirectional Extent –Subluxation –Dislocation Direction –Anterior (and inferior) –Posterior (and inferior) –Superior? –Multidirectional Extent –Subluxation –Dislocation

5. TRAUMA What is Traumatic Shoulder Instability ?

6. 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

7. TUBS AIOS AMBRI

8. The Spectrum of Instability Lesions –Minor instability with activity related pain –Recurrent subluxation –Recurrent dislocation –Locked dislocation with loss of motion

9. The Most Important Factors In Treating Instability Are Recognizing It And Defining It.

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

11. Direction of the Instability Unidirectional Bidirectional Multidirectional Anterior Posterior

12. Mechanisms of Glenohumeral Stability Static Dynamic Negative Intra- articular pressure Labrum (50% of Glenoid depth) Capsule Ligaments- Glenohumeral- Superior, Middle & Inferior (stability & proprioception) Rotator cuff tension

13. Glenohumeral Ligament Variations 66% - Well defined SGHL, MGHL & IGHL 7% - Confluent MGHL & IGHL 19% - Cordlike MGHL with a high riding attachment 8% - No discernable MGHL – IGHL but one confluent anterior capsular sheath

14. Loose Shoulder

15. Pathology of Anterior Instability Lax Capsule Bankart’s lesion # glenoid rim Shape of Glenoid Posterolateral head defect

16. 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

17. Bankart Lesion

18. Anterior Shoulder Instability

19. Bankart Lesion

20. ALPSA lesion

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

23. 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

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

25. SLAP II

26. SLAP III

27. SLAP IV

28. Posterior Capsular Stretching

29. 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

30. 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

31. Goal of arthroscopic shoulder reconstruction Proximal Shift and Restoration of Capsular Tension

32. Examination Under Anaesthesia In various degrees of abduction and ER Side-to-side comparisons Sulcus sign

33. Lateral Decubitus Position Abduction 70 o Traction 3-5 kg

34. Beach Chair Position

35. Portals: Left Shoulder HEAD anteriorposterior

36. Surgical Technique

37. Arthroscopic Reconstruction: Technique 1. Define Pathology 2. Debride damaged tissue 3. Release capsule to/past 6 o’clock 4. Free off subscapularis 5. Abrade glenoid 6. Repair capsulolabral complex 7. Associated Injuries (Posterior capsule, Rotator Interval, SLAP)

38. humerus Bankart lesion glenoid 1. Identify and Define Pathology

39. glenoid rim anterior labrum 2. Mobilize Bankart Lesion and Abrade Glenoid Rim

41. 1 st anchor 5 o’clock 2 nd anchor3 o’clock 3 rd anchor2 o’clock 3. Anchor Insertion 3-4 mm on the articular rim from inferior to superior

42. anchor insertion

43. capsule penetration

45. humerus labrum 4. Suture Passing

46. humerus labrum Completed repair Capsular shift 5. Knot Tying

47. humerus labrum completed repair 6. Assessment of the Final Repair

48. completed repair

49. 7. Associated Pathology RI laxity Posterior Capsule Ant. Capsular Stretch HAGL SLAP Hill-Sachs

50. SLAP repair

51. the capsular “pinch-tuck” technique adjunctive thermal treatment rotator interval closure How to Reduce Capsule Redundancy

52. humerus rotator interval Rotator Interval Closure in external rotation

53. Posterior capsule reefing

54. Posterior Instability

57. Bankart Lesion Healing A second-look arthroscopic study

58. Case 1 labrum Humeral head glenoid 10 months later before Avulsed labrum

59. 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

60. Glenoid Bone Loss > 30% Engaging Hill-Sachs HAGL lesions Limitations of the Arthroscopic Techniques

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

62. The normal glenoid shape

63. Inverted pear glenoid

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

66. Arthroscopic vs Open Shoulder Reconstruction Less trauma Better cosmesis Addresses associated pathology Less postoperative pain On an outpatient basis Faster surgery Better ROM Return to sports Similar recurrence rate Patient Demand Insurance Policy (Less cost) Equipment dependent

67. Open Shoulder Reconstruction familiar to most orthopaedic surgeons requires little special equipment reasonably reproducible recurrence rate addresses large glenoid bone defects

68. Neither technique is "easy" The operation should be tailored to the patient and not the patient to the operation. Both techniques are equivalent in terms of “success”

69. Arthroscopic Techniques are suitable for almost every instability problem Arthroscopic stabilization is the technique of choice when confronted with the patient exhibiting unilateral anterior shoulder instability

70. Keys to Success Mobilization of capsule South to north transfer Anchors on the glenoid At least 3 double suture loaded anchors Address secondary lesions Address capsular laxity Individualized and supervised rehabilitation

71. Conclusions Arthroscopic instability repair gained wider acceptance Results are equivalent to open repairs It is technically demanding but feasible With experience most of the instability problems can be treated arthroscopic