1. Arthroscopic Findings and Treatment of Shoulder Instability Emmanuel Antonogiannakis, 2 nd Orthopaedic Department, Athens Army Hospital WWW.SHOULDER.GR

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 WWW.SHOULDER.GR

3. Instability Biomechanical Dysfunction Failure of static and dynamic stabilizers Ranges from mild subluxation to traumatic dislocation WWW.SHOULDER.GR

4. Direction of the Instability Unidirectional Bidirectional Multidirectional Anterior Posterior WWW.SHOULDER.GR

5. 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 WWW.SHOULDER.GR

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

7. Loose Shoulder WWW.SHOULDER.GR

8. 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 WWW.SHOULDER.GR

9. Bankart Lesion WWW.SHOULDER.GR

10. WWW.SHOULDER.GR

11. ALPSA lesion WWW.SHOULDER.GR

13. WWW.SHOULDER.GR

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

15. 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 WWW.SHOULDER.GR

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

17. SLAP II WWW.SHOULDER.GR

18. SLAP III WWW.SHOULDER.GR

19. SLAP IV

20. Posterior Capsular Stretching WWW.SHOULDER.GR

21. 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 WWW.SHOULDER.GR

22. 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 WWW.SHOULDER.GR

23. Goal of arthroscopic shoulder reconstruction Proximal Shift and Restoration of Capsular Tension WWW.SHOULDER.GR

24. Lateral Decubitus Position Abduction 70 o Traction 3-5 kg WWW.SHOULDER.GR

25. Portals: Left Shoulder HEAD anteriorposterior WWW.SHOULDER.GR

26. Surgical Technique WWW.SHOULDER.GR

27. 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) WWW.SHOULDER.GR

28. humerus Bankart lesion glenoid 1. Identify and Define Pathology WWW.SHOULDER.GR

29. glenoid rim anterior labrum 2. Mobilize Bankart Lesion and Abrade Glenoid Rim WWW.SHOULDER.GR

31. 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 WWW.SHOULDER.GR

32. anchor insertion WWW.SHOULDER.GR

33. capsule penetration WWW.SHOULDER.GR

34. humerus labrum 4. Suture Passing WWW.SHOULDER.GR

35. humerus labrum Completed repair Capsular shift 5. Knot Tying WWW.SHOULDER.GR

36. humerus labrum completed repair 6. Assessment of the Final Repair WWW.SHOULDER.GR

37. completed repair WWW.SHOULDER.GR

38. 7. Associated Pathology RI laxity Posterior Capsule Ant. Capsular Stretch HAGL SLAP Hill-Sachs WWW.SHOULDER.GR

39. humerus rotator interval Rotator Interval Closure in external rotation WWW.SHOULDER.GR

40. SLAP repair

41. Posterior capsule reefing

42. Posterior Instability WWW.SHOULDER.GR

45. 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 WWW.SHOULDER.GR

46. 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 WWW.SHOULDER.GR

47. Glenoid Bone Loss > 30% Engaging Hill-Sachs HAGL lesions Limitations of the Arthroscopic Techniques WWW.SHOULDER.GR

48. Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim WWW.SHOULDER.GR

49. Engaging Hill-Sachs Lesion Articular Arc Deficit glenoid humeral head anterior capsule WWW.SHOULDER.GR

50. Recognition of normal variants and pathologic lesions Cord like MGHL Sublabral hole Bare area ♣ ALPSA ♣ PASTA ♣ HAGL, RHAGL, BHAGL ♣ SLAP ♣ Hill-Sachs ♣ Bankart-Perthes ♣ Patulous capsule ♣ Rotator interval lesions WWW.SHOULDER.GR

51. Cord like MGHL Anterior Band IGHL Subscapularis WWW.SHOULDER.GR

52. ALPSA lesion glenoid labrum capsule WWW.SHOULDER.GR

53. WWW.SHOULDER.GR