1. Jason Phillips

2.  Labrum increases depth of glenoid  IGHL 1 0 static check to A/P and inf @ 45- 90 0  SGHL and MGHL play stabilizing roles in lower ranges of abduction Inferior Glenohumeral Ligament Complex Hunt et al. JAAOS 2007

3.  IGHL complex forms “Hammock”  Anterior band resists anterior translation in Abd/ER  Glenoid “bare spot” is central

4.  Arm in Abducted/ER positon  Was an ER reduction required?  Age?  Contact athlete/Military?  Position?  Ultimate goals?  End/Beginning of Season?

5.  Apprehension- Relocation (Instability)  AbER reproduces symptoms  Posterior force relieves  Load & Shift (Laxity)  Grade I – Up face  Grade II – To Rim w/ immediate reduction  Grade III – Over Rim Bahk et al. AJSM 2007

7. Compare translation of BOTH shoulders for any increase in anterior translation

8.  Risks for recurrent instability  Position of immobiliztion  Length of immobilization  Meeting patients goals and expectations

9.  Rowe 1980 1  <20yo = 94% recurrent instability  21-30yo = 79%  31-40yo = 50%  >40yo = 14%  Arciero 1989 2  Ave age 18yo (17-22)  3wks of immobilization (position not specified)  92% recurrence if treated nonoperatively 1.Rowe CR. Acute and recurrent anterior dislocations of the shoulder. Ortho Clin North Am 1980;11:253-70. 2. Wheeler JH, et al. Arthroscopic vs. Nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy 1989;5:213-217.

10. Arciero et al. Arthroscopic bankart vs nonoperative treatment for acute, initial anterior shoulder dislocations. AJSM 1994;22:589- 594.

11. Group 1 = immobilized IR for 3-4 weeks Group 2 = immobilized IR until patient felt comfortable Group 3 = immobilization less than 3 weeks Hovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.

14. Keys 1.Primary dislocation 2.4wks immobilized IR Robinson CM, et al. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. JBJS AM 2006;88:2326-2336.

15. Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

16. Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89: 1470-1477.

20. Osseous defect at least 21% of glenoid length may cause instability Itoi E et al. JBJS(A) 2000 Jan Anteroinferior glenoid defect diminished stability by almost 50% Bone grafting increased stability by 150% to 230% Montgomery WH et al. JBJS (A) 2005 Sept.

21.  194 consecutive arthroscopic Bankart repairs; 101 contact athletes  Recurrence in Contact Athletes:  Without significant bony defects: 6.5%  With significant bony defects: 89%  Engaging Hill-Sachs  Glenoid bone loss 25% Burkhart SS, DeBeer JF. 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. Arthroscopy 2000;16:677-694.

22. Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

23. Burkhart SS, DeBeer JF. 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. Arthroscopy 2000;16:677-694.

24. Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

25.  Cadaveric study : Quantify glenoid bone loss by arthroscopic means  “The bare spot of the glenoid…consistent reference point from which to determine glenoid bone loss…” Burkhart SS, De Beer JF et al. Arthroscopy, 2002 May

26. Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

33. 3B Effect 1.Labral repair (Bumper effect) 2.Increased bony contact via coracoid transfer (Bony effect) 3.Sling effect of conjoined tendon and lowered subscap (Belt or sling effect) Boileau et al. Orthop Clin N Am 2010;41:381-392.

34. Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta- analysis of the literature. JBJS AM 2010;92:2924-2933.

40.  RCT, Level II, 2yr f/u  198pts sling vs 10 0 ER x 3wks (ER group more compliant (68% vs 80%)  ER group w/ reduced recurrence (38% Rel. Risk)

41.  Immobilize 10 0 ER  Must initiate tx early  Most effective if <30yo

42.  Strengthen GH rotators and scapular stabilizers  Injury Prevention  Graduated Return  GOAL –To keep head centered

43.  Push-up plus  Bear hug  Seated rows  Shrugs  Upright rows Moseley et al., AJSM 1992. Decker MJ, Hawkins RJ, AJSM 1999.

46. SampleFollow UpRecurrence O’Neill JBJS 1999 4152 months5% Mazzocca AJSM 2005 1837 months11% Robinson AOSSM 2006 2851 months7%

47. Porcellini G, et al. JBJS AM 2009;91:2537-2542.

49.  At 15yrs, 98% excellent or good  At 15yrs, only 4/118 redislocated (3%) Hovelius L, et al. JSES 2004;13:509-516.