instability of the shoulder - thal
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Instability of theInstability of the
ShoulderShoulder
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ArthroscopicArthroscopic
Treatment ofTreatment ofShoulderShoulder
InstabilityInstability
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StaticStaticShoulder StabilizersShoulder Stabilizers
Bony ArchitectureGlenoid Labrum
Negative Intraarticular pressureGlenohumeral Ligaments
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D
ynamicD
ynamicShoulder StabilizersShoulder Stabilizers
Rotator CuffProprioception
Biceps TendonScapulothoracic Motion
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Bony ArchitectureBony ArchitectureHumeral & glenoid surfaces are quite
congruentGlenoid articular surface is thickest at
the periphery increasing congruency
Little impact on shoulder stability
? Role of humeral & glenoid version
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Intraarticular PressureIntraarticular PressureNegative intaarticular pressure
(vacuum effect)Venting the capsule reduces translation
force requirements
Greater relative importance in neutral
position & early ROM
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Glenohumeral
GlenohumeralLigamentsLigaments
Descrete thickenings of the capsuleTension at extremes of motion
Primary static stabilizers IGHL complex - primary AP stabilizer
in abduction
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Shoulder StabilizingShoulder StabilizingMechanismsMechanisms
Turkel , et alTurkel , et alJBJS 1981JBJS 1981
as the shoulder approaches 90 of
abduction, the IGHL prevents
dislocation during ER
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Anatomy of theAnatomy of the
IGHL ComplexIGHL ComplexOBrien SJ, et alOBrien SJ, et alAJSM, 1990AJSM, 1990
Hammock providing A/P stability
to the abducted shoulder
Stability may require accurate re-establishment of the normal
ligament anatomy
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Rotator CuffRotator Cuff Joint compression effect
Preload GH ligaments
Increased importance in unstable
shoulderRationale for conservative treatment
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Biceps TendonBiceps Tendon Joint compression effectContributes to anterior stability
Created SLAP lesion leads toincreased IGHL strain in Abd/ER
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Stabilizers &Stabilizers &Arm PositionArm PositionNeutral position - Intra-articularpressure & muscles
Midrange - Increased role of rotator
cuff
Extremes of motion - GH ligaments
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Essential LesionEssential Lesion
Bankart LesionHumeral avulsion
IGHL stretch injury
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ALPSA LesionALPSA LesionNeviaser TJNeviaser TJArthroscopy, 1993Arthroscopy, 1993
AnteriorLabral Ligamentous Periosteal
Sleeve Avulsion
Common variant of a Bankart lesion
Medial/inferior periosteal sleeve migrationPosition of the healed ligament is critical
Avoid medial reattachment
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ALPSA LesionALPSA LesionNeviaser TJNeviaser TJArthroscopy, 1993Arthroscopy, 1993
Common variant of a Bankart lesionMedial/inferior periosteal sleeve
migration
Position of the healed ligament is critical
Avoid medial reattachment
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Bankart LesionBankart LesionBiomechanicsBiomechanics
Speer KP, et alSpeer KP, et alJBJS 1994JBJS 1994
Cadaveric Study
Bankart lesion alone does not allow
complete dislocation of the shoulderPostulate: Capsular stretch is
necessary for complete dislocation
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Tensile PropertiesTensile Propertiesof IGHLof IGHLBigliani, et alBigliani, et al
J Ortho Research, 1992J Ortho Research, 1992
Cadaveric Study (elderly specimen)
Significant capsular stretch occurred
before failure, regardless of failure modeElogation rates 0.4 mm/s & 4.0 mm/s
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Capsular Stretch??Capsular Stretch??Harryman, DT (Letter to Grana)Harryman, DT (Letter to Grana)Arthroscopy, 1994Arthroscopy, 1994
Questions whether capsular stretch is part
of the essential lesion of traumaticinstability
There are no clinical studies thatdocument persistent capsule laxity
Any persistent capsule laxity can beeliminated by working within the avulsion
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CapsularElasticity &CapsularElasticity &VolumeVolume
SperberA, et alSperberA, et alArthroscopy, 1994Arthroscopy, 1994
In vivo study
Evaluated capsular elasticity & joint
volume by measured saline infusionFound no difference between stable &
unstable shoulders
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Open BankartRepairOpen BankartRepairThomas SC & Matsen FAThomas SC & Matsen FA
JBJS, 1989JBJS, 1989
39 shoulders (2-11 year f/u)
Repair only the Bankart lesion
No capsular overlap or plication
1 Recurrence (2.6%)2 Apprehesive (5%)
ave. 84o ER (90o Abd) (43o-108o)
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Open BankartRepairOpen BankartRepairThomas SC & Matsen FAThomas SC & Matsen FA
JBJS, 1989JBJS, 1989
Leave the tissues as healthy &undamaged as possible
Minimize unnecessary dissection
Directly repair the structural defectAdequate repair strength without
capsule overlap
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Open BankartRepairOpen BankartRepairTechniqueTechnique
Thomas SC & Matsen FAThomas SC & Matsen FAJBJS, 1989JBJS, 1989
Curette glenoid neck to bleeding bone
3 drill holes - 4mm onto articular
surface#2 nonabsorbable sutures
Place sutures in capsule to secure, not
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Open BankartRepairOpen BankartRepairTechniqueTechnique
Thomas SC & Matsen FAThomas SC & Matsen FAJBJS, 1989JBJS, 1989
Knots are tied onto the articular surface
Check the repair by palpation
Anatomically repair thesubscapularis/capsule (lateralization is
rarely necessary)
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Open Techniques forOpen Techniques for
Shoulder InstabilityShoulder InstabilityCapsule & Labrum Repair
Capsulorrhaphy
Muscle Plication Procedures
Muscle & Tendon Sling ProceduresBone Block Procedures
Osteotomies
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Open BankartRepairOpen BankartRepairRowe CR, et. al.Rowe CR, et. al.
JBJS, 1978JBJS, 1978
145 patients (146 shoulders)
ave f/u - 6 years (1-30 years)
3% redislocation (5 patients)
69% had full external rotation30 overhead athletes - 10 (33%) returned
as well as pre-op
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Open BankartRepairOpen BankartRepairGill TJ, et alGill TJ, et al
JBJS, 1997JBJS, 1997
56 patients - (60 shoulders)
min. f/u - 8 years (mean 11.9 years)
5% redislocation
mean loss of ER - 12 (0 - 30 )
37% - difficult or unable to sleep on shoulder
52% - throw normally postop
50% - work overhead normally
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Open BankartRepairOpen BankartRepair
AdvantagesAdvantages
low redislocation ratesfamiliar surgical approach
familiar equipment
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Open BankartRepairOpen BankartRepair
DisadvantagesDisadvantages
technically difficultarticular cartilage damage
loss of motion - particularly ER
some are functionally worse
cosmesis
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Arthroscopic BankartRepairArthroscopic BankartRepair
GOALSGOALSrestore stability
maintain range of motion
secure, direct suture repair at
multiple sites (mimic open repair)ability to shift capsule
sim le
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Arthroscopic BankartRepairArthroscopic BankartRepair
GOALSGOALSRepair pathology (Bankart Lesion)
Address Capsular Laxity
Plication within Bankart repair
Capsular plication
Thermal
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Arthroscopic BankartRepairArthroscopic BankartRepair
AdvantagesAdvantages
Maintenance of range of motion
Decreased postoperative pain
Shorter recovery
Complete glenohumeral evaluation
More cosmetic incisions
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Arthroscopic BankartArthroscopic Bankart
Repair TechniquesRepair Techniques
staples, rivets, screwsbioabsorbable tacks
(Suretac)
transglenoid suture repair
suture anchor re air
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Arthroscopic Staple RepairArthroscopic Staple RepairHawkins RBHawkins RBArthroscopy, 1989Arthroscopy, 1989
50 shoulders (47 patients)
ave f/u - 39.4 months (18-54)
16% redislocation
normal ROM by 6 weeks postopcomplications: 2 loose staples, 1 broken
staple, 1 tissue pullout
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Arthroscopic Staple RepairArthroscopic Staple RepairLane JG, et alLane JG, et alArthroscopy, 1993Arthroscopy, 1993
54 shouldersave f/u - 39 months
33% redislocationave loss of ER - 5
15% loose staples
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Suretac RepairSuretac RepairWarner JJP, et alWarner JJP, et alOrtho. Trans., 1991Ortho. Trans., 1991
20 patients
ave f/u - 32 months (24-50)
10% recurrence rate
mean loss of ER - 7 (0 - 10 )
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Suretac RepairSuretac RepairSpeer KP, Warren RF, et alSpeer KP, Warren RF, et al
JBJS, 1996JBJS, 1996
52 patientsave f/u - 42 months (24-60)
21% recurrenceave loss of ER - 6
healed Bankart in 7/8 at reoperation
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Transglenoid Suture RepairTransglenoid Suture RepairSavoie FH, et alSavoie FH, et al
Arthroscopy, 1997Arthroscopy, 1997
161 patients
ave f/u - 58.4 months (36-72)
9% recurrence
2.5% recurrence > age 2226% recurrence < age 18
ROM > 90 degrees in all patients
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Transglenoid Suture RepairTransglenoid Suture RepairGrana WA, et alGrana WA, et alAJSM, 1993AJSM, 1993
27 patients
44% recurrence (8/12 not compliant)
70% < age 20
2 sutures used
ROM not recorded
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SUTURESUTURE
ANCHORSANCHORS
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OptimizingOptimizing
Arthroscopic KnotsArthroscopic KnotsLoutzenheiserLoutzenheiserTD, et. al.TD, et. al.
Arthroscopy, 1995Arthroscopy, 1995
the loop holding capacity of
hand-tied knots was superiorto identical knots tied using apusher.
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DontDontReplaceReplace
the Knot,the Knot,EliminateEliminate thethe
KnotKnot
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Suture AnchorRepairSuture AnchorRepairSavoie, et alSavoie, et al
Arthroscopy, 1997Arthroscopy, 1997
40 patients (high demand)
ave age - 18 (16-27)
7% recurrence (all traumatic)
91% returned to sport at same levelor higher
ave ER - 112 (95 - 135 )
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Suture AnchorRepairSuture AnchorRepairWeber, SCWeber, SC
AOSSM, 1998AOSSM, 1998
106 Open , 42 Arthroscopic (min 2 year f/u)
Recurrences - Open: 3.9%, Arthro: 16.3%
ROM - Increased ER in Arthro group
Admissions - Open: 93, Arthro: 0Return to Elite Level Throwing - More
likely in Arthro group
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Open Capsular ShiftOpen Capsular ShiftBigliani LU, et alBigliani LU, et alAJSM, 1994AJSM, 1994
68 shoulders (63 athletes)
2.9% recurrence
ave age - 23
92% returned; 75% at same level5/10 throwers returned at same level
ave loss of ER - 7 (0 -30 )
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Open Capsular ShiftOpen Capsular ShiftBigliani LU, et alBigliani LU, et alAJSM, 1994AJSM, 1994
68 shoulders (63 athletes); ave age -
23
2.9% recurrence
92% returned; 75% at same level45% varsity or higher returned
5/10 throwers returned at same level
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Knotless SutureKnotless Suture
AnchorAnchor
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Knotless Suture AnchorKnotless Suture AnchorSuture StrengthSuture Strength
K n o t l e s s( # 1 E t h i b o n d L o o p )
5 5 . 9 5 lb s
G I I
(# 1 E th ib o n d )
2 4 . 3 2 lb s
G I I
(# 2 E t h i b o n d )
3 0 . 0 1 lb s
G I I
(# 5 E t h i b o n d )
5 1 . 2 9 lb s
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Capsule Shift StudyCapsule Shift StudyBerg JH, ThalR, et alBerg JH, ThalR, et al
AANAAnnual Meeting, 2000AANAAnnual Meeting, 2000
Average S ift (m m )
B ankart R epair A lone 4 .3
B arrel Stitc 6 .0
C apsular Plication *6 .5
notless Anc or *6 .8
C apsular R eduction *12 .5
* statistically significant
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Knotless Suture AnchorKnotless Suture AnchorPullout StrengthPullout Strength
(90 lb spectra fiber in place of suture)
K n o t l e s s 6 0 . 9 6 l b s
G I I 5 5 . 6 3 l b s
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Knotless Suture AnchorKnotless Suture AnchorClinicalExperienceClinicalExperience
233 Anchors inserted37 Bankart repairs (118 anchors)
28 Rotator CuffRepairs (71 anchors)
25 SLAP repairs (39 anchors)
2 Distal Biceps Tendon Repairs
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Knotless Suture AnchorKnotless Suture AnchorClinicalExperienceClinicalExperience
Complications
3 broken loops
Bankart
2 in first 13 anchors inserted 1 in last 220 anchors
1 traumatic anchor pullout - rotator cuff
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Knotless BankartKnotless BankartRepairRepair
25 patients (23 M, 2 F); 78 anchorsAve age = 27 (13 pts < age 22)
Ave f/u = 13.3 months (longest 24
months)
1 traumatic redislocation (4%)
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Knotless RotatorKnotless RotatorCuffRepairCuffRepair
28 patients (22 M, 6 F); 71 anchors
Ave age = 53
Ave f/u = 14 months (longest 23
months)
1 traumatic anchor pullout
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Capsular LaxityCapsular LaxityPlication within Bankart repair
Capsular plication
Thermal
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Knotless SutureA
nchorKnotless SutureA
nchorAvoid knot tying
Secure suture repair
Excellent capsular shift
Mimics open repair
Arthroscopic & open capability
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Technique forTechnique forA
rthroscopicA
rthroscopicKnotless SutureKnotless Suture
AnchorRepairAnchorRepair