Anatomy GH Joint. Glenohumeral Instability. Components of Stability. Components of Stability 7/7/2017. AllinaHealthSystem
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1 Glenohumeral Instability Dr. John Steubs Allina Sports Medicine Conference July 7, 2017 Anatomy GH Joint Teardrop or oval shape Inherently unstable Golf ball and tee analogy Stabilizers Static Dynamic Components of Stability Components of Stability Static Restraints Version Surface area/contact Labrum Capsuloligamentous structures Dynamic restraints Joint compression Rotator cuff complex Ligament dynamization Scapulothoracic motion Negative intra-articular pressure
2 Glenohumeral Muscles Rotator cuff muscles Instability Spectrum Traumatic Microtrauma Atraumatic Supraspinatus Infraspinatus Teres minor Subscapularis Less laxity Unidirectional More laxity Multidirectional Classification Frequency Acute Recurrent Fixed (chronic) Cause Traumatic event (macrotrauma) Atraumatic event (voluntary, involuntary) Microtrauma Congenital condition Neuromuscular condition (cerebral palsy, seizures) Direction Anterior Posterior Inferior Multidirectional Degree Dislocation Subluxation Microtrauma Classification
3 Classification Classification Traumatic Usually position players Often non-dominant arm Dislocation event High likelihood of recurrence Non-traumatic (microtrauma) Often pitchers Gradual progressive +/- labral tears versus capsular laxity Dominant throwing arm Normal Pathoanatomy Bankart Lesion Anterior labral tear Clinical Evaluation - History Careful history is paramount 1st episode of dislocation or subluxation Degree of trauma - major, trivial, none Dislocation vs. subluxation Position of arm More frequent episodes Treatment
4 Clinical Evaluation - History Arm slips out Dead arm syndrome Pain Anterior/posterior pain = ant/post instability Pain in context of arm position Cocking vs. follow-through Carrying heavy items Secondary impingement Popping/clicking Physical Examination Examine both shoulders Cervical spine Generalized ligamentous laxity Shoulder Exam Muscular atrophy Tenderness AC and SC joint tenderness ROM - active & passive Winging Muscle strength Supraspinatus - 90 o scap elevation/45 o int rot Infraspinatus - 0 o scap elevation/ -45 o rot Subscapularis - lift-off Deltoid/Biceps/trapezius Anterior Apprehension Test
5 Relocation Test Posterior Apprehension Load and Shift Test Grade I - to the glenoid rim Grade II - Over the rim, spontaneous reduction Grade III - Remains dislocated Sulcus Sign 1+ Less than 1 cm cm 3+ Greater than 2 cm Pathognomonic of MDI Neutral vs. ER
6 Imaging Imaging Shoulder AP Scapular (true) AP Axillary view Outlet view Imaging Imaging Stryker Notch View
7 Non-operative Treatment Rest Immobilization Physical therapy Avoidance of inciting activities Rarely successful in young patients with recurrent instability Management of Instability Successful surgical management requires an approach that: Reattaches the fibrocartilaginous labrum Recreates the proper tension of the capsuloligamentous structures Restore the anatomy!!! Arthroscopic Bankart Technique Arthroscopy Mobilize labrum/capsule Prepare glenoid rim 1 to 3 anchors on glenoid rim Beach chair or lateral decubitus
8 Bed Preparation Bed Preparation Glenoid rim labrum Decortication
9 Microtraumatic Anterior Shoulder Instability Altchek, et al., AJSM, 2012 Capsular attenuation leading to pathologic laxity High index of suspicion, history, comprehensive exam Open capsulorrhaphy, 60-81% success Arthroscopic thermal capsulorrhaphy, 93% RTS (results not long lasting) Microtraumatic Anterior Shoulder Instability Altchek, et al. 20 consecutive arthroscopic capsular plications Indications Debilitating pain Persistent instability despite nonop. (3-6 mo) Objective signs of instability Microtraumatic Anterior Shoulder Instability Operative management EUA Positive drive through sign Patulous capsule No labral pathology (no Bankart) Suture plications (70 degree abduction, 45 degree ER)
10 Microtraumatic Anterior Shoulder Instability 18 of 20 RTS, mean 3.6 years No significant loss of ER at 90 degrees compared to opposite arm No complications Posterior Shoulder Instability Bradley, et al., J Arthro and Related Surgery, 2015 Posterior structures at risk in 2 positions Late cocking (internal impingement) Follow through Repairs in throwers versus non-throwers Unidirectional posterior instability Posterior pain, clicking, instability, apprehension, positive exam Posterior Shoulder Instability (Operative Repair) 3 different procedures Capsulolabral plication Capsulolabral plication plus suture anchor Capsulolabral plication plus anchor, plus additional plication Posterior load-and-shift after repair 48 throwers and 48 non-throwers Posterior Shoulder Instability Results, throwers versus non-throwers No difference ASES scores, 94% vs 91% No difference stability scores, 94% vs 92% No difference RTS, 85% vs 88% No difference in function, range of motion, strength or pain No difference pitchers vs other throwers Intact labrum and repair without anchors decreased RTS tenfold
11 Summary Diagnosis often difficult Knotless anchors, especially above equator Restore anatomy Care not to overtighten Structured progressive rehab up to 6 months
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