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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