Shouler Instability

1. SRI SIDDHARTHA MEDICAL COLLEGE, TUMKUR
DEPARTMENT OF ORTHOPAEDICS
TOPIC:- SHOULDER INSTABILITY
CHAIRPERSON:-PROF.&HOD DR. KIRAN KALAIAH
MODERATOR:- PROF. DR. MAHESH K. U.
SPEAKER:- DR. BAIBHAV KUMAR AGARWAL

2. Definition
• Joint instability is an abnormal symptomatic motion for that shoulder
which results in pain, subluxation or dislocation of the joint.
• Dislocation is defined as complete separation of the glenohumeral
surfaces.
• Subluxation implies a symptomatic separation of the surfaces without
dislocation.
• Joint laxity implies a degree of translation in the glenohumeral joint
which falls within a physiological range and which is asymptomatic.
• The glenohumeral joint is the most commonly dislocated joint in the
body representing 45% of all dislocations.

3. Anatomy
• The glenohumeral joint is a synovial multiaxial spheroidal joint
between the roughly hemispherical head of the humerus and the
shallow glenoid fossa of the scapula.
• It is the most mobile joint in the body and the most frequently
dislocated.
• Its anatomy is a compromise between the requirements for motion and
stability; both depend on the surrounding muscular and soft tissue
envelope more than on the shape and surface area of the articulating
surfaces.
• The humeral head is held to the concave glenoid fossa by the
compressive action of the rotator cuff muscles; the stabilizing
mechanism of the glenohumeral joint is one of concavity compression.

4. Articulating surfaces :-
• The articular surfaces are reciprocally curved and are
correctly termed ovoids.
• The surface area of the humeral convexity is
approximately four times that of the glenoid concavity,
which means that only a small portion of the head opposes
the glenoid in any position.
• Both articular surfaces are covered by hyaline cartilage,
thickest centrally and thinner peripherally over the
humerus, and vice versa over the glenoid cavity.
Glenoid labrum :-
• The glenoid labrum is a fibrocartilaginous rim around the
glenoid fossa.
• The labrum deepens the glenoid cavity and so may assist
in stabilizing the humeral head on the fossa.
• It may protect the bone and probably assists lubrication

5. Fibrous capsule:-
• A fibrous capsule envelops the joint.
• It is attached medially to the glenoid neck at a
variable distance from the glenoid labrum.
• Laterally, it is attached to the anatomical neck of
the humerus, i.e. near the articular margin, except
inferomedially, where it descends more than 1 cm
on the calcar humerale.
• The fibres of the capsule are orientated in a spiral
fashion, so that, in elevation of the arm, the
capsule tightens, so bringing the articular surfaces
into closer apposition and contributing to the
concavity compression.

6. Ligaments:-
1. Glenohumeral ligaments
- Superior (from the supraglenoid tubercle to
proximal tip of the lesser tubercle)
- Middle (below the superior glenohumeral
ligament, along the anterior glenoid margin
as far as the inferior third of the rim to the
lesser tubercle
- Inferior (from the anterior, middle and posterior
margins of the glenoid labrum to the inferior
and medial aspects of the neck of the humerus
2. Coracohumeral ligament (from coracoid process to the
greater and lesser tubercles)
3. Transverse humeral ligament (between the humeral
tubercles. It converts the intertubercular sulcus
into a canal

7. Bursae:-
• Between the tendon of subscapularis and the capsule
• Between the coracoid process and capsule
• Between teres major and the long head of triceps
• Anterior and Posterior to the tendon of latissimus dorsi.
• Subacromial bursa
• Between deltoid and the capsule.
Vascular supply:-
• Branches from the anterior and posterior circumflex humeral
• Suprascapular and Circumflex Scapular vessels
Nerve Supply:-
• Mainly from the posterior cord of the brachial plexus through the subscapular nerves.
• The capsule is supplied by the
- Suprascapular nerve (posterior and superior parts)
- Axillary nerve (anteroinferior) and the
- Lateral Pectoral nerve (anterosuperior, including the rotator interval capsule).

9. Classification of Glenohumeral Instability
SEVERITY
• Subluxation
• Dislocation
FREQUENCY
• Initial
• Recurrent
.

10. CHRONICITY
• Acute - time from the episode to presentation in which a closed
reduction is likely to succeed (3 to 6 weeks).
• Chronic – these are typically locked or fixed, i.e. the humeral
head is impaled on the edge of the glenoid making
reduction difficult.
VOLITION
• Voluntary - patient can dislocate at will, is often atraumatic and
can be associated with psychiatric problems or
secondary gain. Called as Habitual Dislocators.
• Involuntary - They can reproduce their instability, but are
symptomatic and try to avoid these positions.

11. ETIOLOGY
• Traumatic - injuries such as falls or motor vehicle accidents in which a
large external force is the major contributor to the instability.
• Microtraumatic - repetitive symptomatic and asymptomatic microtrauma
lead to chronic joint changes and subsequent instability.
Microtraumatic instability is sometimes called acquired
instability.
• Atraumatic - not associated with a single traumatic episode. Congenital
predisposition to instability may be related to glenoid
dysplasia, or systemic syndromes like Ehlers–Danlos.
• Neuromuscular - causes like seizures and strokes in which the imbalance
of the glenohumeral muscular stabilizers leads to
instability.

12. Direction
• Anterior
• Posterior
• Inferior
• Superior
• Bidirectional
• Multidirectional

13. Anterior instability
• Most common type.
• Subcoracoid dislocation as the humeral head is located below the
coracoid process, represents about two-thirds of anterior
dislocations.
• Subglenoid dislocations, in which the humeral head is inferior to
the glenoid, represents about one-thirds of anterior dislocations.
• Subclavicular, in which the humeral head is medial to the glenoid
and inferior to the clavicle.
• Intrathoracic, in which the humeral head lies within the thorax.
• Subclavicular and intrathoracic variant are very uncommon.

14. Posterior instability
• Represents less than 10% of instability.
• TYPES
- Subacromial (most common)
- Subspinous
- Subglenoid
• Posterior subluxation, however, is more common than frank
dislocation.

15. Inferior dislocation
• Also known as luxatio
erecta.
• Humeral head is directly
inferior to the glenoid
and the humerus is
locked in 100 to 160
degrees of abduction.

16. • Superior dislocations are extremely high-energy
injuries. This type should be distinguished from
superior humeral head migration associated with
chronic rotator cuff arthropathy.
• Bidirectional instability - typically anteroinferior
or posteroinferior.
• Multidirectional instability - Instability in two or
more directions.

17. Stability
STATIC FACTORS
• Articular Congruence
• Articular Version ( 7 degree Retroversion of Glenoid )
• Glenoid Labrum
• Capsules and Ligaments
DYNAMIC FACTORS
• Rotator cuff ( Compression effect )
• Biceps tendon ( Head depressor )
• Scapulothorasic Motion ( 2:1 Glenohumeral to Scapulothorasic Motion )
• Negative pressure ( -42 cm H2O in cadavers)
• Proprioception

18. Pathoanatomy
of
Glenohumeral
Instability

19. Bankart Lesion
• The disruption between the anterior inferior labrum and the
glenoid, as seen in traumatic anterior instability, was termed
the “essential lesion” by Bankart in 1938.Subsequently it has
been dubbed the “Bankart lesion.”
• This disruption is critical in the development of recurrent
instability because it serves as the anchor for the IGHLC,
which is the primary static stabilizer against anterior and
inferior humeral translation in abduction and external
rotation.
• Second, the concavity–compression effect formed through the
combination of dynamic humeral head compression and the
increased glenoid concavity by the labrum is disrupted.

20. • Capsular deformation or stretch is likely
necessary for recurrent Instability.
• If the IGHLC detaches with a small piece of
avulsed glenoid, the lesion is called a Bony
Bankart.
• A bony Bankart lesion can also be a “shear”
fracture.
• Posterior labral pathology is also noted in the
recurrent posterior instability.
• There can be a large spectrum of posterior
labral pathology ranging from a marginal
crack without labral detachment (the “Kim”
lesion) to chondral– labral erosion to a
detached posterior labral flap (reverse
Bankart).

21. Anterior Labral Ligamentous
Periosteal Sleeve Avulsion (ALPSA)
• In chronic situations,
the labrum and the
attached periosteum
of the anterior
glenoid can heal in a
medialized position.

22. Superior Labrum Anterior Posterior Tears (SLAP)
• The superior labrum is meniscoid in shape and is loosely attached to the
glenoid rim, especially near the supraglenoid tubercle.
• Approximately 50% of the long biceps tendon arises from the superior
labrum; thus, SLAP lesions are classified by the extent of labral and
biceps involvement.
• Type I is characterized by labral fraying without detachment from the
glenoid or biceps disruption.
• Type II, the most common, the biceps origin is detached in addition to
labral fraying.
• An intact (type III) or disrupted (type IV) biceps anchor is associated
with a bucket-handle tear of the labrum in the final two classes, with
type IV comprising intratendinous tears.

23. Humeral Avulsion of Glenohumeral Ligaments (HAGL)
• This injury is a traumatic rupture of the IGHLC at its humeral
attachment.
• Typically it occurs with the arm in hyper abduction and external
rotation and often results in instability.
• 6 Types ,majority is anterior (>90%),
(1) Anterior
(2) anterior bony avulsion
(3) Concurrent anterior glenoid-sided avulsion
(“floating anterior HAGL”),
(4) Posterior
(5) posterior bony avulsion
(6) floating posterior HAGL.

24. Mechanisms of Injury for Glenohumeral Instability
• Most patients with instability have an initial known traumatic episode
• Anterior instability occurs through an indirect mechanism with arm
abduction, extension, and external rotation with the humeral head
challenging the anterior capsule and ligaments, glenoid rim, and
rotator cuff.
• Rarely there is a episode of direct blow.
• For younger patients, athletic injuries are common.
• Whereas for older patients, falls are more typical.
• Less common types of anterior instability (e.g., intrathoracic) are
typically extremely high energy.

25. • Posterior instability occurs through the indirect mechanism of flexion,
adduction, and internal rotation with an axial load (e.g., fall on an
outstretched arm).
• Patients may suffer either a posterior dislocation from a single traumatic
event or may develop recurrent subluxations from repetitive
microtrauma in this position.
• Neuromuscular events (e.g., alcohol withdrawal, seizures or electric
shock) account for 30% of all posterior dislocations and lead to instability
through violent muscle contraction.
• In these cases, the internal rotators (latissimus dorsi, pectoralis major,
subscapularis) overwhelm the less strong external rotators (teres minor,
infraspinatus) forcing the humeral head over the edge of the glenoid
fossa.

26. • Inferior dislocation (luxatio erecta) occurs with
extreme hyperabduction in which the proximal
humerus levers against the acromion and dislocates
inferiorly.
• These dislocations are often associated with greater
tuberosity fractures or rotator cuff tears.
• Superior dislocations are extremely rare, but occur
with extreme upward force through an adducted arm.

27. Associated
Injuries with
Glenohumeral
Instability

28. Hill–Sachs lesion
• It is a compression fracture of the postero-supero-lateral humeral
head seen as a sequela of an anterior dislocation.
• The lesion is created with the arm in abduction and external
rotation with the posterior humeral head crushed on the anterior
glenoid rim.
• Engaging Hill–Sachs lesions are defined as defects which are
parallel to the long axis of the glenoid rim in positions of function
(abduction and external rotation) and therefore “engage” or
contribute to glenohumeral instability.
• Nonengaging lesions are not parallel to the rim and therefore do
not effect stability in positions of function.
• Reverse Hill–Sachs on the anterior humeral head is seen in
posterior dislocations(29% to 86% cases).

29. • Nondisplaced humerus neck fracture.
• Greater tuberosity fractures (20% of cases, age > 30 years)
• Rotator cuff tears (40% in patients over 40 years of age)
• Neurologic injury is common (13% to 65%). Brachial plexus.
• Axillary nerve injury is the most common (73%)
• Vascular injuries – injury to axillary artery and vein are the
most common, affecting the second part of the vessels, directly
behind the pectoralis major. Occlusion of the artery and vein is
more common with luxatio erecta (inferior dislocation).
• In posterior Instability -neck fractures is most prevalent (19%),
followed by lesser tuberosity (14%) and greater tuberosity
fractures (8%).

30. EVALUATION OF INSTABILITY
HISTORY
• Age
• Trauma-Duration
• Associated Pain
• Sports, throwing or overhead activities
• Voluntary subluxation
• “Clunk” or knock
• Fear and Limitation of Movements
• History of 1st dislocation or injury
• Velocity of injury during 1st dislocation.
• Subsequent dislocations/ subluxations

31. PHYSICAL EXAMINATION
Inspection - Any abnormalities such as asymmetry, muscular atrophy,
scapular winging, or ecchymosis should be noted.
• Deltoid atrophy can be seen and may represent an axillary nerve injury.
Cardinal motions of the shoulder should be measured:
• Forward elevation in the plane of the scapula.
• External rotation and internal rotation with the arm in adduction.
• External and internal rotation in abduction should be noted which can
often be increased (>90) in MDI instability.
• These measurements should always be compared to the contralateral
side and differences between active and passive range of motion should
be noted.

32. • Chronic or missed anterior dislocations typically will have a limitation to
internal rotation and abduction.
• Patients with posterior dislocations will often demonstrate limitations in
external rotation and abduction.
• Five physical signs of generalized ligamentous laxity according to the
Beighton scale should be noted :-
1. Passive dorsiflexion of the little finger beyond 90 degrees
2. Passive apposition of the thumb to the ipsilateral forearm
3. Active hyperextension of the elbow beyond 10 degrees.
4. Active hyperextension of the knee beyond 10 degrees
5. Forward flexion of the trunk with the knees fully extended with the
palms resting flat on the floor.

33. • Each positive test is one point and the first four are performed
bilaterally.
• A score of ≥4 points (out of a possible 9) is diagnostic of
generalized joint laxity.

34. GENERAL
TESTS
FOR
LAXITY

35. Drawer Test
• Patient sitting with the examiner behind the patient.
• The acromion is stabilized with one hand whereas the
other hand manipulates the humeral head for
anterior and posterior translation.
• For normal shoulders, this translation is smooth with
a firm endpoint assessing the static restraints.
• If the translation is excessive, the patient has
increased laxity but not necessarily instability.
• A presumed diagnosis of instability may be
established if consistent with the history and other
examination findings.

36. Load and Shift Test
• The patient is placed supine with arm abducted to 60 degrees.
• An axial pressure is applied to the humeral head to press the
humeral head against the glenoid with the forearm in neutral
position.
• Similar to the drawer test, the humeral head is then grasped and
translated in either the anterior or posterior direction to assess for
laxity and pain.
• Translation of the head to the glenoid rim is graded 1+.
• Translation over the rim with spontaneous reduction is graded 2+.
• Dislocation without spontaneous reduction is grade 3+.

37. Sulcus Test
• Patient is seated with their arm relaxed at their
side and the arm is then pulled downward.
• A positive test reveals a “sulcus” or hollow area
below the acromion.
• The test is measured by noting the translation of
the humeral head away from the acromion.
• <1 cm is graded as 1+;
• 1 to 2 cm is 2+
• >2 cm is 3+.
• The sulcus sign is generally used to test for
inferior laxity and is considered positive for
inferior instability if the patient also has
apprehension or even pain.

38. Gagey Hyperabduction Test
• It is a test for inferior laxity.
• The examiner stands behind the patient with their forearm
pushed down against the shoulder girdle using the other hand to
gently passively abduct the patient’s arm.
• Normal abduction is about 90 degrees as seen in this patient.
• Abduction over 105 degrees reflects increased laxity.
• Whereas symptoms of apprehension suggest a diagnosis of
inferior instability.

39. Specific
Examinations
for
Anterior
Instability

40. Apprehension Tests
• Performed with the patient supine or
sitting with the examiner behind the
patient.
• From a position of 90 degrees of abduction
and neutral rotation, the shoulder is
externally rotated until it reaches its
maximal limit or until the feeling of
apprehension is reported by the patient.
• It may be necessary to hold the arm in this
position for 1 to 2 minutes to fatigue the
subscapularis before apprehension is felt
from capsular insufficiency.

41. Jobes Relocation test
• Patient supine, the shoulder is abducted
and externally rotated
• A posteriorly directed force is placed on
the anterior aspect of the shoulder to
eliminate the feeling of apprehension.
Crank test
• Patient supine, the shoulder is abducted
and externally rotated.
• With an anteriorly directed force on the
posterior humeral head, the instability
is accentuated to cause the sensation of
apprehension or “getting ready to
dislocate

42. Fulcrum test
• It is performed with the patient supine with the shoulder off the
edge of the examination table and the arm in 90 degrees of
abduction.
• The examiner places one hand behind the shoulder which acts as a
fulcrum as the examiner’s other hand is used to gently extend and
externally rotate the patients arm.
• A test is positive if apprehension is felt by the patient.

43. Surprise test
• Examination starts with a posteriorly directed force on
the anterior shoulder.
• As this force is stabilizing the glenohumeral joint, the
patient does not experience apprehension even when
the shoulder is placed in abduction and maximal
external rotation.
• By abruptly removing this force, the patient will
suddenly experience apprehension or pain.

44. JERK Test – For Posterior Instability
• With the arm elevated to 90 degrees and
internally rotated an axial load is placed such
that the humeral head is compressed against
the glenoid and the scapula is stabilized by the
examiner’s other hand.
• This can be easily accomplished by pushing
axially against the flexed elbow.
• By gradually adducting the shoulder, the
humeral head may subluxate or even dislocate
posteriorly and produce a sudden jerk.
• When the shoulder is returned to its original
position, the humeral head will abruptly reduce
back onto the glenoid and produce another jerk

45. Imaging and Other
Diagnostic Studies
for
Glenohumeral
Instability

46. The Grashey View/
True AP View
• In normal shoulders, a
concave contour of the glenoid
fossa should match the convex
articular surface of the
humeral head.
• If any overlap is seen between
the glenoid and the humeral
head, a dislocation should be
suspected.
• Inferior glenoid fractures can
also be seen on this view.

47. Axillary Views
• Standard axillary radiograph
is obtained by placing the
cassette on the superior aspect
of the shoulder and directing
the x-ray beam between the
thorax and the abducted arm.
• Trauma axillary lateral is
performed with the patient
supine with the injured slinged
arm held by a foam wedge or
pillow. This view requires
minimal abduction

48. • Velpeau axillary lateral is performed with the
patient leaning backward with their arm in a
sling until the shoulder is over a horizontal
cassette at the lower back. The x-ray beam is
directed superior to inferior.
• West Point axillary provides a tangential view
of the anterior glenoid and is particularly
useful in the identification of glenoid rim
fractures which are missed on the standard
axillary.
• It is taken with the patient in a prone position
with the cassette placed on the superior
aspect of the shoulder. The x-ray beam is
directed 25 degrees downward from the
horizontal and inward toward the axilla

49. Apical Oblique View or Garth view
• It clearly reveals the anterior inferior and posterior
superior glenoid rims.
• Acute anterior inferior fractures or chronic bone loss
associated with recurrent instability can be seen on
this view.
• Additionally, Hill–Sachs deformities are seen as the
posterolateral humeral head is well defined.
• In this view, the patient is upright with the cassette
flat against the scapula.
• Like the Grashey view, the x-ray beam is directed
orthogonal to the scapula to get a “true” AP of the
joint.
• In addition, a 45-degree caudal tilt is used so the
beam is directed downward and medial to lateral

50. Stryker Notch View
• The Stryker notch view is the best to
characterize the Hill–Sachs defect and the
posterior-superior humeral head.
• The film is taken with the patient supine
with the cassette under the shoulder.
• The palm of the hand rests on the patient’s
head with the arm forward flexed such that
the bent elbow is over the face and pointed
straight upward.
• The x-ray beam is angled approximately 10
degrees caudal relative to a vertical line
orthogonal to the patient’s torso. The beam is
centered over the coracoid.

51. Computed Tomography and
Magnetic Resonance Imaging
• CT is necessary to determine the size and displacement of a
suspected glenoid fracture or the presence of proximal humerus
fractures.
• MRI (in comparison to CT) is considered the standard of reference
for the determination of Pathoanatomy because the majority of
injuries are capsuloligamentous.
• MRI is also necessary to evaluate for rotator cuff tears and humeral
avulsions of the glenohumeral ligaments (HAGL).
• MR arthrography (the injection of contrast into the joint) has been
shown to be more sensitive than conventional MRI in the detection
of labral, capsule, and rotator cuff tears and is the investigation of
choice for soft tissue pathology.

53. TREATMENT

55. Basic Principles Of Treatment
(1) Creating an optimal healing environment
(2) Re-creating the glenoid concavity,
(3) Securing anatomic capsular fixation at the articular edge,
(4) Re-creating physiologic capsular tension, and
(5) Having supervised, goal-specific therapy.

56. BANKART OPERATION
• In the original Bankart operation, the subscapularis and shoulder
capsule are opened vertically.
• The lateral leaf of the capsule is reattached to the anterior glenoid
rim.
• The medial leaf of the capsule is imbricated, and the subscapularis is
approximated.
• Indication :- labrum and the capsule are separated from the glenoid
rim or if the capsule is thin.
• Advantage :- Defect is corrected without requiring any metallic
internal fixation devices.
• Disadvantage :- technically difficult.

57. MODIFIED BANKART REPAIR
• Capsular incision made at centre
(3-o’clock position) of glenoid.
Incision is extended medially over
neck of glenoid. Stay suture is
placed in capsule to mark glenoid
attachment site.
• Suture anchor drill holes are
started in scapular neck adjacent
to glenoid articular surface and
directed medially away from joint
surface.

58. • Suture anchors are placed in each
prepared drill hole. Sutures are
pulled to set anchor. Each
individual suture is pulled to
ensure suture slides in anchor.
• Approximation of capsule to
freshened neck. Two or three
suture anchors are used to secure
inferior capsule firmly to scapular
neck

59. • Superior and middle suture
anchors are used to secure
and advance superior flap in
inferior direction.
• Final imbrication of capsule
is done with interrupted
nonabsorbable sutures.
Extremity is maintained in
45 degrees abduction and 45
degrees external rotation
during closure to prevent
overconstraint.

60. Laterjet-Bristow procedure
• Useful in patients who have an
inverted pear-shaped glenoid and an
engaging Hill-Sachs lesion.
• The bone graft corrects the glenoid
deficiency so that it can resist axial
forces across an expanded glenoid
diameter.
• The graft also lengthens the glenoid
articular arc to prevent the Hill-Sachs
lesion from engaging and is used when
a large (35% to 45%) humeral head
lesion is present.

61. • Vertical incision under tip of
coracoid process.
• Harvest of bone block corresponding
to horizontal part of coracoid
process, retaining conjoined
coracobrachialis tendon and
coracoacromial ligament

62. • Division of subscapularis
horizontally.
• Anteroinferior glenoid
rim is decorticated

63. • Bicortical fixation of bone
block.
• Outer capsular flap is
sutured to remainder of
coracoacromial ligament.

64. Reconstruction Of Anterio Glenoid Using Iliac
Crest Bone Autograft
• Glenoid bone loss approaching 40% of the anterior glenoid or
• posterior bone loss of 25% with recurrent posterior dislocation
should be reconstructed with an autogenous iliac crest bone graft,
or
• occasionally for posterior lesions, the medial aspect of the acromion
can be used as a graft.
• Fresh or fresh-frozen allograft(eg - from the lateral aspect of a
distal tibia) may be used.
• Iliac crest autograft has greater healing potential, and less
potential for resorption than an allograft.

65. Posterior Instability Treatment

66. Neer and Foster posterior capsulorrhaphy
• Inferior capsular shift procedure performed through a
posterior approach.
• Interval between the infraspinatus and teres minor muscles is
split to expose the posterior capsule.
• In this procedure, the posterior capsule is split longitudinally,
and the capsular attachment along the humeral neck is
released as far inferiorly and anteriorly as possible.
• The superior capsule is advanced inferiorly, and the inferior
capsule is advanced superiorly.
• The infraspinatus is cut so that it is overlapped and shortened,
adding further buttress to the posterior capsule.

67. TIBONE AND BRADLEY TECHNIQUE
• Infraspinatus muscle–splitting incision in which
the bipennate muscle is split between its two
innervations, resulting in no long term trauma to
the muscle.
• It allows better exposure of the middle portion of
the posterior capsule and make the capsular shift
easier.
• The advantage of this approach is that imbrication
of the posterior capsule produces a thicker
posterior soft-tissue restraint.

68. Capsular Shift Reconstruction with
posterior glenoid Osteotomy
• Posterior glenoplasty rarely is indicated, although it
can be used if severe developmental or traumatic
glenoid retroversion of more than 20 degrees is
confirmed on CT reconstructed films.
• High recurrence rates of up to 53% have been reported
with this procedure.
• Complication rate of 29%, including osteonecrosis of
the glenoid and degenerative arthritis of the
glenohumeral joint, after this procedure.

69. MCLAUGHLIN PROCEDURE
• For recurrent posterior
dislocation associated with a
large anterior medial Hill-
Sachs lesion, McLaughlin
described transfer of the
subscapularis tendon into the
defect.

70. • Neer and Foster subsequently described transfer of the
subscapularis with the lesser tuberosity into the defect
and securing it with a bone screw.

71. Putti-Platt procedures
• The procedure is based on the concept of
tightening the anterior capsule and
subscapularis with a subsequent accepted loss
of external rotation in order to increase the
stability of the shoulder.
• It has been described as a "vest over pants"
approach and a "double-breasted" technique.

72. Multidirectional Instability Treatment
CAPSULAR SHIFT
• The principle of the procedure is to detach the capsule from the
neck of the humerus and shift it to the opposite side of the calcar
(inferior portion of the neck of the humerus), not only to
obliterate the inferior pouch and capsular redundancy on the
side of the surgical approach but also to reduce laxity on the
opposite side.
• The approach can be anterior or posterior depending on the
direction of greatest instability.

73. ARTHROPLASTY
• Shoulder arthroplasty may be necessary for larger humeral head
defects, or if advanced degenerative changes are present.
• Hemiarthroplasty is usually performed in younger patients
below the age of 50 and patients with good glenoid cartilage.
• Total shoulder arthroplasty is indicated in older patients with
significant glenoid degenerative changes.
• In the elderly patient, reverse total shoulder arthroplasty may
be necessary if the rotator cuff is deficient.

74. COMPLICATIONS
• Incorrect diagnosis
• Infection
• Nerve injury ( 3% for close & 8% for open Procedures
• Hardware complications
• Recurrence of instability ( 0 – 20 %)
• Loss of motion
• Capsulorrhaphy arthropathy
• Subscapularis failure ( in Open Procedures)

75. THANK YOU