shoilder instability

1. DR Harpreet Singh Bhatia
DMCH,Ludhiana,Punjab

2. DEFINITION:
Instability:
• Inability to maintain the humeral head in the glenoid
fossa.
• Includes a spectrum of disorders
Dislocation
Complete loss of glenohumeral articulation
Subluxation
Partial loss of glenohumeral articulation with symptoms
Laxity
Incomplete loss of glenohumeral articulation
unassociated with pain

3. STABILITY
Static Factors
 Articular Congruence
 Articular Version
 Glenoid Labrum
 Capsule and Ligament
Dynamic Factors
 Rotator Cuff
 Biceps Tendon
 Scapulothoracic Motion
 Negative Pressure
 Propioception

4. OSTEOLOGY
 Glenoid fossa
 Pear shaped
 7 deg. of retroversion
 5 deg. of sup tilt
 Glenoid version
 30o anterior
 Humerus
 Neck-shaft – 130o to 140o
 Retrotorsion – 30o

5. Normal glenoid is about 7 degrees retroverted
If the retroversion is excessive, it leads to posterior
instability of shoulder
STATIC FACTORS

6. GLENOHUMERAL JOINT
 Humeral head 3x larger
than glenoid fossa
 Ball and socket with
translation
 3 degrees of freedom
 Flex/Ext
 Abd/Add
 Int/Ext rot
 Plus
Cricumduction

7. GLENOID LABRUM
 Static stabilizer
 contributes 20% to GH
stability
 Fibro cartilaginous tissue
 Deepens glenoid(50%)
 3purposes:
 Inc. surface contact area
 Buttress
 Attachment site for GH
ligaments

8. The labrum increases the superoinferior diameter of
the glenoid by 75% and the anteroposterior (AP)
diameter by 50%

9. CAPSULE AND LIGAMENTS
Capsule
 Attached medially
glenoid fossa
 laterally to anatomical
neck of humerus
 Ant cap thicker than post.
 2-3 mm of distraction
 Little contribution to joint
stability
 Strengthened by GHLs and
RC tendons

10. LIGAMENTS

12. GLENOHUMERAL LIGAMENTS
(Superior, Middle , Inferior)
SGHL
 O = tubercle on glenoid
just post to long head
biceps
 I = upper end of lesser
tubercle
 Resists inf. subluxation
and contributes to
stability in post and inf.
directions

13. MGHL
 O= sup glenoid and labrum
 I = blends with subscapularis tendon
 Limits ant. instability especially in 45 deg abduction
position
 Limits ext rotation

14. IGHL
 O= ant. glenoid rim and labrum
 I= inf. aspect of humeral articular surface and anatomic
neck
 3 bands, anterior, axillary and posterior
 Acts like a sling ,the most important single ligamentous
stabilizer .
 Primary restraint is at 45-90 deg abduction.

15. Coracoacromial ligament
 secondary stabilizer.
Coracohumeral ligament
 Contribute to restraining inferior subluxation with
arm at side,

16. Dynamic Factors
 Rotator Cuff
 Biceps Tendon
 Negative Pressure
 Scapulothoracic motion
 Proprioception

17. ROTATOR CUFF
 Compression enhances conformity
 Greater than static stabilizers
 Coordinated contractions/steering effect
 Supraspinatus most important
 Dynamization

18. Biceps long head, Deltoid
 secondary stabilizer head depressor
Periscapular Muscles
 help position scapula and orient glenohumeral joint
contributes compressive force across joint

19. SCAPULOTHORACIC MOTION
 2:1 glenohumeral to scapulothoracic motion
 Scapulothoracic muscle (trapezius, serratus anterior,
teres major, levator scapulae)
 less stable platform

20. NEGATIVE INTRA-ARTICULAR
PRESSURE
 -42 cm H2O in cadaver
 Secondary to high osmotic pressure in interstitial
tissues
 Only clinically important in the arm at rest in
adduction
 Lost with lax capsule or defect

23. INSTABILITY
Classification:
 Frequency
 Cause
 Direction
 Degree

24. Classification of instability

26. SPECTRUM
Traumatic Microtrauma Atraumatic
Less laxity More laxity
Unidirectional Multidirectional

27. PATHOANATOMY OF SHOULDER
INSTABILITY
Laberal Lesions
 – Bankart
 – Reverse Bankart
 – SLAP lesions
Capsular Injury
 – Intrasubstance Tear
 – HAGL
 – Capsular Laxity
Bone Loss
 – Glenoid
 – Humeral Head-Hill-Sachs Lesion

29. BANKART LESION.
 The traumatic detachment
of the glenoid labrum has
been called the Bankart
lesion. 85%

30. BANKART LESION-labral tear at
anterior half of glenoid rim

31. Reverse Bankart lesion

33. Anchor used for repair

34. HILL-SACHS
LESION
This is a defect in the
posterolateral aspect of the
humeral head.

35. Hill Sach Lesion

36. EVALUATION OF INSTABILITY
History
 Age
 Trauma-Duration
 Associated Pain
 Sports, throwing or overhead activities
 Voluntary subluxation
 “Clunk” or knock
 Fear-Limitation of Movements
 Hx dislocationsand energy associated
 Hx 1st dislocation or injury
 Subsequent dislocations/ subluxations

37. Physical Examination
 Inspection
 Palpation
 ROM
 Winging
 Neurovascular testing
 Generalized ligamentous laxity
 Instability tests

39.  Sulcus sign
 Drawer tests
 Load & Shift test

40.  Apprehension test
 Jobe’s Relocation
 Jerk test
 Fulcrum
Grade = 1 - 4

41. DIAGNOSIS
 X-rays
 CT Scan
 MRI
 Arthroscopy

42. RADIOLOGY
 X-Rays
 Identify Bankart or Hill-Sachs Lesion

43. AP VIEW

44. Normal Shoulder AP view

45. Axillary View

46. Scapular Y-View

47. Stryker view Humeral Head Defect

48. Apical Oblique view Glenoid rim lesion

49. West Point Axillary view Anteroinferior glenoid rim

50. ANTERIOR DISLOCATION
97% of recurrent dislocation
 abduction, extension and
external rotation
 subcoracoid
 subglenoid
 subclavicular
Associated Injuries:
Fractures
 Head & Neck
Rotator Cuff Tears
 > 40 y/o = 30 %
 > 60 y/o = 80%

51. Neurologic Injury
 Axillary nerve
 10-25% incidence 1st time.
 2-5% in recurrent dislocators
 Tx: “watchful expectancy”
 Poor prognosis if no recovery
by 10 wks
Vascular Injury
 Axillary artery
 2nd part thoracoacromial
trunk

52. POSTERIOR DISLOCATION
 Incidence: < 5% all
shoulder dislocations
 Axial load
 Flexed/Adduction
 Bench press-“lock out”
 Swimming- pull thru
 Rowing
 Football Offensive
Lineman

53. Examination
 Shift & load test
 Post. Apprehension test
 Jerk test
 Kim test
Imaging studies
 X-ray
 CT
 MRI

54. TREATMENT
Non Operative
 Immobilization
 Protection
 Rehabilitation
 70-90% improve
 Functional disability
improved
 Instability not eliminated

55. Operative Management
 Overall 50-95 % success
 Higher recurrence vs ant.
instability procedures
Soft Tissue Procedures
 Posterior Capsulorrhaphy
 Reverse Putti-Platt
(IS Capsular Tenodesis)
 McLaughlin
Bone Procedures
 Posterior Glenoid
Osteotomy
 Posterior Bone Block

56. MATSEN'S CLASSIFICATION
TUBS:
 Traumatic
 Unidirectional
 Bankart lesion
 Surgery is often necessary.
AMBRI:
 Atraumatic
 Multidirectional
 Bilateral
 Rehabilitation is the primary mode of treatment.
 Inferior capsular shift & internal closure often performed.

57. OPERATIVE TREATMENT:
Capsulolabral Repair
 Bankart
 Modified Bankart
Subscapularis Procedures
 Putti-Platt
 Magnuson-Stack
Coracoid Transfer
Procedures
 Bristow
 Latarjet

58. TREATMENT OPTIONS
TYPE OF INSTABILITY PREFERRED SURGERY
Traumatic anterior, with Bankart Lesion Open / arthroscopic Bankart repair
Traumatic anterior , with no labral lesion,
just capsular laxity
Open / arthroscopic capsular imbrication
AMBRI lesions Lateral capsular shift( modified Neer and
Foster ) with closure of rotator interval
Recurrent posterior dislocation in
association with a reverse Hill-Sachs lesion
modified McLaughlin procedure
Head defect > 30 – 45 %
> 45 %
Acute disimpaction / Weber osteotomy
Prosthetic replacement
Glenoid defect Bristow – Latarjet coracoid transfer
Structural bone graft

59. Procedures
Procedure Description Results
Neer’s Capsulorrraphy Posterior capsular tightening Generally unsatisfactory,
upto 50 % recurrence
Staple capsulorraphy Tightening done with staples Small study group
Tieborne and bradley
procedure
Capsular Imbrication with a
horizontal T approach
Upto 20 % recurrence
Hawkins and Janda
procedure
Subscapularis advancement
and shortening
0 – 5 % recurrence
Rockwood Glenloid Plasty
with Biceps Tenodesis to the
posterior capsule
Combined bony and soft
tissue procedure
Not often done

60. OPEN BONY PROCEDURES FOR ANTERIOR INSTABILITY
Bristow procedure
Latarjet procedure

61. Helfet first described the Bristow procedure in 1958 and named it after his late
mentor .
In the Bristow procedure and its variants, the coracoid process is
transferred through the subscapularis tendon as a method of treating recurrent
anterior instability of the shoulder.
1) The coracoid tip is transferred to the anteroinferior glenoid neck and likely
serves as a bone block in front of the humeral head. The transferred short head of
the biceps and coracobrachialis are placed so as to produce a strong dynamic
buttress across the anterior and inferior aspects of the joint when the shoulder is
in the vulnerable abducted and externally rotated position. The transfer was held
in place by sutures through the conjoined tendon and subscapularis.
2) Latarjet described a similar procedure in 1954, in which he transferred the tip of
the coracoid along with the conjoined tendon through a horizontal slit in the
subscapularis and fixed it with a screw

62. The procedure involves transfer of the coracoid with it's attached muscles to the
deficient area over the front of the glenoid.
This replaces the missing bone and the transferred muscle also acts as an
additional muscular strut preventing further dislocations.
The procedure has a high success rate (recurrence rate of less than 1%4) and this is
due to the ‘triple effect’ described by Patte.
These are:
1) Increase or restore the glenoid contact surface area;
2) The conjoint tendon stabilises the joint when the arm is abducted and
externally rotated, by reinforcing the inferior subscapularis and anteroinferior
capsule
3) Repair of the capsule. This triple effect is why the Latarjet is such a successful
procedure.

64. Latarjet procedure

67. AMBRI Lesions-Idea of
management
 Primary treatment nonoperative
 Operative management recommended for
patients who have continued pain or disability
despite an adequate rehabilitation
 The gold standard is open stabilization

68. Capsular shift( modified Neer and Foster )

69. OPEN ANTERIOR PROCEDURES FOR POSTERIOR
INSTABILITY
 McLaughlin procedure
 Neers modification of McLaughlin procedure

70. McLaughlin technique
 subscapularis

71. Neer’s modification

72. Putty Platt Operation
Surgical procedure for stabilizing the
glenohumeral joint after recurrent anterior
shoulder dislocations. The subscapularis tendon
is detached near its insertion on the humerus, the
joint opened, and the stump of the tendon on the
lesser tuberosity is sutured to the glenoid labrum.
Sometimes the procedure is combined with
reattachment of the glenoid labrum.
Technically an easy procedure
Disadvantages:
The Putti-Platt procedure is not to be performed
on throwers because it can reduce the range of
movement in the shoulder.
30 – 35 % incidence of late OA

73. Magnuson Stack procedure

74. ADVANTAGES AND DISADVANTAGES OF
ARTHROSCOPIC STABILIZATION
 ADVANTAGES DISADVANTAGES
-Improved cosmesis -Technically demanding
-Shorter operative time -Difficult in revision case
-Short hospital stay -Difficult in altered
anatomy
-Decreased morbidity -Cannot address bony
defect
-Decreased complication
-Lower cost

75. PHASES OF REHABILITATION
 Phase I Rest and immobilization. Pain control with
nonsteroidal anti-inflammatory drugs and ice applied to the
shoulder
 Phase II Isometric strengthening Isotonic strengthening.
Begin exercises with shoulder in adducted, forward- flexed
position, progressing to abducted position
 Phase III Endurance building along with strengthening
exercises. Goal: the patient reaches 90% strength in the injured
shoulder compared with the uninjured shoulder
 Phase IV Increase activity to sport- or job-specific activities

76. THANKS