1. Arthroscopic Stabilization in Anterior
Instability
Indications, Pearls and Pitfalls
Benjamin Shaffer MD

2. In 2009…
Arthroscopic stabilization has become
the “de facto” standard

3. Improved outcomes likely due to:
 Indications
 Contributory pathology
 Technology, instrumentation
 Technical skill

4. “Ideal” Arthroscopic Indication
 Post-traumatic
 Unidirectional
 Discrete Bankart
 Good tissue quality
 Overhead throwing
athlete

5. Contraindications
1. HAGL
 Avulsion off humeral
side
 Index of suspicion
 Exposed subscap
 Best seen w/ 70 lens
 Easy to repair open

6. Contraindications
1. HAGL
2. Poor Quality Capsulolabral
Tissue
 Tissue Insufficient
 Revision Cases
 Soft tissue
augmentation

7. Contraindications
1. HAGL
2. Poor Quality Capsulolabral
Tissue
3. Intra-capsular
IGHL rupture

8. Contraindications
1. HAGL
2. Poor Quality Capsulolabral Tissue
3. Intra-capsular IGHL rupture
4. Revision Surgery
 Previous failed
arthroscopic
 Patient disappointed
and/or hostile –need to do
the surgery with the
highest success rate

9. Contraindications
1. HAGL
2. Poor Quality Capsulolabral
Tissue
3. Intra-capsular IGHL rupture
4. Revision Surgery
5. Significant Glenoid or Bony
Bankart Pathology

10. Significant Glenoid Or Bony
Bankart Lesion
 ~ 22% initial traumatic
dislocations
 up to 73% of recurrent cases

11. Significant Glenoid Bone Loss
Good screening x-ray - Bernageau View
Arthroscopy Sept. 2003

12. Significant Glenoid Bone Loss
 CT Scan
 3-D Reconstructions

13. Bone Loss With Inverted Pear
 Failure rate ~ 60%
with arthroscopic
repair
(Lo, Burkhart Arthroscopy 2000) Inferior
 ↓ stability to ant
transl w/ defect
>21% glenoid width

14. How to assess arthroscopically?
Glenoid Bare spot
provides consistent
reference point to
quantify % bone
loss of inferior
glenoid

15. Calculate Bone Loss
 Measure Radius
(12.5mm)
 Estimate Normal
Diameter (25mm)
 Measure Actual (25-20)/25
B D
Diameter (20mm) x100 = 20%
A C
 Bone Loss: Bone
loss

16. Significant Glenoid Bone Loss
Treatment Options
>20 – 25% Loss: Bony
(Open) Procedure
Anatomic Salvage
Glenoid Reconstruction Bristow-Laterjet

17. Contraindications
1. HAGL
2. Poor Quality Capsulolabral
Tissue
3. Intra-capsular IGHL rupture
4. Revision Surgery
5. Significant Glenoid or Bony
Bankart Pathology
6. Engaging Hill-Sachs Lesion

18. Humeral Bone Loss
Significant Hill-Sachs Lesion
 25% w/ ant sublux
 80% w/ 1º ant Disl
 Up to 100% w/
recurrent ant
instability

19. Humeral Bone Loss
Significant Hill-Sachs Lesion
Arthroscopic (Soft tissue) procedures
cannot prevent Hill-Sachs lesion from
engaging rim (articular arc deficiency)

20. How to Asses Pre-Op
 Stryker Notch
 Apical Oblique View.

21. How to Asses Pre-Op
CT scan
 Measure length, width and depth
 > 25% of articular surface or depth > 15%
HHD may need tx

22. “Engaging” Hill-Sachs Lesion
Treatment Options
Anatomic
 Fill defect with
bone/substitute
 Repair defect

23. “Engaging” Hill-Sachs Lesion
Treatment Options
Non-anatomic
 Fill defect with soft
tissue
 Bristow

24. Humeral Bone Loss
Engaging Hill-Sachs Lesion
OATS ALLOGRAFT
Miniaci ASES 2004
 18 patients, defect > 25% of
humeral head
 Irradiated humeral head
allografts, anterior approach
 50 month f/u
 No recurrences

25. Humeral Bone Loss
Engaging Hill-Sachs Lesion
 OATS AUTOGRAFT
Clinical Results Pending

26. Humeral Bone Loss
Engaging Hill-Sachs Lesion
John Kelly MD
BONE SUBSTITUTE plugs Arthroscopy abstract ’07
 12 pts
 arthroscopic grafting of the
engaging humeral head
lesions.
 No significant intra-operative
complications
 Clinical results pending

27. Humeral Bone Loss
Engaging Hill-Sachs Lesion
 Prosthetic (HEMI-CAP)
 Multiple sizes
 Limited data
 OA, ON, focal
chondral defects

28. Humeral Bone Loss
Engaging Hill-Sachs Lesion
Auto Body Technique w/
“transhumeral elevation and
allograft augmentation of
the impacted head
fragment”

30. Humeral Bone Loss
Engaging Hill-Sachs Lesion
 Remplissage (French: “To Fill”)
Arthroscopic technique limits engagement of defect

31. Humeral Bone Loss
Engaging Hill-Sachs Lesion

32. Remplissage
Results
•In an unpublished review, only 2 of 24
patients (7%) had recurrent instability
•Both recurrences occurred after sig
trauma.
•No sig complications or loss of ROM

33. Salvage
Bristow-Latarjet

34. Contraindications
1. HAGL
2. Poor Quality Capsulolabral
Tissue
3. Intra-capsular IGHL rupture
4. Revision Surgery
5. Significant Glenoid or Bony
Bankart Pathology
6. Engaging Hill-Sachs Lesion
7. Contact/Collision Sport Athlete

35. Collision sports (football, hockey)
 Stability more important than full motion
 Cosmesis not a concern
 Can you afford failure in your high level athlete?

36. Another explanation…
Higher failure rates in these athletes may
be due to bone deficiency rather than
sport.

37. Goals of Reconstruction
 Restore Stability
 Anatomic Repair
 Minimal Morbidity

38. Instrumentation
 Standard Scope, 30° and
70° Lenses
 Periosteal elevator
 Suture Anchors
 Suture Passing Instruments
 Knot pusher/cutter
 Cannulae (and introducers)
which accommodate
instrumentation

39. Surgical Steps
1. Position Patient
2. Establish Portals
3. Evaluate and Treat Pathology
4. Prepare (and mobilize) opposing tissues
5. Insert Anchors
6. Pass Sutures
7. Secure Fixation
8. Address Capsular Patholaxity

40. 1. Position Patient/EUA

41. 2. Establish Portals
In the
beginning…
 “Twin” anterior
portals
 High ASP
 Low AIP

42. 2. Establish Portals

43. 3. Evaluate/Tx Pathology

44. 4. Prepare Tissues

45. 5. Insert Anchors

46. 6. Pass Sutures

47. 7. Secure Fixation

48. Complete the Repair

49. 8. Address Capsular
Patholaxity/Rotator Interval
• Difficult to recognize
• Occurs even w/
“isolated” Bankart
pathology IGHL
• Addressed w/ apical
stitch/plication
• RI
6 Glenoi
d

50. Post-op Rehabilitation
 3 wks immobilization
 Progressive ROM,
strength
 RTA 4-6 months

51. Arthroscopic Bankart Results
# Mean F/U Recurrence
Year Author(s) Shoulders (months) Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
13.5% <22yrs, 7.5% in
2007 Thal 72 Min 2yr 6.9% contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA

52. Arthroscopic Bankart Results
# Mean F/U Recurrence
Year Author(s) Shoulders (months) Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
13.5% <22yrs, 7.5% in
2007 Thal 72 Min 2yr 6.9% contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA

53. Arthroscopic Bankart Results
# Mean F/U Recurrence
Year Author(s) Shoulders (months) Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
13.5% <22yrs, 7.5% in
2007 Thal 72 Min 2yr 6.9% contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA

54. Arthroscopic Bankart Results
# Mean F/U Recurrence
Year Author(s) Shoulders (months) Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
13.5% <22yrs, 7.5% in
2007 Thal 72 Min 2yr 6.9% contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA

56. Complications
 Recurrent instability
 Uncommon
 Loss of Motion
 Implant-related problems
 Nerve Injury

57. Summary
 Most instability surgery can be performed w/
scope.
 Don’t do arthroscopic procedure in pts with
deficient capsule and sig bone defects
 Consider arthroscopic repair for revision
cases, HAGL lesions and contact/collision
sports athletes.
 Practice makes perfect
 Good to excellent results in most cases.

58. Thank You