1 / 50

Anterior Glenohumeral Instability

Anterior Glenohumeral Instability. Jason Phillips. Normal Anatomy:. Labrum increases depth of glenoid IGHL 1 0 static check to A/P and inf @ 45-90 0 SGHL and MGHL play stabilizing roles in lower ranges of abduction. Inferior Glenohumeral Ligament Complex. Hunt et al. JAAOS 2007.

loyal
Download Presentation

Anterior Glenohumeral Instability

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Anterior Glenohumeral Instability Jason Phillips

  2. Normal Anatomy: • Labrum increases depth of glenoid • IGHL 10 static check to A/P and inf @ 45-900 • SGHL and MGHL play stabilizing roles in lower ranges of abduction Inferior Glenohumeral Ligament Complex Hunt et al. JAAOS 2007

  3. Normal Anatomy: • IGHL complex forms “Hammock” • Anterior band resists anterior translation in Abd/ER • Glenoid “bare spot” is central

  4. History: • Arm in Abducted/ER positon • Was an ER reduction required? • Age? • Contact athlete/Military? • Position? • Ultimate goals? • End/Beginning of Season?

  5. Physical Exam: • Apprehension-Relocation (Instability) • AbER reproduces symptoms • Posterior force relieves • Load & Shift (Laxity) • Grade I – Up face • Grade II – To Rim w/ immediate reduction • Grade III – Over Rim Bahk et al. AJSM 2007

  6. Laxity or Excessive TranslationDoes Not Equal Instability

  7. EUA is Critical: Compare translation of BOTH shoulders for any increase in anterior translation

  8. How should we treat the primary event? • Risks for recurrent instability • Position of immobiliztion • Length of immobilization • Meeting patients goals and expectations

  9. Risks for Recurrent Instability • Rowe 1980 1 • <20yo = 94% recurrent instability • 21-30yo = 79% • 31-40yo = 50% • >40yo = 14% • Arciero 1989 2 • Ave age 18yo (17-22) • 3wks of immobilization (position not specified) • 92% recurrence if treated nonoperatively Rowe CR. Acute and recurrent anterior dislocations of the shoulder. Ortho Clin North Am 1980;11:253-70. Wheeler JH, et al. Arthroscopic vs. Nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy 1989;5:213-217.

  10. Risks for Recurrent Instability Arciero et al. Arthroscopic bankartvsnonoperative treatment for acute, initial anterior shoulder dislocations. AJSM 1994;22:589-594.

  11. Risks for Recurrent Instability Group 1 = immobilized IR for 3-4 weeks Group 2 = immobilized IR until patient felt comfortable Group 3 = immobilization less than 3 weeks Hovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.

  12. Risks for Recurrent Instability Hovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.

  13. Risks for Recurrent Instability Hovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.

  14. Keys Primary dislocation 4wks immobilized IR Robinson CM, et al. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. JBJS AM 2006;88:2326-2336.

  15. Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

  16. Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477.

  17. Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477.

  18. Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477.

  19. Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477.

  20. Glenoid Bone Loss: Biomechanical Evidence Osseous defect at least 21% of glenoid length may cause instability Itoi E et al. JBJS(A) 2000 Jan Anteroinferior glenoid defect diminished stability by almost 50% Bone grafting increased stability by 150% to 230% Montgomery WH et al. JBJS (A) 2005 Sept.

  21. Risk Factors for Failure • 194 consecutive arthroscopic Bankart repairs; 101 contact athletes • Recurrence in Contact Athletes: • Without significant bony defects: 6.5% • With significant bony defects: 89% • Engaging Hill-Sachs • Glenoid bone loss 25% Burkhart SS, DeBeer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic bankart repairs: significance of the inverted-pear glenoid and the humeral engaging hill-sachs lesion. Arthroscopy 2000;16:677-694.

  22. Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

  23. Burkhart SS, DeBeer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic bankart repairs: significance of the inverted-pear glenoid and the humeral engaging hill-sachs lesion. Arthroscopy 2000;16:677-694.

  24. Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

  25. Quantifying the Risk Factor • Cadaveric study : Quantify glenoid bone loss by arthroscopic means • “The bare spot of the glenoid…consistent reference point from which to determine glenoid bone loss…” Burkhart SS, De Beer JF et al. Arthroscopy, 2002 May

  26. Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

  27. Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

  28. Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

  29. Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

  30. Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

  31. Risks for Recurrent Instability

  32. 3B Effect Labral repair (Bumper effect) Increased bony contact via coracoid transfer (Bony effect) Sling effect of conjoined tendon and lowered subscap (Belt or sling effect) Boileau et al. OrthopClin N Am 2010;41:381-392.

  33. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.

  34. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.

  35. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.

  36. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.

  37. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.

  38. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. JBJS AM 2010;92:2924-2933.

  39. Itoi, JBJS 2007 • RCT, Level II, 2yr f/u • 198pts sling vs 100ER x 3wks (ER group more compliant (68% vs 80%) • ER group w/ reduced recurrence (38% Rel. Risk)

  40. Itoi, JBJS, 2007 • Immobilize 100 ER • Must initiate tx early • Most effective if <30yo

  41. Conservative Treatment: • Strengthen GH rotators and scapular stabilizers • Injury Prevention • Graduated Return • GOAL–To keep head centered

  42. Scapular Exercises: • Push-up plus • Bear hug • Seated rows • Shrugs • Upright rows Moseley et al., AJSM 1992. Decker MJ, Hawkins RJ, AJSM 1999.

  43. Arthroscopic Repair after Primary Event?

  44. Arthroscopic Repair after Primary Event?

  45. Results of Arthroscopic Repair: Contact Athletes

  46. Risks after Primary Repair Porcellini G, et al. JBJS AM 2009;91:2537-2542.

  47. Risks after Primary Repair

  48. Results of Latarjet • At 15yrs, 98% excellent or good • At 15yrs, only 4/118 redislocated (3%) Hovelius L, et al. JSES 2004;13:509-516.

  49. Tibial Plafond Allograft

More Related