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Glenohumeral Instability

Glenohumeral Instability. Matt Nugent, MD Steadman Hawkins Clinic of the Carolinas Feb 25, 2013. Matt Nugent, MD June 7, 2013. Normal Anatomy:. Labrum increases depth of glenoid IGHL 1 0 static check to A/P and inf @ 45-90 0

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Glenohumeral Instability

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  1. Glenohumeral Instability Matt Nugent, MD Steadman Hawkins Clinic of the Carolinas Feb 25, 2013 Matt Nugent, MD June 7, 2013

  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 • MGHL @ <45 abduction, • MGHL: resists ER when arm is FF 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. Younger PatientsRecurrence Rates

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

  12. Contact AthletesRecurrence Rates

  13. 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.

  14. 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.

  15. 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.

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

  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. 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.

  21. 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.

  22. 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.

  23. 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.

  24. 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.

  25. 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.

  26. 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.

  27. 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)

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

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

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

  31. Arthroscopic Repair after Primary Event?

  32. Results of Arthroscopic Repair: Contact Athletes

  33. Brophy RH and Marx RG. A systematic review. Arthroscopy 2009

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

  35. Risks after Primary Repair

  36. 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.

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

  38. 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.

  39. 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.

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

  41. 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

  42. 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.

  43. 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.

  44. 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.

  45. 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.

  46. 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.

  47. Risks for Recurrent Instability

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