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Anterior Glenohumeral Instability

Anterior Glenohumeral Instability. John W. Sperling, MD. Anterior Glenohumeral Instability. Anterior Glenohumeral Instability Introduction. Glenohumeral instability Rockwood and Green: 1400 references Clinics in Sports Medicine x 2 Common 1.7% [Sweden; Hovelis]

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Anterior Glenohumeral Instability

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  1. Anterior Glenohumeral Instability John W. Sperling, MD

  2. Anterior Glenohumeral Instability

  3. Anterior Glenohumeral Instability Introduction • Glenohumeral instability • Rockwood and Green: 1400 references • Clinics in Sports Medicine x 2 • Common • 1.7% [Sweden; Hovelis] • 8.2/100,000 [Rochester, MN] • Males 2x> Females • Surgeons and Primary Care physicians • Emerging areas of treatment

  4. Anterior Glenohumeral Instability Overview • Classification • Anatomy/Biomechanics • Mechanisms of Injury • Patient Presentation/Evaluation • Treatment • Reduction • Rehabilitation • Surgery: Open vs Arthroscopic

  5. Anterior Glenohumeral Instability Classification • Voluntary vs Involuntary • Direction • Traumatic vs Atraumatic • overuse vs hyperlaxity • Acute vs Chronic • Subluxation vs Dislocation

  6. Anterior Glenohumeral Instability Classification

  7. Anterior Glenohumeral Instability Classification Instability Spectrum TUBS AMBRI Atraumatic Multi-directional Bilateral Responds to Rehab Inferior Capsular Shift Traumatic Unilateral Bankart Surgery

  8. Anterior Glenohumeral Instability Anatomy • Built for Mobility not Stability • Important neurovascular structures • Complex: • Movers vs Stabilizers

  9. Anterior Glenohumeral Instability Shoulder Anatomy

  10. Anterior Glenohumeral Instability Shoulder Anatomy: Anterior

  11. Anterior Glenohumeral Instability Shoulder Anatomy: Posterior

  12. Anterior Glenohumeral Instability Anatomy • Glenoid • Labrum • Glenohumeral Ligaments

  13. Anterior Glenohumeral Instability Glenohumeral Ligament Complex Biceps Tendon Rotator Cuff Sup. GH Lig Subscapularis Humeral Head

  14. Anterior Glenohumeral Instability Biomechanics: Static • Congruity of articular surface of glenoid • Labrum: increases contact area by 50% • Negative intra-articular pressure

  15. Anterior Glenohumeral Instability Labral Anatomy

  16. Anterior Glenohumeral Instability Biomechanics: Dynamic • Glenohumeral ligaments: • different roles in different positions • Rotator cuff: • dynamic compression/steering effect • Biceps tendon • active stabilizer

  17. Anterior Glenohumeral Instability IGHL Anterior Slip

  18. Anterior Glenohumeral Instability Mechanism of injury • Outstretched/Abducted/Externally Rotated • Young: athletic • Older: fall

  19. Anterior Glenohumeral Instability Mechanism of Injury

  20. Anterior Glenohumeral Instability Patient Presentation • Anterior shoulder deformity • Holds arm abducted/externally rotated • Unable to adduct/internally rotate arm

  21. Anterior Glenohumeral Instability Patient Presentation

  22. Anterior Glenohumeral Instability Patient Evaluation • Complete neurovascular exam: • 30-60% will have neurologic injury (axillary/brachial plexus) • vascular injuries are rare • Radiographs • A/P • Axillary • Scapular Y/Neer view

  23. Anterior Glenohumeral Instability Treatment • Adequate analgesia • Various reduction maneuvers • Repeat neurovascular exam • Post-reduction x-rays

  24. Anterior Glenohumeral Instability Reduction Techniques Rockwood and Green’s Fractures in Adults, 4th Ed; 1996

  25. Anterior Glenohumeral Instability Hippocratic Technique Modified Hippocratic Technique Skeletal Trauma, 2nd Ed., 1998

  26. Anterior Glenohumeral Instability Stimson Technique Scapular Rotation Maneuver Skeletal Trauma, 2nd Ed., 1998

  27. Anterior Glenohumeral Instability Kocher Technique Milch Technique Skeletal Trauma, 2nd Ed., 1998

  28. Anterior Glenohumeral Instability Aronen Self -Reduction Technique

  29. Anterior Glenohumeral Instability Radiographs True A/P x-ray Internal Rotation External Rotation

  30. Anterior Glenohumeral Instability Radiographs Axillary x-ray

  31. Anterior Glenohumeral Instability Radiographs Stryker-Notch View

  32. Anterior Glenohumeral Instability Associated Injuries • Bankart Lesion: (85-90%) • Hill-Sachs: up to 70% • Rotator Cuff: age dependent; • 65% of patients >50: Ribbans et al. JBJS 1990 • Greater tuberosity fractures: 10-33% • Glenoid rim fractures: 5% • SLAP lesions: 5% • Coracoid process fractures

  33. Anterior Glenohumeral Instability Bankart Lesion Bankart Lesion Classification

  34. Anterior Glenohumeral Instability Labral Tear

  35. Anterior Glenohumeral Instability Normal Labrum

  36. Anterior Glenohumeral Instability Associated Injuries • Bankart Lesion: (85-90%) • Hill-Sachs: up to 70% • Rotator Cuff: age dependent; • 65% of patients >50: Ribbans et al. JBJS 1990 • Greater tuberosity fractures: 10-33% • Glenoid rim fractures: 5% • SLAP lesions: 5% • Coracoid process fractures:

  37. Anterior Glenohumeral Instability Hill-Sachs Lesion Normal Humeral Cartilage

  38. Anterior Glenohumeral Instability Associated Injuries • Bankart Lesion: (85-90%) • Hill-Sachs: up to 70% • Rotator Cuff: age dependent; • 65% of patients >50: Ribbans et al. JBJS 1990 • Greater tuberosity fractures: 10-33% • Glenoid rim fractures: 5% • SLAP lesions: 5% • Coracoid process fractures:

  39. Anterior Glenohumeral Instability Post Reduction Care • Immobilization and Rehabilitation • Surgery

  40. Anterior Glenohumeral Instability

  41. Anterior Glenohumeral Instability Natural History

  42. Anterior Glenohumeral Instability Natural History • McLaughlin and Cavallaro: Am J Surg, 1950 • Rowe: Orth Clin NA, 1980 • Simonet and Cofield: AJSM, 1984 • Hovelius et al: JBJS, 1983 96% of recurrent dislocators have initial episode younger than 30

  43. Anterior Glenohumeral Instability Immobilization • Watson Jones: 4 weeks, 0 redislocation: JBJS, 1948 • Rowe: 3 weeks maximum: Clin Ortho, 1961 • Kiviluota et all: higher rate < 30 y/o: 1 week vs 3 weeks: Acta Ortho Scand, 1980 • Hovelius: no difference < 40 y/o: 3-4 weeks vs early mobilization: ASES, 1994 • Aronen and Regan: 25% re-dislocation rate with aggressive program: AJSM, 1984

  44. Anterior Glenohumeral Instability Rehabilitation • Immobilization Age dependent • Early passive range of motion • Strengthening in scapular plane of motion • Restore dynamic stability of rotator cuff • Sport specific activities

  45. Anterior Glenohumeral Instability Recurrent Instability • Essential Lesion ?: • Bankart • Capsular tear • Injury to subscapularis • Cadaveric Studies • Apreleva et al: JBJS,1998: • Speer et al: JBJS, 1994 • Bigliani et al: J Ortho Res, 1992 • Clinical Experience

  46. Anterior Glenohumeral Instability Dr. Bankart British Medical Journal 2:1132, 1923

  47. Anterior Glenohumeral Instability Repair of Recurrent Instability • Open: History • Hippocrates • Perthes, 1906 • Bankart, 1923: Capsulolabral repair • 250 Different procedures described • Induce scarring: Putti-Platt, Magnusun-Stack • Bony Block: Bristow • Osteotomies to change orientation of Glenoid/Humerus • Anatomic Reconstruction: Bankart

  48. Anterior Glenohumeral Instability Apprehension Sign

  49. Anterior Glenohumeral Instability Open Bankart Repair

  50. Anterior Glenohumeral Instability Open Bankart Repair

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