Indications for Shoulder Instability Surgery Anthony Miniaci M.D. - - PowerPoint PPT Presentation

Indications for Shoulder Instability Surgery

Anthony Miniaci M.D. FRCSC Professor of Surgery Cleveland Clinic Sports Health

Considerations

• Instability classification
• Natural history
• Patient demographics-age,

activity level, occupation, associated morbidities

• Associated pathology
• Prior treatments

Indications for Shoulder Instability Surgery

Instability Classification: Spectrum

• Unidirectional
• “Classic” MDI
• More surgery on “MDI”
• Multidirectional instability

lacks definitions-”MDI” has grown?

Shoulder Instability

Surgery…………………………..Rehabilitation

Multidirectional Instability

Lack of definitions

• 1. Patient population
• 2. Symptom

definition

• 3. Surgical pathology

Multidirectional Instability

Patient Population

• Type of instability -

voluntary, involuntary, habitual

• Direction- anterior,

posterior,multi

• Injury pattern- none,

trauma, atraumatic (“born, torn, worn loose”)

• Laxity- degree, focal vs.

general, symmetry

Voluntary, positional, Posterior,Traumatic Multi, Involuntary, Atraumatic Anterior, Involuntary Atraumatic

• 2. Symptom Definition
• pain, Instability or Both
• Instability- degree

(subluxation/dislocation)

• Apprehension,

microinstability

Multidirectional Instability ! Laxity vs. Instability

• Be sure looseness is

source of Sx

• Watch out for neck,

AC joint, etc.

• Reproduce symptoms

with subluxation

The MDI patient pathology- Imaging Studies

Labral Tears Rotator cuff tears Capsular laxity Leakage of dye

• Best results in milder forms of

instability (subluxation), multidirectional laxity, anteroinferior instability with MD laxity

• Good for patients with PAIN and

laxity

• Associated pathology best treated

arthroscopically

Arthroscopic Capsular Shifts

What about Posterior Instability?

• Dislocation
• Fixed, Chronic
• Recurrent
• Subluxation
• Traumatic
• Micro
• macro
• Muscular- Voluntary
• Scapula winging
• Asymmetric muscular contraction
• Positional- Involuntary

What about Posterior Instability?

• Dislocation
• Fixed, Chronic
• Recurrent
• Subluxation
• Traumatic
• Micro
• macro
• Muscular- Voluntary
• Scapula winging
• Asymmetric muscular contraction
• Positional- Involuntary

What about Posterior Instability?

• Dislocation
• Fixed, Chronic
• Recurrent
• Subluxation
• Traumatic
• Micro
• macro
• Muscular- Voluntary
• Scapula winging
• Asymmetric muscular contraction
• Positional- Involuntary

What about Posterior Dislocation ?

Posterior Dislocation- Arthroscopy

Reverse Hill Sachs Lesion Posterior Glenoid

Posterior Instability/Subluxation

• Repetitive microtrauma → posterior

labral/ligamentous/capsular attenuation & tearing

RPS – Recurrent Posterior Subluxation

• Weightlifters, Linemen, tennis players,

throwers, swimmer

• Present with vague and diffuse posterior

shoulder pain

• Not typical to have recurrent dislocations
• Pathoanatomy
• posterior labrum, post capsule and

posterior part of IGHL

Treatment

Non operative

• Rehabilitation, biofeedback,

proprioceptive training

• Cuff, deltoid, periscapular

strengthening

Surgical

• Several options exist –

arthroscopic/open capsulolabral reconstruction

• Arthroscopic labral repair
• Anatomic, minimally invasive,

effective

Anterior Instability Epidemiology

• Most common
• Bimodal distribution
• 2nd & 6th decades
• 96% result from traumatic event
• Overall incidence 1.7%
• ~3 times incidence in males

Rowe et al., ‘56; Hovelius et

• al. ‘82
• Recurrent Shoulder Instability
• Age-related recurrence following traumatic anterior instability
• < 20 years old – 66-94%
• 20 to 40 years old – 40-74%
• > 40 years old – 10%- ROTATOR CUFF tears

Recurrent Instability

Associated pathology

Osteoarthritis

• Hovelius JSES ’09
• Nonoperative tx with 1 more recurrence had

more arthropathy

• Buscayret AJSM ‘04
• number of dislocations linked to risk for

postop OA

• Ogawa AJSM ‘10
• 5-20 yr f/u study of 167 open Bankarts

evaluated with pre and postop CT

• Postop OA correlates with increased number
• f instability events

Arthroscopy

• 127 patients; diagnostic arthroscopy, x-rays (AP, Glenoid,

West Point), MRI

Anterior Shoulder Instability

Surgical Pathology

• Labral tears
• Capsular redundancy

Unrecognized Pathology

• Capsular

Deficiencies/Avulsions

• Labral pathology/ALPSA
• Subscapularis tears- Open
• BONE LOSS
• Glenoid erosion or

fractures(Bankart)

• Hill-Sachs defects

Treatment options

Glenoid Bone Loss

• 1. Bristow /Latarjet
• 2. Bone Graft- auto/allo

Humeral Bone Loss

• 1. Remplissage
• 2. Decreased ER
• 3. Arthroplasty

Glenoid Bone Loss

• <20% may treat

arthroscopically/ soft tissue/open

• Larger defect requires
• pen fixation if bone

stock adequate

• Quantify with 3D CT
• Consider combined

effect of a humeral defect- treat smaller lesions

Provencher et. al. JBJS, 2010

Bois, Jones, Miniaci et. al. AJSM, 2012

Glenoid Bone Loss

• <20% may treat

arthroscopically/ soft tissue/open

• Larger defect requires
• pen fixation if bone

stock adequate

• Quantify with 3D CT
• Consider combined

effect of a humeral defect- treat smaller lesions

Provencher et. al. JBJS, 2010

Bois, Jones, Miniaci et. al. AJSM, 2012

What about the Hill Sachs ?

Hill Sachs

• >25-30% Humeral Head

must be addressed

• Remplissage
• French for “to fill”
• Infraspinatus tucked into

defect

• Probably not enough

when defect is >25%

Provencher et al., JAAOS, 2012

Hill Sachs

• >25-30% Humeral Head

must be addressed

• Remplissage
• French for “to fill”
• Infraspinatus tucked into

defect

• Probably not enough

when defect is >25%

Provencher et al., JAAOS, 2012

2013 Anatomic Reconstruction Options

• Matched Allograft
• Autogenous Iliac crest

Autograft

• Focal Resurfacing

Option

• Both studies with

reported 0% redislocation

• Preservation of motion!!

Combined Humeral Head and Glenoid Reconstruction

Shoulder Instability Surgery Summary

• Know your patient
• Demographics, activity

etc

• Know the pathology
• Type of instability
• Associated pathology
• Know the natural

history

Anthony Miniaci M.D. FRCSC Professor of Surgery Cleveland Clinic