Anterior Shoulder Instability

Home , Bankart lesion

Shoulder: Orthopaedic Perspectives

Scott Rosenfeld MD

Hip Program Director Texas Children's Hospital Baylor College of Medicine Houston, TX Disclosure

• I have no relevant financial disclosures

• I am not a radiologist

xxx00.#####.ppt 1/15/2016 10:11:20 AM What won’t be in this talk

• Physical exam findings

• Surgical techniques

• Outcomes of treatment

• How to read an MRI

xxx00.#####.ppt 1/15/2016 10:11:20 AM What will be in this talk • Shoulder from the perspective of the treating surgeon – Common pediatric shoulder problems – What it looks like on the inside – How I use imaging – What I want to know from you

xxx00.#####.ppt 1/15/2016 10:11:20 AM In this talk

• Pertinent anatomy

• Anterior Instability

• Peri-clavicular injuries

• Glenoid dysplasia

xxx00.#####.ppt 1/15/2016 10:11:20 AM The Shoulder

• Unique joint – Huge ROM – Very stable

• Differs from hip and knee – Shallow socket – No ligaments tensioned

xxx00.#####.ppt 1/15/2016 10:11:20 AM Pediatric Shoulder

• 25 million in school sports

• 20 million in rec sports

• 2.5 million sports injuries/yr

• 10% shoulder

xxx00.#####.ppt 1/15/2016 10:11:20 AM Pediatric vs Adult shoulder

• Differences in – Anatomy – Late epiphyseal closure

xxx00.#####.ppt 1/15/2016 10:11:20 AM Pediatric vs Adult shoulder

• Differences in – Injuries

xxx00.#####.ppt 1/15/2016 10:11:20 AM Pediatric vs Adult Shoulder

• Differences in – Injuries

xxx00.#####.ppt 1/15/2016 10:11:21 AM Pediatric vs Adult Shoulder

• Differences in – Injuries

xxx00.#####.ppt 1/15/2016 10:11:21 AM Normal Shoulder Anatomy

Static stabilizers

xxx00.#####.ppt 1/15/2016 10:11:21 AM Glenohumeral ligaments

xxx00.#####.ppt 1/15/2016 10:11:21 AM Normal Shoulder Anatomy

• Labrum – Cavity compression – 50% of socket depth – Anchors IGHL – Anchors biceps tendon

xxx00.#####.ppt 1/15/2016 10:11:21 AM Normal Shoulder Anatomy

• SGHL – Inferior translation • MGHL – Anterior and posterior translation • IGHL – Primary restraint to anterior translation

xxx00.#####.ppt 1/15/2016 10:11:21 AM xxx00.#####.ppt 1/15/2016 10:11:21 AM xxx00.#####.ppt 1/15/2016 10:11:22 AM Normal Shoulder Anatomy

• Biceps tendon – Humeral head depressor

xxx00.#####.ppt 1/15/2016 10:11:22 AM Normal Shoulder Anatomy

• Bare area of glenoid

xxx00.#####.ppt 1/15/2016 10:11:22 AM Common shoulder problems

1. Shoulder instability 1. Hill sachs/bankart 2. HAGL 2. Medial clavicle fx 3. Distal clavicle fx 4. BPP – Glenoid dysplasia

xxx00.#####.ppt 1/15/2016 10:11:23 AM Anterior Shoulder Instability

• 18 year old snowboarder – Dislocated shoulder – First time injury

xxx00.#####.ppt 1/15/2016 10:11:23 AM Anterior Shoulder Instability

• Why does it matter?

• 1st time dislocators – Non-operative treatment = 80% recurrence – Correct surgical = 14% recurrence

xxx00.#####.ppt 1/15/2016 10:11:23 AM Anterior Shoulder Instability • Range of possible injuries – Bankart – Bony Bankart – Hill-Sachs – SLAP – GLAD – ALPSA – HAGL

xxx00.#####.ppt 1/15/2016 10:11:23 AM Anterior Shoulder Instability

• Shoulder series radiographs – AP, axillary lateral – Clavicle, AC joint – Reduction – Bony bankart – Hill-sachs lesion

xxx00.#####.ppt 1/15/2016 10:11:23 AM Anterior Shoulder Instability

• Range of injuries

• I need to know what I will see at surgery – Plan surgery – Counsel family

xxx00.#####.ppt 1/15/2016 10:11:23 AM Bankart Lesion

xxx00.#####.ppt 1/15/2016 10:11:23 AM Bony Bankart

• What I want to know – What % of the width of the glenoid • 25% – Determines scope vs open repair – High risk of failure if not addressed

xxx00.#####.ppt 1/15/2016 10:11:23 AM Bony Bankart

• CT – 3D gives excellent measure of size

• MRI – Can measure size – Soft tissue

xxx00.#####.ppt 1/15/2016 10:11:24 AM Bony Bankart

xxx00.#####.ppt 1/15/2016 10:11:24 AM Bony Bankart • What I need to know – What is the % relative to the bear spot?

• Treatment – <25% - arthroscopic debridement and soft tissue bankart repair – >25% - open treatment • Latarjet / Graft

xxx00.#####.ppt 1/15/2016 10:11:24 AM Hill Sachs • Most common finding along with Bankart • What I want to know – Size of the lesion (25%) – Does it engage the glenoid rim? • Determined at time of arthroscopy – Yes = open treatment

xxx00.#####.ppt 1/15/2016 10:11:25 AM Hill Sachs

xxx00.#####.ppt 1/15/2016 10:11:25 AM HAGL Lesion

• IGHL • Need to know if avulsed off humerus • Changes surgical approach to open

xxx00.#####.ppt 1/15/2016 10:11:25 AM xxx00.#####.ppt 1/15/2016 10:11:25 AM Peri-clavicular injuries

• Medial clavicle fracture – Often confused with SC dislocation – Late closure of medial physis • SH 1 or 2 fracture – What I need to know • Anterior or posterior • Underlying structures – Serendipity radiograph – CT/MRI

xxx00.#####.ppt 1/15/2016 10:11:25 AM xxx00.#####.ppt 1/15/2016 10:11:25 AM xxx00.#####.ppt 1/15/2016 10:11:25 AM xxx00.#####.ppt 1/15/2016 10:11:25 AM Peri-clavicular injuries

• Lateral clavicle fractures – Confused with AC dislocations – Late closure of lateral physis – Need to know amount/direction of displacement – Radiographs sufficient

xxx00.#####.ppt 1/15/2016 10:11:25 AM xxx00.#####.ppt 1/15/2016 10:11:25 AM xxx00.#####.ppt 1/15/2016 10:11:25 AM xxx00.#####.ppt 1/15/2016 10:11:26 AM xxx00.#####.ppt 1/15/2016 10:11:26 AM Many don’t need to be fixed

xxx00.#####.ppt 1/15/2016 10:11:26 AM xxx00.#####.ppt 1/15/2016 10:11:26 AM Glenoid Dysplasia

• Most common long term consequence of untreated brachial plexus palsy • Contribute to posterior shoulder instability

xxx00.#####.ppt 1/15/2016 10:11:26 AM Shoulder Sequela of BPP

Unequal muscle forces… • Soft tissue contractures • Posterior shoulder subluxation/dislocation • Osteocartilaginous deformation • Glenoid dysplasia • Proximal humeral epiphyseal flattening

xxx00.#####.ppt 1/15/2016 10:11:26 AM Glenohumeral Dysplasia for BPP… early and often

• van der Sluijs et al. JBJSBr 2001 – shoulders treated less than 1 year of age • < 5 months old -> 5/7 normal shoulders • > 5 months old -> 2/10 normal shoulders Early detection = possible prevention of dislocation

xxx00.#####.ppt 1/15/2016 10:11:26 AM Glenoid Dysplasia Imaging • US (infants) – Posterior – Dynamic exam – No sedation – Limited radiation • MRI or CT – Sedation – Radiation – Static exam

xxx00.#####.ppt 1/15/2016 10:11:26 AM US in glenoid dysplasia

– Posterior approach P P – Observe humerus in relation to posterior scapular line A A • In normal shoulders – center of humeral head lies anterior to line • In subluxed or dislocated – head lies posteriorly

*Moukoko et al. JBJS 2004

xxx00.#####.ppt 1/15/2016 10:11:26 AM Treatment BPP Shoulder • Younger patients – No bony deformity – Stretching – Tendon lengthening/transfers – Closed/Open reduction joint • Bony deformity (older) – Proximal humeral osteotomy – Possible glenoid osteotomy

xxx00.#####.ppt 1/15/2016 10:11:27 AM Failed early treament or late presentation (> 7 y.o.)

Waters • Subluxed/dislocated shoulder • Loss of ER • Glenoid dysplasia • I order CT/MRI to evaluate glenoid • What I want to know:

xxx00.#####.ppt 1/15/2016 10:11:27 AM Glenoid Dysplasia

xxx00.#####.ppt 1/15/2016 10:11:27 AM Humeral Rotation Osteotomy

• Gold standard • Transpose the existing arc of motion into a more functional one

xxx00.#####.ppt 1/15/2016 10:11:27 AM Glenoid Osteotomy

Freer in GH joint • New technique Bone block • Controversial • Not well studied Glenoid • Similar to salter osteotomy for Infraspinatus DDH

Scapula

xxx00.#####.ppt 1/15/2016 10:11:27 AM Bone Block

xxx00.#####.ppt 1/15/2016 10:11:27 AM Thank you

xxx00.#####.ppt 1/15/2016 10:11:27 AM Questions

1. A patient undergoes an MRI arthrogram for recurrent shoulder instability. Based on the imaging, the surgeon feels that arthroscopic treatment is contra-indicated and recommends open treatment. What is the most likely diagnosis? A. Glenolabral articular disruption (GLAD) B. Humeral avulsion of the glenohumeral ligament (HAGL) C. Superior labrum tear from anterior and posterior (SLAP) D. Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA)

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Questions

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• 1. Stein DA, Jazrawi L, Bartolozzi AR. Arthroscopic stabilization of anterior shoulder instability: A review of the literature. Arthroscopy 2002;18:912-924. PMID:12368791 • 2. Neviaser TJ. The GLAD lesion: Another cause of anterior shoulder pain. Arthroscopy 1993;9:22- 23. PMID:8442825

xxx00.#####.ppt 1/15/2016 10:11:27 AM Questions

• A 21-year-old rugby player has recurrent pain and instability of the right. Figure is an image taken during diagnostic arthroscopy viewing from the posterior portal. In addition to a Bankart lesion, what other associated intra- articular condition is most likely present? A. Rotator cuff tear B. SLAP tear C. Posterior labral tear D. Hill-Sachs lesion

xxx00.#####.ppt 1/15/2016 10:11:27 AM Questions

• A 21-year-old rugby player has recurrent pain and instability of the right. Figure A is an image taken during diagnostic arthroscopy viewing from the posterior portal. In addition to a Bankart lesion, what other associated intra- articular condition is most likely present? A. Rotator cuff tear B. SLAP tear C. Posterior labral tear Labrum D. Hill-Sachs lesion

Glenoid

xxx00.#####.ppt 1/15/2016 10:11:28 AM • 1. Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med. 2002 Jan-Feb;30(1):116-20. PMID:11799007 • 2. Hintermann B, Gachter A,: Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995;23:545-551 PMID:8526268

xxx00.#####.ppt 1/15/2016 10:11:28 AM Questions

3. Which of the following is the most common long term consequence of untreated brachial plexus birth palsy? A. Humeral length inequality B. Glenoid hypoplasia and retroversion C. Scapular winging D. Anterior shoulder instability

xxx00.#####.ppt 1/15/2016 10:11:28 AM Questions

xxx00.#####.ppt 1/15/2016 10:11:28 AM • 1. Waters PM, Bae DS. Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am. 2005 Feb;87(2):320- 5. PMID:15687154 • 2. Pearl ML. Shoulder problems in children with brachial plexus birth palsy: evaluation and management. J Am Acad Orthop Surg. 2009 Apr;17(4):242-54. Review. PMID:19307673

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