Arthroscopic Stabilisation

 

 

1.  EUA

 

Compare both shoulders

- ROM

- anterior and posterior draw

- load and shift

- sulcus sign

 

2.  Labral Assessment

 

A.  Above equator

 

Labral detachments here not uncommon 

- degenerative tear in throwing athlete

- likely a SLAP constributes to instability

 

Beware normal variations in this area

 

Rao JBJS Am 2003

- variations in the antero-superior labrum

- found in 13% of patients

- 3 main types

 

1.  Sublabral foramen

 

 

2.  Sublabral foramen with cord like MGHL

 

 

3.  Absence of AS labrum with cord like MGHL

- Buford complex

 

 

B.  Below equator 

 

Labral detachments / Bankart

- cause of instability

- 3 to 6 o'clock

- tear of anterior IGHL with labrum

- can be variants (ALPSA, GLAD, Perthes)

 

 

C.  Exclude HAGL

 

Assess anterior IGHL attachment to humeral neck

 

 

D.  Posterior Labrum

 

Always assess

- place camera through anterior portal

 

 

3.  Bony Assessment

 

A.  Anterior Glenoid

- measure bone anterior to bare area in centre of glenoid

- compare to bone posterior to bare area

- beware > 4 mm difference

- look for pear shaped glenoid

- is there sufficent bone for ST surgery alone?

 

 

 

Solution

- anterior bony procedure

 

B.  Hill Sachs

- posterolateral with anterior dislocation

- assess ER

- only a problem if engages with head centred and ER < 30 - 40^o

 

 

Solution

 

1.  Latarjet / Bristow

- ensures no engagement on anterior glenoid

 

2.  Wolf Remplissage

- mobilisation of capsule and infraspinatous into Hill sach's

- renders defect extra-capsular

 

3.  Humeral head allograft

 

4.  Humeral head osteotomy

 

Technique Anterior Bankart Repair

 

 

Set up

 

Beachchair / lateral (surgeon preference)

Pressure pump

- usually less pressure required than subacromial work

- 40 mmHg

 

Portals

 

 

A.  Standard posterior portal

- 2 cm below and 2 cm medial to PL acromion

- in soft spot

- good angle for GHJ work

 

B.  Anteroinferior Portal (AI)

- for anchor placement

- rotator interval just above SSC
- 1 cm lateral to glenoid

- establish with spinal needle

- need to access 3 - 6 o'clock

- 8 mm portal

 

 

Anterosuperior Portal (AS)

- for suture management

- 1 cm superior and 5 mm lateral

- spinal needle

- enters rotator interval at angle between biceps and glenoid

- 8 mm cannula

 

 

Problem

- can make rotator interval very crowded

- repair can be done through single portal

 

Mobilise labrum

 

 

Labral mobiliser / rasp / scissors

- labral tear can be obvious, but may have partially healed or healed medially

- mobilise until can see SSC muscle underneath

- change camera to ASL portal for better view

 

 

Bony Fragments

- important to recognise

 

Options

 

1.  Incorporate in repair

- pass sutures medially to bony fragments

 

2.  Remove / debride

 

 

Debride bone to bleeding base

- tear is from 3 to 6 o'clock

- use shavers / burrs

 

 

Labral Repair

 

Anchors

- 2.3 or 3.2 mm bioabsorbably anchors

 

Insert inferior anchor

- most difficult and most important

- via anteriorinferior portal or via stab incision in SSC

- on anterior edge of glenoid cartilage

- want to recreate bumper effect

- inferior anchor first at 5.30

- insert drill guide, pass drill, insert anchor

- usefull to have assistant distract head laterally at this point

 

 

Suture passer

- again, assistant distracts shoulder

- right angled for right shoulder, left angled for left

- via the AI portal

- decide whether to take labrum only or capsule then labrum

- want to pull tissue superiorly and laterally

- suture passer with loop / single nylon in anterior to posterior direction

- retrieve through portal

- retrieve suture posterior to anterior through portal

 

 

Tie knot

- simple knot / Duncan Ely / Modified Roeder

- ensure post / subsequent knot is anterior to labrum

- recreate bumper effect

 

 

Remaining anchors

- 5 mm apart

- beware lysis and risk of anterior glenoid / postage stamp fracture

- up to glenoid equator

- usually three in total

 

 

Additional Issues / Continued Instability

 

Capsular Shift

- take bite of capsule with suture passer, then labrum

 

 

SLAP

- contributes to inferior instability

- requires repair

 

Rotator Interval

- can tighten with continued instability

- close capsule in this area with suture

- must do with arm at 30^o ER

- do away from glenoid on humeral side or will make patient very stiff

- SGHL to MGHL

- must do last

 

Results

 

Primary Arthroscopic Stabilisation

 

Altchek et al Am J Sports Med 2010

- Hospital for Special Surgery New York

- prospective follow up 88 patients 2 years

- 18% recurrent instability episode / 3% revision

- identified patients < 25 / ligamentous laxity / Hill Sachs > 250mm³ high risk

 

Carreira et al Am J Sports Med 2006

- prospective follow up 87 patients followed for 2 years

- 10% recurrent instability

 

Arthroscopic v Open Bankart Repair

 

Bottoni et al Am J Sports Med 2006

- RCT open v arthroscopic, 2 - 3 year follow up

- 2 failures in open group v 1 failure in arthroscopic group

- open took significantly longer and was associated with decreased ER

 

Revision of Failed Arthroscopic Stabilisation

 

Cho et al Am J Sports Med 2009

- revision of 26 failed arthroscopic stabilisation with open bankart

- redislocation in 3 shoulders all with engaging Hill Sachs and ligamentous laxity

 

Francheschi et al Am J Sports Med 2008

- 10 patients with failure of arthroscopic stabilisation

- managed with repeat arthroscopic stabilisation

- 1 recurrence