Approach to shoulder instability

Moderator : Dr Shirish Adhikari

Presenter: Dr Ajay Shah (Resident)

Department of Orthopedics and Trauma Surgery

IOM,TUTH
Evaluation of instability
Clinical Evaluation

History

• Demographic data( age, sex, occupation)

• Mode of onset
• Duration
• Frequency/episodes
• Associated activities and energy related/Electric shock
• Provocative activities (e.g., overhead activities, activities requiring
external rotation, or position during sleep)
• Fear/sensation of dislocation
• Mechanism of injury
• History of self reduction
Family History
• Connective tissue disorders

Medical History
• Seizure
• Psychiatric illness
• Previous surgery

Sports History
• Swimming, gymnastics
Examination
Inspection
• Scar marks
• Swelling
• Ecchymosis
• Asymmetry of
shoulders
• Muscular atrophy
• Scapular winging
• Position of limb
Palpation
• Tenderness
• Abnormal bony points
• Crepitus
• ROM
• Strength of dynamic stabilisers
• Any nerve injury?
• Generalized ligamentous laxity
Hyperlaxity of capsule

• Collagen related disorders

• Plastic deformation of capsulologamentous

complex from single macrotraumatic event
or repetitive microtraumatic events.
General Tests for Laxity

• Drawer test
• Load and shift test
• Sulcus test
• Gagey hyperabduction test
 Drawer test
If the maneuver reproduces the clinical
symptoms of apprehension or pain, a presumed
diagnosis of instability
(anterior or posterior) may be established if
consistent with the history and other
examination findings

• Translation of head to glenoid rim is graded

1+
• Translation over rim with spontaneous
reduction is grade 2+
• Dislocation is grade 3+
 Load and shift test

• Easy subluxation of the humeral head

indicates loss of the glenoid concavity.
Sulcus Test

If distance between humeral head and

acromion
• <1cm :1+
• 1-2 cm:2+
• >2cm:3+

Subluxation at 0 deg is indicative of

laxity at rotator interval and that at 45
deg is indicative of IGHL complex
Gagey hyperabduction test
• Abduction over 105 deg reflects incraesed
laxity
• Symptoms of apprehension-inferior instability
• Typically positive with MDI
• Should be performed for all patients with
posterior instability as there is frequently a
bidirectional component
Specific Examinations for Anterior Instability

• Apprehension test
• Relocation test
• Crank test
• Fulcrum test
• Surprise test
Apprehension test
• Although pain may be used as an indicator for instability, it is typically not as
specific or as reliable as apprehension in documenting anterior instability.
Fulcrum test Crank test
Jobe’s relocation test

• Used for evaluating instability in athletes

involved in sports requiring overhead
motion
• A feeling of apprehension or subluxation
indicates anterior instability
 Specific Examinations for Posterior
Instability

Jerk test
• Provocative for posterior instability
• With a positive test, sudden jerk occurs
when the humeral head slides off the
glenoid and when it is reduced back
onto the glenoid
Kim Test

• Combination of positive Kim and

jerk tests has 97 % sensitivity for
posterior instability

• Indicates reverse bankart lesion

Examinations for Multidirectional Instability

No specific test for MDI, but inferior instability, by definition, is a major aspect of
the pathology. Therefore, specific tests of inferior laxity such as
• Sulcus test
• Gagey hyperabduction test
• Drawer test
• Load and shift test
X-rays

Anteroposterior View

• Due to oblique position of scapula, the

shadow of humeral head will overlap with
glenoid in AP view fossa.
• So this view is difficult to interpret with
respect to glenohumeral joint
 True AP View

• Grashey view
• X-ray beam is angled 35 to 45 degrees
oblique to the sagittal plane of the
body

• X-ray beam is parallel to the joint so

that there is no overlap between
humeral head and glenoid surface

• If any overlap is seen dislocation

should be suspected
Axillary Views

• Accompanied with AP view to document the location of humeral head relative

to glenoid fossa
• Shows the direction and magnitude of humeral head displacement
• Associated fractures of both the humeral head and glenoid can be seen.
• Axillary views:
Standard axillary view
For patient who cannot abduct arm
Trauma axillary lateral view
Velpeau axillary lateral view
West Point View
• Provides tangential view of anterior glenoid
• Prone position
• Beam is angled approximately 25 degrees from midsagittal plane (A) to provide a tangential view of
glenoid.
• In addition, beam is angled 25 degrees downward (B) to highlight anterior and posterior aspects of
glenoid.
Apical Oblique View

• Sometimes referred to as the Garth view

• Clearly reveals the anterior inferior and
posterior superior glenoid rims

• X-ray beam angled approximately 45 degrees

(A) to provide a “true AP” view of the glenoid.

• In addition, the beam is angled 45 degrees

downward (B) to highlight the anterior
inferior aspect of the glenoid
Scapular Y view
• Cassette placed on the anterolateral aspect of the
shoulder
• X-ray beam is directed parallel to the plane of the
scapula(medial to lateral)
• Outline the scapula as the letter “Y”—hence the
name of this view.
• Two upper limbs of letter Y represent scapula spine
and coracoid process whereas inferior limb of the Y
represents scapular body
Stryker Notch View
• Best to characterize the Hill–Sachs defect and the posterior-superior humeral head
• Supine position
• Arm flexed to 120 degrees so that the hand can be placed on top of the head
• X-ray beam angled approximately 10 degrees.
• Radiograph shows presence of any osseous defects
CT scan

• Most sensitive for detecting and measuring bone deficiency, retroversion

of glenoid or bony pathology
• Indications:
Blunting of glenoid outline or obvious bony defect on plain x-rays
Evaluation of recurrent instability
Failed surgical procedures
CT Arthrography

• Useful in patients without clear-cut clinical signs of subluxation or dislocation, but

with pain, clicking, and vague discomfort suggestive of instability

• Helps in visualization of soft tissue pathology such as rotator cuff tears and
capsular lesions.

• Sensitivity of CT arthrography approaches conventional MRI in evaluating labral

tears (80% to 90%) with specificities in the 90% range
Estimation of bone loss
According to Lo et al., an anterior defect of 7.5 mm
corresponds to approximately 25% of total bone loss

Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: An indicator of significant
glenoid bone loss. Arthroscopy. 2004;20(2):169–174.
MRI

• Instability, if consideration is given to surgical treatment, MRI (in comparison to

CT) is considered the standard
• Best for: capsuloligamentous, labral and rotator cuff lesions
• MR arthrography more sensitive than conventional MRI
• In MR arthrography, labral and rotator cuff tears all had sensitivities >95% and
specificities of nearly 100%
• Conventional 3-T MRI had similar specificities, but lower sensitivities in the 80%
to 90% range
Diagnostic Arthroscopy

• Examination under anesthesia

• If any doubt of clinical diagnosis or pathological lesion
• More useful in multidirectional instability
• Reports have demonstrated sensitivity and specificity of 100% and
93% respectively
 Advantages Disadvantages

•Reproducible technique •Requires general anesthesia

•Visualization of all pertinent structures •Risk of infection
•Technique can be performed in beach •Risk of iatrogenic injury to anatomic
chair or lateral decubitus positions structures
•Thorough 360° glenohumeral evaluation •Risk of traction neuropathy in lateral
•Gold standard to diagnose shoulder decubitus position
pathology •Risk of cerebral hypoperfusion in beach
chair position

Diagnostic Shoulder Arthroscopy: Surgical Technique

Ian M. Crimmins, B.S.,a,∗ Mary K. Mulcahey, M.D.,b and Michael J. O'Brien, M.D.b
Anterior Instability

Non-operative Treatment
Relative Contraindications
Indications
• First-time acute dislocation
• Irreducible first-time acute
• Recurrent instability without
dislocation
prior treatment
• Recurrent instability failing
• Recurrent atraumatic instability
• Chronic dislocation with good nonoperative management
• Open injuries
function and no pain
• Chronic dislocation with poor
• Patient medically unstable for
function and pain
surgery
• Unstable epilepsy
Operative Treatment

Indications Relative Contraindications

• Irreducible or unstable first
time acute dislocation
• Recurrent instability failing
nonoperative management
• Open injuries
• Chronic dislocation with poor function
and pain
• Dislocation associated with displaced
proximal humerus
fracture
• Reducible, first time acute dislocation
• Recurrent instability without prior
treatment
• Patient medically unstable for Surgery
• Chronic dislocation with good function
and no pain
• Unstable epilepsy
Conservative or surgery in first time dislocaters???
• The long-term results of surgical arthroscopic stabilisation and conservative
primary treatment for first-time traumatic anterior shoulder dislocation were
compared in a study by Jakobsen et al.
• At follow-up two years after treatment, it was found that the recurrent instability
rates were 54% for the nonsurgical treatment group and 10% for the surgically
treated group.
• At follow-up ten years after treatment, the instability rates were 26% and 9%,
respectively.

First-time anterior shoulder dislocations: should they be arthroscopically stabilised? Singapore Med J. 2014
Oct; 55(10): 511–516
 The three major reasons cited in the literature for supporting immediate
stabilisation over conservative treatment are:

(a) The unacceptable high risk of recurrence in the young athletic population
(b) The recurrent instability that propagates significant and progressive soft tissue
and bony trauma
(c) The improvement in the quality of life conferred by surgery
• Goals of surgery: repair the anatomical lesion and retension of tension
of capsuloligamentous structures.

• Restoring normal anatomy is guiding principle

If labrum is detached, reattach to glenoid rim
If capsule is stripped off, reattach to glenoid rim
If glenoid fossa>1/3rd is involved, bony block procedure

• Younger patients engaging in overhead or collision sports have higher

recurrence rates after arthroscopic only stabilization.
Open or arthroscopy???
• A recent randomized controlled trial comparing open and arthroscopic
stabilization for recurrent traumatic anterior shoulder instability in 196 patients
showed increased recurrence in those who underwent arthroscopic stabilization
(23% versus 11%), despite no differences in patient-reported outcome scores
after two years of follow-up.

• Despite historical data indicating the superiority of primary open stabilization,

this treatment method has fallen out of favour even in the treatment of young,
active patients, as it is more invasive than arthroscopic stabilization, is associated
with the risk of subscapularis insufficiency, and because recent data have shown
equivalence or superiority of modern arthroscopic techniques.

Open and Arthroscopic Anterior Shoulder Stabilization. Investigation performed at the Hospital
for Special Surgery, New York, NY
Today, the decision of open versus arthroscopic surgery is largely based on :

Surgeon preference and experience, although most surgeons agree that an

open technique is preferred for substantial glenoid bone loss.

History of surgical intervention of anterior shoulder instability J Shoulder Elbow Surg (2016)
Soft tissue procedures for anterior instability

Modified Bankart repair

Engaging Hill Sachs lesion
• If there is a large Hill-Sachs lesion, at the time of arthroscopy, the shoulder can be
taken through a physiological range of motion and the Hill-Sachs lesion can be
observed to determine if it has a tendency to engage with the edge of the
glenoid.

• This is a potential cause of failure of an arthroscopic Bankart repair and add a

‘remplissage’ procedure to the standard arthroscopic Bankart repair.

• A meta-analysis by Camus et al. suggested that in case of anterior shoulder

instability with engaging Hill-Sachs lesion and with up to 20–25% glenoid bone
loss, arthroscopic Bankart repair + remplissage reduces recurrent instability by 4-
fold comparing with an isolated Bankart repair, with better functional outcomes.
 Remplissage (to fill up)

• Can be reliably utilized when there is minimal or no glenoid bone loss

• Involves capsulotenodesis of the posterior capsule and infraspinatus tendon
to fill the Hill-Sachs lesion.
• Lesion is converted to extraarticular

Current Trends in the Management of Recurrent Anterior Shoulder Instability ,Bulletin of the
Hospital for Joint Diseases 2014;72(3):210-6
• In appropriately selected instability patients (those with engaging Hill-Sachs
lesions and adequate glenoid bone stock), this procedure has shown reduced
rates of recurrent instability.

• In addition, postoperative MRI has shown good healing of the capsulotenodesis

into the humeral head defect, with a minimal external rotation deficit of 8°.

• Biomechanical comparison of remplissage versus Latarjet transfer showed similar

reductions in instability and maintenance of motion for the 2 procedures in
patients with less than 25% glenoid bone loss.

Arthroscopic Remplissage for Engaging Hill-Sachs Lesions in Patients With Anterior Shoulder Instability
Christopher L. Camp, M.D., Diane L. Dahm, M.D., and Aaron J. Krych, M.D 2015 Oct; 4(5)
Anterior stabilisation with glenoid deficiency

Latarjet-Bristow procedure
Indications:
• Inverted pear shaped glenoid and engaging Hill-Sachs lesion
• Graft increases the safe arc of joint and is used when large (35-
45%)humeral head lesion is present
The triple effect by which the Latarjet technique works are
• The “bone block effect” restoring glenoid bone loss
• The “sling effect”, in which the conjoined tendon limits anterior translation
in a position of abduction and external rotation
• The “ligament effect” by using the coracoacromial ligament stump to
reattach the medial capsule.

Current concepts in anterior glenohumeral instability: diagnosis and

treatment SICOT-J 2021, 7, 48
• Group 1: glenoid defect of less than 25% plus on-track Hill-Sachs lesion
• Group 2: glenoid defect of less than 25% plus off-track Hill-Sachs lesion
• Group 3: glenoid defect of 25% or more plus on-track Hill-Sachs lesion
• Group 4: glenoid defect of 25% or more plus off-track Hill-Sachs lesion

Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-
Engaging” Lesion to “On-Track/Off-Track” Lesion,Arthroscopy Association of North America
• Group 1: Arthroscopic Bankart repair
• Group 2: Arthroscopic Bankart repair plus remplissage
• Group 3:Latarjet procedure
• Group 4: Latarjet procedure plus humeral-sided procedure (humeral bone
graft or remplissage) if the HillSachs lesion is engageable by surgeon on
operating room table after Latarjet procedure or only Latarjet procedure if
Hill-Sachs lesion is not engageable by surgeon after Latarjet procedure
Posterior instability
Initial treatment:- non-operative (posterior deltoid and external rotators
strengthening exercises).
Avoid provocative activities & educating the patients to avoid specific
voluntary maneuvers that causes posterior subluxation.

Indications Contraindications
• Failed nonoperative treatment for
recurrent instability
• Unstable epilepsy
• Failed closed reduction
• Dislocation >3–6 wks
• Reverse Hill–Sachs >20–25%
• Significant glenoid defect
• Proximal humerus fracture
Neer inferior capsular shift procedure
Tibone and bradley technique
Mclaughlin procedure

• Done in recurrent posterior dislocation a/w large anterior medial Hill-Sachs

lesion

• Transfer of subscapularis tendon into defect

• Modified by Neer and Foster by transferring subscapularis tendon along with

lesser tuberosity into defect and fixed with screws
McLaughlin technique
Neer & Foster modification of McLaughlin
Technique
Rockwood technique
Multidirectional Instability

Primary abnormality:-loose, redundant inferior pouch.

• Initial approach is always conservative.
• Surgical procedure:-principle is to detach the capsule from neck of humerus
and shift to calcar portion so as to obliterate the pouch and laxity.
Neer and Foster Technique of inferior capsule shift
References

• Rockwood and Green fracture in adults,8th edn

• Campbells Operative Orthopaedics,13th edn
• Apleys system of Orthopedics,9th edn
• Related journals and articles