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Being aware of arthroscopic shoulder stabilization pitfalls may help avoid them
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SAN DIEGO — When patients present with anterior, posterior or multidirectional shoulder instability, the orthopedist should view an arthroscopic procedure not as a diagnostic tool, but a means to correct anatomical abnormalities and re-stabilize the shoulder minimally invasively, the director of a shoulder and sports surgery center said at the Arthroscopy Association of North America 2011 Specialty Day Meeting, here.
 Matthew T. Provencher |
“Know your diagnosis before going to the operating room. We know that laxity does not equal instability,” CDR Matthew T. Provencher, MD, MC, USN, associate professor of surgery and orthopedics at the U.S. Naval Center in San Diego, said.
For Bankart repairs, open procedures have traditionally been the gold standard, so addressing shoulder instability arthroscopically is a challenge for many clinicians, he noted.
“Recognizing important history and examination findings ensures optimal patient care and helps improve overall outcomes of shoulder instability surgery,” Provencher told Orthopedics Today via e-mail. “Proper recognition of the pathology associated with shoulder instability also allows for the application of proven surgical techniques for the betterment of patient care and by learning the pitfalls of instability repair, one may improve upon sound technical treatment principles.”
Imaging advantages
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Images: Provencher MT |
During his presentation, Provencher urged those interested in treating shoulder instability arthroscopically to perform a thorough examination, get a complete bilateral history and look for signs of glenoid bone loss, which commonly occurs in cases of recurrent and chronic shoulder instability.
An important examination finding to detect bone loss is instability in mid-ranges of motion — abduction 45° to 60° with some external rotation — and is often associated with the patient having a history of progressive ease of instability and numerous instability events. Bone loss can be detected through preoperative imaging studies including radiographs, MRI and CT scans.
“I preferentially obtain a CT scan in young patients with a history suggesting glenoid bone loss or plain radiographs that reveal a potential evidence of bone loss ,” he said.
Advanced studies
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A 3-D CT scan with digital subtraction of the humeral head facilitates more accurately measuring glenoid bone loss and determining glenoid shape, either acute fracture, partial loss bone loss, or complete bone loss. Provencher noted glenoid shape is often a predictor of recurrence risk and other problems.
“An arthroscopic repair is an attractive way to fix these moderately-sized glenoid bone defects,” he said at the meeting.
Imaging also indicates whether a superior labral anterior posterior (SLAP) lesion or other labral tear involves soft tissue alone or both soft tissue and bone, which can be telling, according to Provencher.
“If you have a glenoid issue, you almost always have a Hill-Sachs [lesion] issue and vice versa. They also potentiate each other.”
An expert’s advice
Among the surgical advice that Provencher offered to meeting attendees was the following:
- know the principles of an anatomic repair;
- find the labrum, liberate it and restore its normal anatomic position;
- be aware that anterior labrum periosteal sleeve avulsion (ALPSA) tears are associated with twice the bone loss and triple the failure rates;
- accurately diagnose humeral avulsion of the glenohumeral ligaments (HAGL) lesions, which are more prevalent in women and patients with vague pain symptoms;
- learn to discern between the pathology of posterior and anterior instability; and
- avoid subacromial decompressions in young patients because a different diagnosis is nearly always involved.
Being familiar with the anatomy of the rotator interval is another “pearl” Provencher discussed.
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“I think the bottom line that we need to understand is that an arthroscopic shift is not the same as what we do with an open rotator interval closure. There may be some range of motion issues. We may not provide the exact benefit desired if you do this arthroscopically vs. what has traditionally been described with an open approach,” he said.
Provencher ended by describing the left decubitus position as the “work horse” position for treating anterior instability. “It provides ease of access, ease of instrumentation and ease of inferior anchor placement, as well as the ability to put anchors anywhere around the glenoid face,” he said.
Intraoperatively, the correct amount of the capsular shift may be custom-tailored for the patient based on their laxity seen in the operating room, said Provencher, who noted the importance of accurate portal placement. “A 3 to 5 mm difference in skin incision placement can alter your case dramatically and turn this into a very fun case from one that might be quite challenging,” he said. – by Susan M. Rapp
Reference:
- Provencher MT. Arthroscopic shoulder instability pitfalls: What not to miss and how to stay out of trouble. Presented at the Arthroscopy Association of North America 2011 Specialty Day Meeting. Feb. 19. San Diego.
- CDR Matthew T. Provencher, MD, MC, USN, can be reached at the U.S. Naval Medical Center, San Diego, Department of Orthopaedic Surgery, 34800 Bob Wilson Drive, San Diego, CA 92134; 619-532-8427; e-mail: matthew.provencher@med.navy.mil.
- Disclosure: Provencher has no relevant financial disclosures.
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Dr. Provencher has provided an excellent overview on the current state of arthroscopic instability surgery in 2011. While arthroscopic instability repair has become a commonly performed procedure for many orthopedic surgeons, Dr. Provencher provides some important pearls to try and prevent untoward outcomes. Firstly, a proper patient history and thorough physical examination will typically lead the surgeon to make the correct initial diagnosis – primarily anterior, primarily posterior, or multidirectional instability. However, MRI-arthrogram, to identify soft tissue lesions (labral tears, SLAP tears, ALPSA (anterior labral periosteal sleeve avulsion) lesions), and 3D-CT with humeral subtraction, to identify glenoid bone loss, are critical to making the proper pre-operative diagnosis and operative plan. Arthroscopic labral repair leads to predictably good results in most patients. However, those patients identified with significant glenoid bone loss should be treated with a bony augmentation procedure (Latarjet coracoid transfer, for example), as soft-tissue procedures have a very high failure rate.
— William N. Levine, MD
Vice Chairman and
Professor, Department of Orthopaedic Surgery
Co-Director, Center for
Shoulder, Elbow, and Sports Medicine
Columbia University Medical Center,
New York
Orthopedics Today Editorial Board member
Disclosure: He receives research support from Arthrex and Zimmer.