Rockwood Adults CH34

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SECTION TWO • Upper Extremity

characteristics (i.e., chronicity, number of dislocations, cap- sular insufficiency, and bony deficiencies), is paramount to achieving success with arthroscopic surgery. 22,73,130,180,209,254 It is important to remember that while arthroscopic Bankart repair is suitable for most patients with anterior instability, there are certain factors that should prompt consideration of an open or bony procedure. ANTERIOR GLENOHUMERAL INSTABILITY Indications/Contraindications

conservative management in this subset of patients after pri- mary dislocation. Surgery should only be indicated after a pro- longed trial of therapy or with recurrence of instability. 134 Arthroscopic Anterior Labral (Bankart) Repair Preoperative Planning ✔ ✔ Arthroscopic Anterior Labral (Bankart) Repair: PREOPERATIVE PLANNING CHECKLIST

❑❑ Regular OR table with rails that allows placement of the arm traction apparatus ❑❑ Beach chair table with arm holder

OR table

Operative Treatment of Anterior Glenohumeral Instability: INDICATIONS AND CONTRAINDICATIONS Indications

❑❑ Lateral decubitus or beach chair

Position/positioning aids

Relative Contraindications

❑❑ 30 and 70 degrees arthroscope ❑❑ 6- and 8-mm threaded cannulas ❑❑ Labral elevator and CoVator ❑❑ Curved passer (Mitek Ideal 45 degrees with Chia) ❑❑ Anchors loaded with sutures and labral tape ❑❑ Drill and drill guide (2.9-mm drill bit) ❑❑ Ring grasper and regular grasper

Equipment

• Patients who have more than one shoulder subluxation or dislocation with anterior labral detachment (Bankart lesion) • Recurrent anterior shoulder instability despite adequate conservative treatment including physical therapy • Anterior locked dislocation with failed closed reduction under anesthesia will require open reduction contact or overhead athletes) who sustain a traumatic first-time dislocation with document Bankart lesion on MRI (relative indication) • High-risk athletes (i.e.,

• Uncooperative or medically unstable patient including active seizure disorder • Presence of capsular

deficiency or history of thermal capsulorrhaphy

• Patients with primary

collagen disorders (Ehlers– Danlos or Marfan syndrome) • Patients who have atraumatic shoulder instability and have evidence of ligamentous laxity on examination or patients who are voluntary dislocators • Patient with neurologic injury resulting in paralysis of the axillary or suprascapular nerve • Patients with recurrent instability in the setting of active infection or several posttraumatic arthritis

Both radiographs and advanced imaging should be obtained prior to surgery. MRA is both more sensitive and specific than MRI for the detection of anteroinferior labral tears. The amount of glenoid bone loss must be assessed prior to indica- tion for arthroscopic Bankart repair. The critical bone loss that changes the indication from arthroscopic Bankart repair to a bone procedure is between 13.5% and 17.3% according to the literature. In the subset of patients who are at higher risk for recurrent instability (male, young, contact sports, etc.), a bone- based procedure at the primary surgery should be considered at the lower range of the critical defect size (13.5%), whereas in low-demand patients, 17.3% critical bone loss is the critical threshold between an arthroscopic procedure and an open bone procedure. Positioning The patient is set up either in the lateral decubitus or beach chair position depending on the surgeon’s training and preference. In the lateral decubitus position, the patient is intubated and placed lateral on a bean bag. A pillow is placed under the leg to protect the common peroneal nerve. The operative extremity is prepped and placed in an arm holder with Coband to allow for traction. A balanced traction with 5 to 10 lb of weight is used with traction and lateral distraction (Fig. 34-30A). Addition- ally, a small bump can be placed underneath the axilla to help further distract the glenohumeral joint to allow for improved visualization. The beach chair set up starts with the patient intubated and a head holder is placed. A bump is placed under- neath the body and the patient is sat up to approximately 70 to 80 degrees of flexion. The affected arm is placed in a spider arm holder, which allows for positioning throughout the case. As with the lateral decubitus position, a small bump can be

The importance of recognition and quantification of Hill–Sachs lesions and glenoid bone loss in treatment consideration for traumatic anterior shoulder instability and failed instability sur- gery is growing. 138,209 As a result, there is a resurgence of bony augmentation procedures such as coracoid transfer (Latarjet, Bristow) and autogenous or allogenic bone block procedures for treatment of anterior shoulder instability. In the following sections, we will discuss the operative treatment decision algo- rithm, operative approach and techniques, and outcomes of open and arthroscopic Bankart repair and bony augmentation for treatment of traumatic anterior instability. There are many studies on the management of anterior shoulder instability in the adult patient population. However, a paucity of literature exists regarding shoulder dislocations in skeletally immature patients. The presence of open proximal humeral physis changes the management of these patients with primary shoulder dislocations. Recent literature shows a rela- tively low rate of recurrent instability after the primary disloca- tion compared with older literature. The authors recommended