Shoulder Instability, Dr. Ioannis Pappou

Can hurt a lot less than an arthroscopic rotator cuff repair.
It beats me I think you see that every day like how those five punkest incisions hurt more than that, cutting off your joint putting in a new implant it’s just it’s so much less painful. Anyway, shoulder instability.
This is usually a subject that is the course for a grand round for an hour and a half talk. So we’re gonna cram a lot of information in 15 minutes. The shoulder is composed of four joints. Everybody focuses on the glenohumeral joint but truly whenever you raise the arm the motion of course that for joints. It starts with your sternoclavicular, acromioclavicular glenohumeral and finally your shoulder blade moves on the thoracic cage. This cabin cabinet thoracic instability can involve all four joints. We’re not gonna talk about scapula thoracic when just copula is separated from the thorax. That’s usually some sort of internal amputation that you rarely see in trauma centers or we’re not going to talk about that. We’re going to talk about the other three. SC joints usually that’s obvious on physical exam but you do need special views you’re not gonna pick that up on a plane X-rays and I’m going to show you some examples.
It can be anterior or posterior instability. They usually both occur as a result of trauma. The posterior dislocations are usually locked meaning it doesn’t go in and out of socket. Its posterior and stays posterior and that needs to be reduced in the operating room and I’ll show you why the anterior dislocation sometimes take less trauma sometimes joint this little case as a result of arthritis that kind of words out there than to your joint capsule in slips in and out of the socket and is usually better tolerated and we can try to treat this known operative. We’ve tried to ignore that we’re trying not to operate on that but surgery is possible. Here’s an example of Sternoclavicular joint instability. Anterior on the top the middle end of the clavicle is prominent under the skin and particularly when you compare that to the other side it’s very obvious the X-rays are pretty normal unless you get a CAT scan that shows the middle end of the clavicle being until your pursuer dislocated you’re not gonna be able to see that on just the next rate but the exam is very obvious.
Go back one please. Yeah. So, this is an example of a posterior dislocation. You can see the middle end of the clavicle is posterior to the sternum and that the clavicle end is directly abutting the great vessels is usually the right on the subclavian artery in the vein and that can be on or called vascular injury like the bone is like creating a small rent in the vessel and when you reduce it I can start to bleed profusely and that is the reason why we put them back in the operating room with a vascular surgeon and backup. The nice thing about the posterior dislocations is that once it’s back in socket it stays in the socket. That’s usually stuff for trauma centers you’re not going to see that in private practice severely and practice a lot.
ACL stability that is the most frequent is the ability of the AC joint dislocating the early joined like John did. There’s six types I keep missing of his button there’s six types. Step one is just a sprain of the structure. Type 2 you rupture the AC joint capsule but you have the ligaments which in your core are quoted in the clavicle the so-called CC coracoclavicular ligaments being intact. So although it’s sprained and painful the alignment is maintained in type 3 and Type 5. You have a complete failure of all of those like the capsule and those ligaments are gone and so the clavicle stays in place. But what happens is that the shoulder blade and the arm droops down away from the position of the clavicle. The difference between the 3 and 5 is that there’s what the bookstore on the picket is that there’s like a flash on top of that the insertion of the deltoid and trapezious on the AC joint in that fashion and somehow preserved the alignment.
When you tear the flash as well it creates a much more of use deformity in dripping off the shoulder blade and I have an example of that. So that’s the difference between the three and 5 is the amount of displacement. This is usually about the clavicle springs up by about a hundred percent and this is at least 300 percent usually these rare dislocations the 4 and 6 I’ve never encountered them. They’re described in books in the type for the clavicle dislocated straight posterior Li you may in fact miss that on the plain x ray because on the AP view looks relatively normal but on the excellent view the clavicle will be dislocated posterior lines of the trapeze use Type 6. I don’t even know how that happens but it can happen. The clavicle can come to lie underneath the coracoid. Very violent injuries. So this is the difference between a type three and type five.
This is a normal shoulder you’re looking for symmetry and although this guy’s this he joins our bulbous like mine. They’re symmetric on this one. The clavicle is there but there’s a bigger distance between the chromium and the clavicle right over there and that’s how the extra looks like you can see that the joint there is sprung whereas there is located. So when it’s sprung that’s the type through this location. This is the type 5 that 2 that the difference is bigger and that this is built from the clavicle to the acromion is at least 300 percent usually. So this type 3 injuries that’s the most frequent and AC separation that we see. We try to treat them as an operatively and when the patient comes back a few weeks later nine out of ten times they do quite well within a number of management. Then go back to normal. But they are a whole lot better to the point where they can resume useful activities perhaps even athletic activities and don’t require surgery.
We tend to reserve surgery for those types 3s only for that subset of patients that doesn’t improve with expectant management type fives that typically need to go to the operating room right away. And we used to do many complicated surgeries and there’s like a hundred time one hundred variations of that but now we have all evolved and pretty much do one surgery. We tried to recreate. We tried to reduce their joint between that acromion and the clavicle indirectly without exposing the actual join. And then we place a loop of tissue and suture from the clavicle around the coracoid and we do that now days believe it or not arthroscopic assisted for that little incision there we got sort of tunnel underneath that Coracoid and using the out of the scope and special issue we can shuttle suture and the graph and create a loop of tissue that holds the clavicle reduced and everything scars back in place and that’s probably the most frequent way to fix this injury nowadays.
Glenohumeral instability so this is what most people refer to as a dislocated my shoulder. It’s really dislocating humeral joint. The most important thing to do in this case is just to get a very thorough history on the first event. Many people missed that. You have to be thorough about it. How did the injury occur? What was the position of the arm and then was it a true dislocation where the shoulder could not be put back in place? You went to an emergency room there is documented X-rays with a dislocation in an emergency room physician put it back in place versus the patient thinks the shoulder joint slipped out of socket and then put it back in place. Very different documented dislocation versus the patient perceiving it as a dislocation. You’ve got to have good plain films and you must have axillary films or you or you lose dislocations.
So what I want. So primary care physicians in the room when they go back to their practices. If they write the scripts themselves or if they have their office managers write the scripts whenever you’re ordering you want to make sure you’re order a Grashey AP view and axillary and y view. Those two particularly the first ones are very important and I’ll show you examples why then the treatment or the dislocation depends on the patient age activity level and the magnitude of the bone and soft tissue injury in most of the times you can treat people nonoperatively. So we’re going to talk a little bit about doing the humeral stability static versus dynamic stabilizers that Dr. Michael alluded to. This is the ball and socket joint. Truly the socket in this joint is very flat.
And I’d like to liken it to like a golf ball on a golf team. If you have like any type of the efficiency of that golf tee. Like in cases of bony bank artery or injuries of the or socket it’s very easy for the ball to slide off and dislocate. And that happens in the shoulder joint just like a golf ball on a golf tee. You’ve got to have all of the bone on the shoulder socket it’s every millimeter of bone counts on the glenoid. This is the labarum and the ligaments. When you take the ball out of the socket the socket is only this big. The labrum composes actually about 20 percent of the joint surface more so it’s like an O ring on the shoulder socket. It deepens the shoulder socket and it gives them more cavities so they it’s there’s more space for the shoulder to do to sit on for the ball of the humans or sit on rather than not having your labrum. And you can see how all those ligaments anterior and posteriorly really, they take off from the labrum, so whenever you tear the labrum off from the shoulder socket as part of a dislocation its detentions the ligaments and that’s how you get instability.
Most cases of instability they happen on sterility fairly and you tear the labrum right about there, it rips off the bone and then dynamic stability is conferred by the rotator cuff muscles they all compress the ball in the socket and they help to keep it maintained and that’s where therapy is directed at is getting your scapula thoracic stabilizers and then the rotator cuff muscle strong again to compress the in the socket so immediate surgery for the glenohumeral joint would do that only when there is a very large unstable bankart injury and I will show you that. Or a very large rotator cuff tear and that’s something that you can pick up on physical examine an X-ray you’re early in an MRI to decide like in the first visit patient comes into the office to see me with a shoulder dislocation from a physical exam and an X-ray I know if they’re going to need surgery right away or not. Most patients we try to treat them non operatively in a sling for four to six weeks and rehab them and we tend to reserve surgery for instability if the instability is recurrence and in those cases in those recurrent instability cases then we’ll need an MRI program and a cat scan to look for bone inefficiencies.
So this is what we call a bankart and hill sach when you dislocate your shoulder the ball will come to lie on the front of the Glenoid in the Glenoid edge is very sharp and hard bone whereas the cancellous bone on the humerus is soft. So the Glenoid leaves a divot in the humerus that’s called a heel sax lesion in the area where the labrum is of course is called the bankart injury. Sometimes the labor room can take a small piece of bone from the interior with it and it’s called a bankart fracture. That’s an example of a small piece of bone of the anterior Glenoid and an indentation on the human head.
This is how you properly measure the glenohumeral joint. This is a true shoulder AP where the beam comes just perpendicular to your trunk. The joint itself however is inclined about 30 degrees this way.
So if you get a true perpendicular if you do the joint now you can actually see the joint space between the Glenoid and the humerus. And that view is very important. So when you order an AP and it would be a grashey AP of a grashey view. And this is how you’re going to miss a dislocation if you don’t get an axillary view you just get it like this AP view. It looks a little funky perhaps even some widening of the glenohumeral joint space. You get an axillary view, the joint is completely dislocated. I mean that’s the socket. That’s the ball. But if you don’t get that you can actually be missed. So make sure you order axillary. Anterior dislocations, the appearance of the joint even on the AP view is typically not normal. But they too can go undetected. Look Tom I was just framing a case of a patient who went to an emergency room and they completely missed the entire dislocation but the appearance is not as subtle as a posterior dislocation prestigious location are easier to miss.
So this is some examples of how we surgically fix these shoulder instabilities in cases where you have. Normal bone. You just have the labrum from the socket. We do that arthroscopically. This is a pure labral tear a pure bankart injury. Go in arthroscopically, mobilize the labrum. We’ll put suture anchors shuttle sutures are on it and then we’ll bring that all ring back to the shoulder socket and we’ll create like a nice bumper here and deep in the shoulder socket you see it’s not quite flat. The labrum is protruding off from the surface of the glenoid. That’s what you want you want to create like a little cavity there. In cases where there is also a large defect in the human head.
When you look at the shoulder joint that defect in the human head can actually engage and dislocate because you’re missing an arc of articular surface.
So what you can do is you can fill that in with the rotator cuff. Again arthroscopically will put in anchors into the humeral head and sutures will go through into the human head through the rotator cuff and they will insist that rotator cuff into the defect and then then what that does is we shorten the articular arc but we make the defect now extra articular and you can no longer engage. That’s called the remplissage procedure and that’s also done arthroscopically in cases where there’s a large bony banker like this we can actually fix the fix those out of the sky quickly. You can usually just put sutures around that piece and compress them into the shoulder so I can fix that. And this is a very rare case. One of my favorite cases to do though when you have cases where do they Glenoid is missing bone from multiple dislocations. The golf tees eroded and the shoulder just slides in and out of the socket very easily. So what you have to do is you have to replace like was like and we have to do a blended graft. There are main types but I like to use his distal tibia. We found out in the lab that the distal TBI matches perfectly the human head and you can simply cut out that piece and put that in it usually involves open surgery and give them a new shoulder socket if it advances.
So in summary this for joint you want to refer patients like that to an orthopedic surgeon. The treatment depends on which joint is dislocated and most patients can be treated non-operated. What I want to stress out is that in younger patients the most typical problem is recurrent instabilities in by younger women under 25 in patients who are older 40 or above. Their problem tends to be tearing their rotator cuff. The dislocations or stabilize nonoperatively but in most patients were over 40. We need to carefully examine their terror cough and make sure they don’t have an acute traumatic rotator cuff tear and that is typically what is required is a rotator cuff repair in patients over 40 not a shoulder stabilization surgery that’s reserved for the younger 30 population. Thank you.