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1. Shoulder Arthroscopy:Shoulder Arthroscopy:
Where we are where weWhere we are where we
are heading for?are heading for?
Manos AntonogiannakisManos Antonogiannakis
Director of Center for ShoulderDirector of Center for Shoulder
ArthroscopyArthroscopy
IASO General HospitalIASO General Hospital
AthensAthenswww.shoulder.gr

2. The Shoulder
 Greatest Range of Motion in the Body
 Motion in all 3 planes of movement
 Prone to injuries
 8-20% of all sports injuries

3. HistoryHistory
1931 First Cadaver Shoulder Arthroscopy1931 First Cadaver Shoulder Arthroscopy BurmanBurman
1974 First Shoulder Arthroscopy in vivo1974 First Shoulder Arthroscopy in vivo Johnson LLJohnson LL
1982 First Arthroscopic repair1982 First Arthroscopic repair Johnson LLJohnson LL
of Shoulder Instabilityof Shoulder Instability
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4. Diagnostic arthroscopyDiagnostic arthroscopy
The way everything began!!The way everything began!!

5. Arthroscopy in its infancyArthroscopy in its infancy

6. Diagnostic ArthroscopyDiagnostic Arthroscopy
Distinguish Normal AnatomyDistinguish Normal Anatomy
Anatomic VariantsAnatomic Variants
Variation of GHLsVariation of GHLs
Sublaral HoleSublaral Hole
Cord-like middle GHLCord-like middle GHL
Buford ComplexBuford Complex
Rotator Crescent Sign (cuff “ridge”)Rotator Crescent Sign (cuff “ridge”)
SLAP lesionsSLAP lesions
Bursal side RC tearsBursal side RC tears
Internal ImpingementInternal Impingement
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7. Glenohumeral LigamentGlenohumeral Ligament
VariationsVariations
 66% - Well defined SGHL, MGHL & IGHL66% - Well defined SGHL, MGHL & IGHL
 7% - Confluent MGHL & IGHL7% - Confluent MGHL & IGHL
 19% - Cordlike MGHL with a high riding19% - Cordlike MGHL with a high riding
attachmentattachment
 8% - No discernable MGHL – IGHL but one8% - No discernable MGHL – IGHL but one
confluent anterior capsular sheathconfluent anterior capsular sheath

8. Diagnostic ToolDiagnostic Tool
Bufford ComplexBufford Complex
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9. Diagnostic ToolDiagnostic Tool
Sublabral holeSublabral hole
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10. Diagnostic ToolDiagnostic Tool
Os acrmialeOs acrmiale
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11. Diagnostic ToolDiagnostic Tool
SLAP LesionsSLAP Lesions
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12. Diagnostic ToolDiagnostic Tool
Internal ImpingementInternal Impingement
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13. Shoulder ArthroscopyShoulder Arthroscopy
the evolution of the techniquethe evolution of the technique
Diagnostic
Tool
Final
Treatment
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From tool of the devil the treatment of choice of most shoulder
pathologies

14. Therapeutic ArthroscopyTherapeutic Arthroscopy
Rotator Cuff diseaseRotator Cuff disease
Tears (Full, Partial, Intratendonious)Tears (Full, Partial, Intratendonious)
Calcifying TendonitisCalcifying Tendonitis
InstabilityInstability
Anterior, Posterior, MultidirectionalAnterior, Posterior, Multidirectional
Bony Bankart lesionsBony Bankart lesions
Glenoid defectsGlenoid defects
HAGL and reverse HAGL lesionsHAGL and reverse HAGL lesions
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15. Therapeutic ArthroscopyTherapeutic Arthroscopy
SLAP lesionsSLAP lesions
Frozen ShoulderFrozen Shoulder
AC jointAC joint
ArthritisArthritis
DislocationDislocation
Biceps PathologyBiceps Pathology
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16. Arthroscopic EvolutionArthroscopic Evolution
Metal Anchors
Absorbable
Anchors
Peek Anchors
Single suture
Double sutures
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17. Cuff repairCuff repair
Tendon to bone repairTendon to bone repair
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18. Rotator CuffRotator Cuff
Single Row
Double Row
Triple Row
Different
Suture
Passing
techniques
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24. RC Arthroscopic RepairRC Arthroscopic Repair
1.1. Recognition, of the type of the tearRecognition, of the type of the tear
2.2. Retraction and releasesRetraction and releases
3.3. Repair Options:Repair Options:
AnchorsAnchors:: metallic or absorbablemetallic or absorbable
Type of stitchType of stitch:: Mason-Allen,Mason-Allen,
Mc Stitch,Mc Stitch,
Mattress sutures,Mattress sutures,
Horizontal mattress,Horizontal mattress,
Simple suturesSimple sutures
Restoration of footprintRestoration of footprint:: Double row orDouble row or
Single rowSingle row www.shoulder.gr

25. Risk to Benefit RatioRisk to Benefit Ratio
• Rot cuff tears DO NOT heal spontaneously
• Tear repairability
• Think of Size, Elasticity and Chronicity
• Fatty infiltration is not fully reversible
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Operative TreatmentOperative Treatment
Act aggressive and early

26. Act early try to avoid irreversibleAct early try to avoid irreversible
bad tissue qualitybad tissue quality

27. What is Bad Tissue Quality?What is Bad Tissue Quality?
Large or massive tears,Large or massive tears,
Retracted tears,Retracted tears,
Coutallier three or four fatty infiltrationCoutallier three or four fatty infiltration
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28. ANY TYPE OF RECONSTRUCTIONANY TYPE OF RECONSTRUCTION
MUST AVOID TENSION OVER-LOADMUST AVOID TENSION OVER-LOAD
OF THE REPAIROF THE REPAIR
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29. Recognize the Tear PatternRecognize the Tear Pattern
Tears must be repaired in the directionTears must be repaired in the direction
of greatest mobility -> minimal strainof greatest mobility -> minimal strain

30. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears
Side to side sutures from medial to lateralSide to side sutures from medial to lateral
Progressively converge the margin of theProgressively converge the margin of the
tear lateral to bone bedtear lateral to bone bed
Closing 50% of a U-Shaped tear ->Closing 50% of a U-Shaped tear ->
reduces strain at converge margin by areduces strain at converge margin by a
factor of 6factor of 6
[Burkhart S][Burkhart S]

31. Side to Side Repair
Cuff repair
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32. Double Row Fixation
Restoration of the footprint
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33. 1st
Anchor Insertion – Medial Row
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34. 1st
suture passage- Medial row - mattress
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35. suture passage- Medial row – post. anchor
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36. Lateral Row 1st
Anchor Insertion
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37. Inspection of Suture Position
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38. Final Repair
Double row fixationDouble row fixation
Stronger repair biologically
attractive but
Time consuming and of
raised difficulty www.shoulder.gr

39. Massive Contracted ImmobileMassive Contracted Immobile
TearsTears
No mobility from medial to lateral or fromNo mobility from medial to lateral or from
anterior to posterioranterior to posterior
Subcategories:Subcategories:

Massive Contracted Longitudinal TearsMassive Contracted Longitudinal Tears

Massive Contracted Crescent TearsMassive Contracted Crescent Tears
Represent 9.6% of massive tearsRepresent 9.6% of massive tears
[Burkhart][Burkhart]

40. Massive Contractive TearsMassive Contractive Tears
better mobilization techniquesbetter mobilization techniques
Anterior Interval SlideAnterior Interval Slide
and/orand/or
Posterior Interval SlidePosterior Interval Slide

41. Massive TearsMassive Tears
Easily repairedEasily repaired
Difficult repair (anterior & posterior Slide)Difficult repair (anterior & posterior Slide)
Medialized repairMedialized repair
Impossible repairImpossible repair
Incomplete RepairIncomplete Repair
Graft JacketsGraft Jackets
Tendon transfersTendon transfers

42. Rotator CuffRotator Cuff
Rot cuff tears that can be repaired withRot cuff tears that can be repaired with
open techniques can be repaired withopen techniques can be repaired with
arthroscopic techniques alsoarthroscopic techniques also
Irreparable Tears:Irreparable Tears:
Partial repairPartial repair
Medialized repairMedialized repair
Grafts and substitutesGrafts and substitutes
Tendon transfersTendon transfers
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43. Rotator CuffRotator Cuff
Massive Tears
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44. Rotator CuffRotator Cuff
Massive Tears
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45. Rotator CuffRotator Cuff
Graft Jacket
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46. Rotator CuffRotator Cuff
Subscapularis Tear
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47. Rotator CuffRotator Cuff
Subscapularis
Tear
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48. Rotator CuffRotator Cuff
Calcifying TendonitisCalcifying Tendonitis
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49. Rotator CuffRotator Cuff
Calcifying TendonitisCalcifying Tendonitis
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50. Frozen ShoulderFrozen Shoulder
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51. AC JointAC Joint
Distal Clavicle ExcisionDistal Clavicle Excision
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52. AC JointAC Joint
Distal Clavicle ExcisionDistal Clavicle Excision
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53. AC JointAC Joint
DislocationDislocation
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54. Shoulder InstabilityShoulder Instability
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55. The Spectrum of Instability Lesions

Minor instability withMinor instability with
activity related painactivity related pain

Recurrent subluxationRecurrent subluxation

Recurrent dislocationRecurrent dislocation

Locked dislocation withLocked dislocation with
loss of motionloss of motion

56. Bankart Lesion

57. Bankart Lesion
the essential lesion
 Avulsion of the IGHL from the glenoid rim
from 2 o’clock to 6 o’clock
 Primary restraint to anterior translation
at 90o
of abduction
 85% in traumatic anterior dislocations
 Not enough to induce symptomatic instability

58. ALPSA lesion

59. humerus
Bankart lesion
glenoid
1. Identify and Define Pathology

62. Our findings in first shoulderOur findings in first shoulder
dislocationdislocation
Hemarthrosis 100%Hemarthrosis 100%
Bankart 78.2%Bankart 78.2%
Bony Bankart 13.04%Bony Bankart 13.04%
Hill-Sachs 65.21%Hill-Sachs 65.21%
capsular laxity 8.69%capsular laxity 8.69%
SLAP lesions 21.73%SLAP lesions 21.73%
C. Yiannakopulos E Mataragas E.Antonogiannakis
Arthroscopy Sep 2007

63. Arthroscopic Shoulder
Reconstruction
Goal of the Operation: Define the pathology
Restoration of the Labrum to its anatomic attachment
Reestablishment of the appropriate tension
in the IGHL complex and capsule
Repair bony Bankart and large Hill-Sachs lesions
Repair SLAP lesions
Repair rot cuff tears

64.  Patients of all ages and all activity levels with
recurrent anterior instability who are impaired
functionally and in whom nonoperative treatment
has failed
 Revision stabilization
 First-time, acute shoulder dislocations
Arthroscopic Shoulder Stabilization
Patient Selection

65. InstabilityInstability
Anterior Instability – Bankart LesionAnterior Instability – Bankart Lesion
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66. humerus
labrum
completed repair
6. Assessment of the Final Repair

67. SLAP repair

68. InstabilityInstability
Posterior InstabilityPosterior Instability
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69. InstabilityInstability
Posterior InstabilityPosterior Instability
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70. Posterior capsule reefing

71. Posterior Instability

72. Posterior Instability

73. InstabilityInstability
MultidirectionalMultidirectional
InstabilityInstability
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74. Multidirection instability
Plication of the posterior capsule

75. InstabilityInstability
Anterior Instability. Bony defects – HillAnterior Instability. Bony defects – Hill
SachsSachs
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76. InstabilityInstability
Anterior Instability –Hill Sachs -RemplisageAnterior Instability –Hill Sachs -Remplisage
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77. InstabilityInstability
Anterior Instability – Hill Sachs -RemplisageAnterior Instability – Hill Sachs -Remplisage
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78. InstabilityInstability
Anterior Instability. Bony defectsAnterior Instability. Bony defects
Glenoid bone lossGlenoid bone loss

79. Normal Glenoid
inverted
pear
Bony Bankart
pear
Compression
Bankart
loss of
anterior rim

80. The normal glenoid shape

81. Inverted pear glenoid

82.  Glenoid Bone Loss > 30%
 Engaging Hill-Sachs
 HAGL lesions
Limitations of the
Arthroscopic Techniques

83. Future of instability repairFuture of instability repair
HAGL lesions can be repaired withHAGL lesions can be repaired with
arthroscopic techniquesarthroscopic techniques
Engaging Hill-Sachs. The remplisageEngaging Hill-Sachs. The remplisage
technique of Eugene Wolftechnique of Eugene Wolf

84. Future of instability repairFuture of instability repair
Glenoid bone loss:Glenoid bone loss:
arthroscopic bone grafting describedarthroscopic bone grafting described
by E. Tavernaby E. Taverna
Arthroscopic coracoid transferArthroscopic coracoid transfer
described by L. Laffossedescribed by L. Laffosse

85. Arthroscopic success rateArthroscopic success rate
Savoie 1997 93%Savoie 1997 93%
Burchart, De Bear 2000 96%Burchart, De Bear 2000 96%
J Tauro 2000 93%J Tauro 2000 93%
Kim 2003 96%Kim 2003 96%
Snyder 2006 93%Snyder 2006 93%
Fabbriciani 2004 100%Fabbriciani 2004 100%

86. Trends in arthroscopic surgeryTrends in arthroscopic surgery
•Mechanically stronger repair
techniques
•Arthroscopic techniques for tendon
substitutes
•Better tendon mobilization
techniques
• Arthroscopic repair of Bone
defects in instability surgery
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87. ConclusionConclusion
Today, apart from Shoulder ReplacementToday, apart from Shoulder Replacement
and major Shoulder Fractures,and major Shoulder Fractures,
nearly all Shoulder Pathologynearly all Shoulder Pathology
can be treatedcan be treated
With arthroscopic techniquesWith arthroscopic techniques
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88. ConclusionConclusion
Literature suggests equal or betterLiterature suggests equal or better
results than Open Surgeryresults than Open Surgery
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89. ConclusionConclusion
Combined withCombined with
Lower MorbidityLower Morbidity
Day Case surgeryDay Case surgery
Smalls IncisionsSmalls Incisions
No Deltoid injuryNo Deltoid injury
Earlier MobilizationEarlier Mobilization
Less PainLess Pain
Earlier Return to Daily ActivitiesEarlier Return to Daily Activities
Better Understanding of Shoulder PathologyBetter Understanding of Shoulder Pathology
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90. You are all WelcomeYou are all Welcome
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91. Thank YouThank You