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
www.shoulder.gr
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
www.shoulder.gr
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
13. Shoulder ArthroscopyShoulder Arthroscopy
the evolution of the techniquethe evolution of the technique
Diagnostic
Tool
Final
Treatment
www.shoulder.gr
From tool of the devil the treatment of choice of most shoulder
pathologies
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
www.shoulder.gr
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
www.shoulder.gr
28. ANY TYPE OF RECONSTRUCTIONANY TYPE OF RECONSTRUCTION
MUST AVOID TENSION OVER-LOADMUST AVOID TENSION OVER-LOAD
OF THE REPAIROF THE REPAIR
www.shoulder.gr
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]
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]
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
www.shoulder.gr
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
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
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
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
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
www.shoulder.gr
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
www.shoulder.gr
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
www.shoulder.gr
90. You are all WelcomeYou are all Welcome
www.esskacourse.grwww.esskacourse.gr
