shoulder

Indications

Engaging Hill Sachs

Epidemiology

Usually 50-60 years old

Aetiology

1° uncommon

2° most common

- AVN

- trauma

- cuff arthropathy (Neer)

- instability

Pathology

Cuff & biceps intact as rule

- rare to have OA and rotator cuff pathology

Approaches

Anterior

Anterolateral

Posterior

Anterior Approach / Deltopectoral

Indications

- shoulder stabilization

- arthroplasty

- fracture fixation

Approach

Position

- beach chair

- upper body elevated 30- 40^o / reduces venous pressure and bleeding

Throwing

Wind-up

- cocking

- ER up to 180^o in pitcher

Acceleration

- large scapular muscles 

- acceleration - 7000^o/sec

- rotatory acceleration similar to car tyre at 130 kph

Control and deceleration

- fragile cuff & glenohumeral ligament complex 

Anatomy

Advantage

Fewer complications than TSR

Simpler procedure

1.  Arthroscopic Posterior Bankart Repair +/- Capsular Plication

Technique

Posterior Portal

- make slightly inferior and lateral compare to normal

- inspect joint

1.  EUA

Compare both shoulders

- ROM

- anterior and posterior draw

- load and shift

- sulcus sign

Causes for failure

1.  Patient factors

A.  Recurrent Trauma

- contact athletes higher risk

B.  MDI / Ligamentous Laxity / Voluntary dislocaters

C.  Poor rehabilitation

- poor motivation

- too rapid

- patients rarely get stiff, better to go very slow

2.  Surgeon Factors

A.  Unrecognised bony defect

Definition

Humeral Avulsion of Glenohumeral Ligament

Incidence

Bokor et al JBJS Br 1999

- 514 cases surgical treatment traumatic instability

- incidence 7.5%

- 25% associated SSC tear

- likelihood of HAGL if no Bankart or MDI 27%

Putti-Platt

Concept

Plication subscapularis & capsule

Problems

Loss ER 

Secondary OA if ER < 0°

Contraindication

MDI

- will force head out posteriorly

Technique

Divide SSC 2.5cm from insertion 

- may divide capsule in same plane