-

1. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Multidirectional Instability:
Diagnosis and Treatment
Manos Antonogiannakis
Orthopaedic Surgeon
Director of 3rd Orthopaedic Department
Centre for Arthroscopy & Shoulder Surgery
Hygeia General Hospital
ESSKA Advanced Shoulder Arthroscopy Course
All About Instability & Other Glenohumeral Disorders
Verona, 12-13 June 2017 .

2. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
The Shoulder
 Greatest Range of Motion in the Body
 Motion in all 3 planes of movement
 Prone to instability
Sacrifices stability for mobility

3. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
What is Instability
 Biomechanical Dysfunction
 Failure of static and dynamic stabilizers
 Ranges from mild subluxation to traumatic dislocation

4. www.shoulder.gr
First described in detail
in 1980 by
Charles S. Neer
and
Craig R. Foster
www.shoulder.g

5. www.shoulder.gr
 NOT associated with severe trauma
Congenital hyperlaxity of the joint capsule or
generalized joint laxity in association with failure
of dynamic stabilizers and minor trauma
www.shoulder.g
Ehlers-Danlos Syndrome

6. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
T.U.B.S.
Traumatic
Unidirectional
Bankart lesion
Surgery
A.M.B.R.I.
Atraumatic
Multidirectional
Bilateral
Rehabilitation
Inferior capsular shift
A.I.O.S.
Acquired
Instability
Overstress
Surgery
Instability Profiles

7. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
TUBS AIOS AMBRI

8. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Types of instability
Not a black or white issue

9. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
The most common presentation
A patient with some degree of laxity genetically
controlled dislocates his shoulder after a minor or
major accident

10. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Laxity: physiologic and multidirectional
Instability: pathologic, mono-/bi-/tridirectional
usually anteroinferior or posteroinferior

11. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017

12. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017

13. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017

14. www.shoulder.gr
LOOSE SHOULDER Definition
A joint with excessive range of motion
in all planes but with no symptoms of
pain or instability
www.shoulder.gr

15. www.shoulder.gr
Definitions: unstable loose joint
 A symptomatic loose joint
 Usually, the patient experiences symptoms of
apprehension or subluxation in one direction, but
the examination reveals more directions of
instability
 minimum trauma or microtrauma precipitates the
initiation of symptoms
 A confusion in terminology exists: multidirectional
instability , hyperlaxity with pain , unstable painful
shoulder
www.shoulder.gr

16. www.shoulder.gr
Atraumatic multidirectional instability
clinical presentation
 Frank dislocations with minimum violence often
reduced by the patient
 Subluxations and positive apprehension sign in
one or more directions in a loose joint individual
usually teenager
 Pain and functional impairment in a loose joint
individual, the patient mainly complaining for pain
and not for instability

17. www.shoulder.gr
Types of multidirection instability
 Voluntary dislocation
 Involuntary dislocation
should be recognized early
www.shoulder.gr

18. www.shoulder.gr
Voluntary dislocation
 Patients with good muscle control who can
dislocate and relocate their shoulder at will from
an early age . That may lead to gradual strain of
the capsule and loss of control of the dislocations
 Voluntary dislocators with psychiatric problems
www.shoulder.gr

19. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Symptomatic glenohumeral joint subluxation or dislocation
occuring in more than one directions
MDI: 20-30 years old with non-specific activity-related pain

20. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Clinical examination:
Generalized joint laxity
1. Elbow or metacarpophalangeal joint
hyperextension
1. Genu recurvatum
1. Patellar instability
1. Ability to rest the thumb on the
ipsilateral forearm
2. Hyperabduction test

21. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Positive sulcus sign
AND
 Positive Load-and-Shift Test or
 Positive Apprehension Test
in at least 1 of the positions that stress the anterior
(abduction, external rotation) or posterior (flexion,
adduction) joint complex
Symptomatic instability in at least 2 directions
AND
Warby et al, BMJ Open, 2016

22. www.shoulder.gr
Clinical examination
16 years old dislocating the shoulder for fun
Minor trauma producing involuntary painful
dislocation-subluxation

23. www.shoulder.gr
Clinical examination

24. www.shoulder.gr
Highly clinical diagnosis
 History
 Clinical examination
 Marginal help of imaging studies
(plain radiographs, MRI, MRI-arthrography)
 Highly supportive:
 Arthroscopic findings
www.shoulder.g

25. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
‚ABER‘ images
Crescent sign: enhancing layer between HH and AIGHL
Triangle sign: triangular space between HH, AIGHL, glenoid
Good sensivity: 48-62%
Excellent specifity: 94-100%
MDI diagnosis
Schaeffler et al., Eur Radiol., 2014

26. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
a) Normal appearance of anteroinferior labral ligamentous
complex
b) Crescent sign
c) Sigmoid shape of the redundant AIGHL
d) Triangle sign
Schaeffler et al., Eur Radiol., 2014

27. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Schaeffler et al., Eur Radiol., 2014
Measurement of HH centring to the glenoid fossa
Crescent sign Triangle sign / posterosupirior
decentring

28. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Rotator interval herniation on sagital oblique MRA
Herniation of RI beyond the circle
outlining the SSP/SSC
Schaeffler et al., Eur Radiol., 2014

29. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
MRA and labro-capsular distance
Lim et al., Skeletal Radiol, 2015
mid-glenoid
cut
Line A-B: humeral head center-
glenoid center
Line C-D: parallel to A-B from
the point that the anterior capsule
extended the farthest
Line E-F: anterior or posterior
labrum to the C-D line (vertically)
Anterior LC Distance Posterior LC Distance

30. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Inferior LC Distance
Lim et al., Skeletal Radiol, 2015
MRA and labro-capsular distance

31. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Inferior LC distance: statistically significant different
Anterior and posterior LC distance: not statistically
significant different
Inferior LC distance > 16,88mm
suspicion of MDI
Lim et al., Skeletal Radiol, 2015

32. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Arthroscopic findings
Lim et al., Skeletal Radiol, 2015
Drive-through Sign Inferior capsular laxity
• Usually, no true Bankart lesion

33. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Loose Shoulder

34. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Exercise-based managenent
 most commonly primarily recommended treatment
Goal: Strengthening scapular and RC muscles (active
control of the shoulder, humeral head centering) +
proprioceptive exercises

35. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Watson MDI Programme: focuses on scapular control
(typically scapular upward rotation) prior to any RC or
deltoid strengthening
12-week exercise programme
Watson, Warby et al. Shoulder Elbow, 2016

36. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
80% of the pat. have good to excellent
results with physiotherapy

37. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
 After capsuloplasty surgical techniques: 7,5%-10%
recurrence rate
 21% of the pat. undergoing physiotherapy for MDI
subsequently required surgical intervention
Longo et al., Arthroscopy, 2015

38. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Patient with MDI with
• atraumatic history
• poor muscle patterning
• poor scapula biomechanics
• intact glenohumeral complex
Exercise
management
Patient with MDI with
• significant trauma
Rö/CT/MRT
Exercise management
or
surgery
Longo et al., Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2015

39. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Patient with MDI with
• no definitive structural lesion
• failure after 3-6 months of conservative therapy
large capsular volumes
surgery
Longo et al., Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2015

40. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Arthroscopic capsular plication
Anterio-inferior capsular plication
5:30 4:30
Posterio-inferior capsular plication
6:30 7:30
1cm of plication 10% volume reduction
Witney-Lagen, J Shoulder Elbow Surg, 2016

41. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Positioning the patient
Lateral decubitus
My preferred position

42. www.shoulder.gr
Capacious axillary pouch
www.shoulder.g

43. Arthroscopic Findings
Usually, no true Bankart lesion
www.shoulder.gr

44. www.shoulder.gr
Arthroscopic Treatment Options
 Thermical Shrinkage
 Capsular plication
www.shoulder.gr

45. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Posterior capsule reefing

46. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Fine Instrumentation- gentle handling

47. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Arthroscopic pancapsular capsulorrhaphy
Raynor et al., Am J Sports Med, 2016
2-3 anchors anterior
2-3 anchors posterior
Closure of RI

48. www.shoulder.gr
Arthroscopic Treatment
www.shoulder.gr

49. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017

50. www.shoulder.gr
Arthroscopic Treatment
www.shoulder.gr

51. www.shoulder.gr
What to expect
 Painless shoulder
 Full ROM
 No atrophies
 Return to the same sport level
Rowe scores:
78% excellent / good [Snyder, 2001]
75% excellent / good [Wolf, 1999]
88% excellent / good [Treacy, 2002]
www.shoulder.gr

52. www.shoulder.gr
What to expect 2 years post op.
www.shoulder.gr

53. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Arthroscopic labral augmentation
 Glenoid labrum reconstruction with a resorbable surgical
mesh
 Increase glenoid height and surface
 Additional step to the traditional capsuloplasty procedures
– not an alternative to them
 Graft acts as a barrier against humerus translation
Gervasi et al, Arthroscopy Techniques, Feb 2017

54. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Labrum augmentation Indication
Atraumatic or voluntary instability in symptomatic patients
Multidirectional recurrent instability with laxity
Revision in patients with no bone deficiency

55. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Gervasi et al, Arthroscopy Techniques, Feb 2017

56. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Conclusions –Take home message
• Although the terminology is confusing a shoulder may dislocate with
no trauma or after minimal trauma
• In most cases this type of instability is best treated nonoperatively
• Regaining scapula control and rot cuff strengthening is very important
• Surgery is indicated in cases of failure of the rehab program
• Arthroscopic pancapsular plication yields very good results >80-85%
• cases

57. www.shoulder.gr
 Most patients present in their late teens
 Complaints of pain during athletic activities or ADL
 Uncountable dislocations and subluxations even at
sleep reduced by the patient in a tall thin loose
joint individual
 Excessive ROM in more joints
www.shoulder.g
Conclusions –Take home message

58. www.shoulder.gr
 Excesive translation of the joint anterior posterior
and inferior at clinical examination with
aprehension in one or more directions
 At arthroscopy a patulous thin capsule with few
other findings.
Conclusions –Take home message

59. www.shoulder.gr
 Treatment should address all factors of instability
mainly the dynamic stabilizers with an aggressive
rehabilitation program and if this fails arthoscopic
or open capsulorraphy in order to reduce the
volume of the capsule
Conclusions –Take home message

60. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
Thank you for your attention!!!
Save the date: 1-3 February 2018