Shoulder Arthritis of Instability-Biologic Reconstruction

By: Vivek Agrawal

This is a patient with significant arthritis that’s developed secondary to long-standing instability. He still has excellent range of motion, and rather than focus on the arthritis and consider some sort of joint replacement, our goals are to perform a biologic reconstruction, including rotator cuff repair, bicep tenodesis, suprascapular and axillary nerve decompression and extensive recentering of the glenohumeral joint, which will significantly improve the patient’s function and pain while hopefully also significantly slowing down the progression of arthritis. We have successfully utilized this approach for similar patients over the past decade and have not had to move to a joint replacement for any of these patients to date. For biologic reconstruction to work well, we do want the patient to not have a lot of deformity because of the arthritis and still have a reasonable level of range-of-motion. This approach isn’t appropriate for patients whose arthritic symptoms are the predominant symptom generators. We will start with repair of the superior labrum after the biceps has been tenodesed. Here it's easy to see, once we've mobilized the labrum, that it had been knocked down medially preventing it from performing its function as a bumper cushion/speed bump.

These all-suture anchors are placed one at a time for the SLAP lesion repair allowing us to replace the labrum on top of the superior glenoid which somewhat covers up the area of full thickness cartilage loss superiorly and posteriorly. Here we've completed the SLAP lesion repair and we'll switch to the superior portal for viewing. Again, at first blush it seems like this labrum isn't torn and just frayed, and many may be tempted to just debride it, meaning just cleaning up the fraying. But you can see it's been significantly torn and a lot of scar tissue developed that makes it look like it’s relatively normal. But it's healed very medially and once we’ve mobilized it, it tends to want to place itself back up on top of the glenoid face. For the posterior and inferior quadrants, we place all of the anchors at once, which allows us to tailor the placement of the capsule and labrum much better. Here we've place all our anchors for the capsular shift and we'll start the shift typically at the six o'clock position inferiorly that will allow us to recenter and rebalance the entire capsular ligamentous complex.

Here we see the six o'clock suture being passed. The blue PDS suture is used as a suture shuttle to allow us to pull the permanent braided hollow suture through the capsule. These are then retrieved and tied sequentially until the entire capsular shift and labrum reconstruction has been completed. So even though the patient has had some cartilage loss, this results in excellent recentering of the glenohumeral joint. Biologic reconstruction rather than shoulder replacement also allows patients to return to heavy occupations and higher levels of function.

Shoulder Arthritis of Instability-Biologic Reconstruction

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