deep vein thrombosis treatment for orthopaedic.pptx

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1. Supervision by: Ghazi Ariki RESEARCH Of deep veen thrombosis and pulmonary embolism Done by : basheer mohammed alkamali بشير محمد دبوان الكمالي Level 4 Group B

2. Contents Shoulder anatomy. Shoulder dislocation defination. Mechanism of shoulder dislocation. Classification of shoulder dislocation. Clinical picture. Diagnosis. DD Non-operative reduction. Patho-anatomy of shoulder dislocation . Introduction to shoulder arthroscopy. Arthroscopic treatment of shoulder dislocation.

3. DVT Migration PE Thrombus Embolus VTE - deep vein thrombosis (DVT) & pulmonary embolism (PE)

4. Introduction VTE, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important cause of morbidity and mortality among patients . The incidence of VTE is estimated to be 1 per 1,000 people annually . pulmonary embolism (PE) is a form of venous thromboembolism (VTE) that is common and sometimes fatal. Pulmonary embolism is third most common cause of cardiovascular death after coronary artery disease and stroke Pulmonary thromboembolism is not a disease in and of itself. Rather, it is a complication of underlying venous thrombosis.

5. Introduction Pulmonary embolism is present in 60-80% of patients with DVT, even though more than half these patients are asymptomatic. Pulmonary embolism is increasingly prevalent among elderly patients, yet the diagnosis is missed more often in these patients than in younger ones because respiratory symptoms often are dismissed as being chronic. Death due to massive PE is often immediate 2/3 of deaths due to pulmonary emboli occur within 30 minutes of embolization Anticoagulation is the mainstay of therapy for DVT, with the goal of preventing progression to PE and recurrence of thrombosis.

6. Introduction The risk of VTE remains high for up to 2 months after noncancer general surgery. Pulmonary embolism is increasingly prevalent among elderly patients, yet the diagnosis is missed more often in these patients than in younger ones because respiratory symptoms often are dismissed as being chronic. Death due to massive PE is often immediate 2/3 of deaths due to pulmonary emboli occur within 30 minutes of embolization Anticoagulation is the mainstay of therapy for DVT, with the goal of preventing progression to PE and recurrence of thrombosis.

7. DVT and PE Definition An embolus :- is a clot or plug that is carried by the bloodstream from its point of origin to a smaller blood vessel, where it obstructs circulation. DVT :- is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that return blood to the heart. Pulmonary embolus (PE) :- refers to obstruction of the pulmonary artery or one of its branches by material (eg, thrombus, tumor, air, or fat) that originated elsewhere in the body.

8. Mechanism

9. The temporal pattern of presentation Acute – Patients with acute PE typically develop symptoms and signs immediately after obstruction of pulmonary vessels. Subacute – patients with PE may present subacutely within days or weeks following the initial event. Chronic – Patients with chronic PE slowly develop symptoms of pulmonary hypertension over many years (ie, chronic thromboembolic pulmonary hypertension; CTEPH).

10. hemodynamic status Hemodynamically unstable PE is that which results in hypotension( a systolic blood pressure <90 mmHg or a drop in systolic blood pressure of ≥40 mmHg from baseline for a period >15 minutes ) or hypotension that requires vasopressors or inotropic support and is not explained by other causes such as sepsis, arrhythmia.... Hemodynamically stable PE is defined as PE that does not meet the definition of hemodynamically unstable PE. Hemodynamically stable PE is called "submassive" or "intermediate-risk" PE Hemodynamically unstable PE is also called "massive" or "high-risk" PE.

11. The anatomic location and symptoms Saddle PE : embolus lodges at the bifurcation of the main pulmonary artery, often extending into the right and left main pulmonary arteries. distal PE embolus lodge distally in the main lobar, segmental, or subsegmental branches of a pulmonary artery. symptoms sympatomic PE :- This leads to Clinical suspicion of PE to be followed by Radiologic confirmation ASYMPTOMATIC:- discovered incidentally by Radiologic methods done for another reason

12. Anterior (forward ): Over 95% of shoulder dislocation cases are anterior. Most anterior dislocations are sub-coracoid Sub-glenoid subclavicular intrathoracic retroperitoneal dislocations

13. Posterior (backward) Posterior dislocations are occasionally due to electric shock or seizure and may be caused by strength imbalance of the rotator cuff muscles. Posterior dislocations often go unnoticed, especially in an elderly patient and in the unconscious trauma patient . An average interval of 1 year was discovered between injury and diagnosis of posterior dislocation in a series of 40 patients.

14. Inferior (downward) Inferior dislocation is the least likely form, occurring in less than 1% of all shoulder dislocation cases. This condition is also called luxatio erecta because the arm appears to be permanently held upward or behind the head. It is caused by a hyper abduction of the arm that forces the humeral head against the acromion. Inferior dislocations have a high complication rate as many vascular, neurological, tendon, and ligament injuries are likely to occur from this kind of dislocation.

15. - Occurs mainly due to : Stripping of capsule from anterior margins of the glenoid rim . Denting of humeral head at the posteriolateral aspect . In most cases the recurrence is Anterior . It occurs when the arm is abducted , extended and rotated medially . Recurrent Dislocation

16. Anterior dislocation Posterior dislocation

17. Clinical picture Significant pain, which can sometimes be felt past the shoulder, along the arm. Inability to move the arm from its current position, particularly in positions with the arm reaching away from the body and with the top of the arm twisted toward the back. Numbness of the arm. Visibly displaced shoulder. Some dislocations result in the shoulder appearing unusually square. No bone in the side of the shoulder showing shoulder has become dislocated.

18. Diagnosis HEIGHT CENTIMETERS INCHES AT BIRTH 50 20 AT 1 yr 75 30 2 – 12 yr age ( yr ) x 6 + 7 age ( yr ) x 2 ,5 + 30

19. Differential Diagnoses • Acromioclavicular Joint Injury • Bicipital Tendonitis • Clavicular Injuries •Rotator Cuff Injury •Shoulder Dislocation •Swimmer's Shoulder

20. Technique of reduction of Anterior dislocation Stimson’s technique : the patient is left prone with the arm hanging over the side of the bed. After 15 or 20 minutes the shoulder may reduce. Hippocratic method gently increasing traction is applied to the arm with the shoulder in slight abduction, while an assistant applies firm counter traction to the body (a towel slung around the patient’s chest, under the axilla, is helpful). Kocher’s method, the elbow is bent to 90° and held close to the body; no traction should be applied. The arm is slowly rotated 75 degrees laterally, then the point of the elbow is lifted forwards, and finally the arm is rotated medially. This technique carries the risk of nerve, vessel and bone injury and is not recommended. Another technique has the patient sitting on a reduction chair and with gentle traction of the arm over the back of the padded chair the dislocation is reduced. The acute dislocation is reduced (usually under general anaesthesia ) by pulling on the arm with the shoulder in adduction a few minutes are allowed for the head of the humerus to disengage and the arm is then gently rotated laterally while the humeral head is pushed forwards. If reduction feels stable the arm is immobilized in a sling . Technique of reduction of Posterior dislocation

21. Strong Predisposing factors (Odds Ratio>10) Fracture (hip or leg) Hip or knee replacement • Major general surgery • Major trauma • Spinal cord injury Arthroscopic knee surgery • Central venous lines • Chemotherapy Congestive heart or respiratory failure • Hormone replacement therapy • Malignancy Oral contraceptive therapy • Paralytic stroke • Pregnancy/postpartum • Previous venous thromboembolism • Thrombophilia Moderate risk factors (odds ratio 2 to 9) Weak risk factors (odds ratio < 2) Bed rest > 3 days • Immobility due to sitting (eg, prolonged car or air travel) • Increased age • Laparoscopic surgery (eg, cholecystectomy) • Obesity • Pregnancy/antepartum • Varicose veins Risk factor

22. Patho-Anatomy of Shoulder Instability

23. Introduction to Arthoscopic treatment Arthroscopy Definition Arthroscopy is a procedure that orthopaedic surgeons use to inspect, diagnose, and repair problems inside a joint.

24. Cont.. The word arthroscopy comes from two Greek words, " arthro " (joint) and " skopein " (to look). The term literally means "to look within the joint." During shoulder arthroscopy, the surgeon inserts a small camera, called an arthroscope , into the shoulder joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments. Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery. This results in less pain for patients, and shortens the time it takes to recover and return to favorite activities. Shoulder arthroscopy has been performed since the 1970s. It has made diagnosis, treatment, and recovery from surgery easier and faster than was once thought possible. Improvements to shoulder arthroscopy occur every year as new instruments and techniques are developed.

25. Patient Positioning Two basic positions for shoulder arthroscopy have been described: the lateral decubitus the "beach-chair" positions. The lateral decubitus position probably is the most commonly used.

26. LATERAL DECUBITUS POSITION

27. BEACH-CHAIR POSITION

28. Portal Placement The number of described arthroscopic portals for the shoulder has greatly increased as shoulder surgical procedures have become more complex. Before making arthroscopic portals, a thorough understanding of the local anatomy is necessary to prevent damage to neurovascular structures. Arthroscopic portals can be made in the glenohumeral , subacromial , and acromioclavicular joints. The glenohumeral joint portals can be made posteriorly, superiorly, and anteriorly; the subacromial joint portals are placed anterior, posterior, and lateral. the acromioclavicular joint can be approached from the subacromial space or anteriorly or posteriorly.

29. 1-POSTERIOR PORTAL The posterior portal is the primary entry portal for shoulder arthroscopy. It allows examination of most of the joint and assists in the placement of subsequent portals. This portal is located approximately 2 to 3 cm inferior and 1 cm medial to the posterolateral tip of the acromion.

30. 2-Posteroinferior Portal an accessory posteroinferior portal for the inflow cannula during arthroscopy in the beach-chair position. This portal is located approximately 2 cm above the posterior axillary fold and enters the joint in the axillary recess. They believe that as long as the portal is not directed caudally, the axillary nerve and posterior humeral circumflex artery are safe.

31. 3-ANTERIOR PORTAL Multiple anterior portals have been described for both diagnostic and surgical stabilization techniques. For complete diagnostic examination of the shoulder, an anterior portal is essential to allow observation of the posterior capsule and the rotator cuff and for an anterior view of the glenohumeral ligaments and the subscapularis tendon.

32. 4-Anteroinferior Portal Wolf described an accessory anteroinferior portal for stabilization procedures that improves access to the inferior aspect of the glenohumeral joint, the inferior glenohumeral ligament labral complex, and the anteroinferior aspects of the glenoid rim and scapular neck. We prefer placing the portal just lateral and usually slightly superior to the coracoid.

33. 5- SUPERIOR PORTAL Neviaser is credited with the description of the superior portal (supraclavicular or suprascapular portal). This portal is most useful as an inflow site, but it may allow limited viewing of the posterior glenoid labrum, posterior humeral head, and posterior aspect of the rotator cuff. This portal is bounded anteriorly by the clavicle, laterally by the acromion, posteriorly by the base of the acromion and the scapular spine, and inferiorly by the posterosuperior rim of the glenoid .

34. Arthroscopic treatment of shoulder dislocation Arthroscopic bankart repair technique Arthroscopic treatment of posterior shoulder dislocation. Arthroscopic treatment of multidirectional instability. Arthroscopic repair of posterior humeral avulsion of glenohumeral ligament. Arthroscopic repair of hill sachs lesion.

35. 1-Arthroscopic bankart repair technique Place the patient on the operating table in the lateral decubitus position with a beanbag and kidney rest. Carefully protect all bony prominences as well as the axillary area. Apply a heating blanket and serial compression devices around the lower extremities.Place the arm in 45 to 60 degrees of abduction and 20 degrees of forward flexion using 12 to 14 lb of traction. Outline the bony landmarks and mark the potential portals on the skin. Place the posterior portal 2 cm inferior and just medial to the posterolateral edge of the acromion. Before making additional portals, thoroughly examine the shoulder through the posterior portal to identify the most appropriate sites for placement of the anterior portals and for any additional posterior portals that may be necessary. Carefully visualize the entire labrum, 360 degrees of the shoulder joint, and the attachment of the glenohumeral ligament to the humerus from anterior to posterior.Thoroughly evaluate the glenohumeral joint for bony loss of the glenoid or humeral head. After identifying the quadrant or quadrants of injury to the labrum, create the planned portals using spinal needle localization according to the quadrant approach as shown in Figure 52.19. Make an anterosuperior portal with the cannula entering the shoulder just posterior to the biceps tendon and anterior to the leading edge of the supraspinatus tendon. I

36. Cont Make an anterior central portal to place an 8.25-mm clear cannula just above the superior edge of the subscapularis tendon at an angle of approximately 45 degrees to the glenoid articular surface. This is used for placement of anchors and for instrumentation using a suture shuttle. If the lesion extends posterior, make a 7-o’clock portal posteriorly using spinal needle localization. Enter the joint at an appropriate angle for placement of a suture anchor in the inferior part of the glenoid if necessary or for placement of a shuttle for passing sutures along the capsular ligamentous complex. While viewing from the anterosuperior portal, use an elevator to free up the capsule down to the subscapularis muscle, which should be visible. Abrade the glenoid neck to stimulate healing (see Fig. 52.22A). While viewing from the anterosuperior portal if necessary, perform a capsular plication procedure posteriorly, extending along to the attachment of the posterior band of the inferior glenohumeral ligament. Using a rasp, freshen the soft tissue and the intended area of plication to incite some inflammation without damaging the tissue. Use a suture shuttle to pass PDS sutures, starting at about the 6-o’clock position and taking a bite of approximately 1 cm of capsule in a pinch-tuck technique, making sure that the needle comes out through the capsule and passes up under the labrum in its appropriate position.

37. Now perform the anterior part of the Bankart procedure. Abrade the anterior neck and free up the capsule and labral complex so it can be advanced superiorly (Fig. 52.21A). Plan the position of the suture anchors, trying to get three or four anchors placed below the 3-o’clock position. The most inferior anchor often is best placed using a 5-o’clock percutaneous portal made with the help of a spinal needle for localization. Place the spinal needle at a 45-degree angle to the articular surface. The Spear point guide can be placed at the 5:30 position on the neck, 1 to 2 mm on the articular surface for reaming and placement of the suture anchor. Note the exact position of the drill hole, observe the anchor as it is placed in the hole, use a mallet to tap the anchor down, and then check security by tugging on the sutures. To obtain the best area of bone for drilling at a lower level, an angled reamer and anchor inserter can be placed percutaneously. This provides excellent fixation in this position (Fig. 52.21B). Cont

38. The second and third anchors may be either single-loaded or double-loaded anchors and usually are PEEK doubleloaded anchors. Recently, we have used knotless anchors to provide secure fixation without the risk of knot impingement. When knots are used, use the cannula to direct the knot away from the articular surface as it is being seated. With this technique, take the most inferior suture out the posteroinferior cannula using a suture grasper. Obtain a good bite of the capsule and labrum just distal to the intended site of the anchor (Fig. 52.21C). Take the shuttle out of the posterior inferior cannula and secure it around the inferior suture limb of the anchor, and then retrieve it out the anterior cannula. Grasp the two sutures not involved in the first knot with a suture retrieval device from the posterior cannula, take them out the posterior cannula, and store them for later tying. The arthroscopic knot is then tied. Firmly secure the first suture that was passed through the labrum to the capsule and labrum up to the edge of the glenoid, creating an anterior bumper. Pass the superior of the two suture limbs that were passed out the posterior cannula back through the anterior cannula. Use the shuttle to pass the shuttle loop through the capsule and labrum. Carry this shuttle out the posterior cannula and shuttle the second suture through the capsule and out the anterior cannula. Use the cannula to direct the knot away from the joint surface as it is secured. Cont

39. Place a third anchor either single-loaded or double-loaded using the same technique. Sometimes, some of the lower sutures can be used in either a single simple repair or as a mattress suture, depending on the type of tear and tissue involved. This is determined at the time of surgery. Place three or four anchors, each separated by 5 to 7 mm. Tie the knots securely, re-creating a soft-tissue bumper (Figs. 52.21D and 52.22). At this time, if the plication sutures have not been tied, they should be tied posteriorly from the posterior cannula and secured. In our practice, we generally tie these earlier in the procedure when they are placed, but some authors prefer to tie them later. If the patient had hyperlaxity and significant sulcus associated with the Bankart lesion, perform a rotator interval closure at this time by withdrawing the anterior central cannula to just outside the capsule. Pass a crescent spectrum needle through the middle glenohumeral ligament several millimeters into the ligament and out into the joint. Maintain one limb outside the capsule while the limb in the joint is retrieved using a penetrator device through the anterior central cannula. Grasp the ­intraarticular limb of the suture at the level of the superior glenohumeral ligament and retrieve it out of the cannula for extracapsular tying using an SMC (Samsung Medical Center, Seoul, South Korea)–type knot (see Fig. 52.57). Generally, two sutures are passed in securing the rotator interval if it is thought that the slight loss of external rotation is offset by the added stability of these additional sutures (Figs. 52.23 and 52.24). Upon completion, close the portals with subcuticular poliglecaprone 25 (Monocryl). Apply a sterile dressing and an UltraSling (DJO Global, Vista, CA). Cont

40. Posterior instability Arthroscopic posterior shoulder stabilization has rapidly gained favor in recent years, with the results of open procedures having been less than adequate.

41. 2-Arthroscopic treatment of posterior shoulder dislocation (KIM ET AL.) Place the patient in the lateral decubitus position and prepare and drape the shoulder. Maintain the arm with lateral traction in 30 degrees of abduction and 10 degrees of forward flexion. Create a posterior portal 2 cm inferior to the posterolateral acromial angle. Create two anterior portals, just distal to the acromioclavicular joint and proximal to the leading edge of the subscapularis. Introduce a small meniscal rasp (CONMED, Utica, NY) through the posterior portal to abrade the incomplete tear of the posteroinferior aspect of the labrum and the corresponding glenoid wall. Abrade the inferior and posterior aspects of the capsule to enhance healing. Place a suture anchor at the posteroinferior glenoid surface, within 2 mm of the margin of the glenoid, through the posterior portal. (Fig. 52.25). Retrieve one end of the suture through the anterior midglenoid portal. Introduce a 90-degree angle suture hook, loaded with a Shuttle Relay (CONMED), through the posterior portal to pierce the posterior band of the inferior glenohumeral ligament at the same level as the glenoid surface. The posterior band of the inferior glenohumeral ligament is always incorporated into the first suture. Shift the suture hook about 1 cm superiorly and pass it under the posteroinferior aspect of the labrum. Retrieve the Shuttle Relay through the anterior midglenoid portal. Load the suture into the Shuttle Relay and pull it back out of the posterior portal and tie an SMC knot. (Fig. 52.26).

42. Multidirectional instability Capsular laxity producing unidirectional and multidirectional instability can be successfully treated arthroscopically with plication or a shift procedure in one or more quadrants of the shoulder. Results of capsular volume reduction have been shown to be comparable with open techniques, although the capsular reinforcement by the open shifting of one leaf over the other is not replicated. We have had success arthroscopically comparable with open techniques but with much less morbidity. Bradley has shown that the use of anchors greatly increases the reliability and security of the shift. When posterior-inferior instability with a 2 to 3+ sulcus sign is present, a rotator interval closure is performed, and the capsule is shifted along the entire inferior glenohumeral ligament from the 3-o’clock to the 9-o’clock position. Overtightening of the capsule can result in eccentric wear and arthritis.

43. 3-Arthroscopic treatment of multidirectional instability Place the patient in a lateral decubitus position and maintain the position with a beanbag and kidney rest. Carefully pad bony prominences. Apply a heating blanket and serial ­compression devices to the lower extremity. Outline bony landmarks and potential portal sites on the skin. Make a posterior portal is made about 3 cm distal and in line with the posterolateral acromial edge to evaluate the shoulder. The anterior portals are the anterosuperior lateral portal and the anterior central portal, which usually is about 1 cm lateral to the coracoid. Place working 8.25-mm cannulas later in the procedure in the posterior and anterior central portals. Use a small arthroscopic rasp to abrade the capsule and labrum around the area to be plicated. Starting on the side of the shoulder where the most instability is present, place 2-mm PEEK anchors at the articular edge spaced 3 cm or more apart. Carry the capsular plication around inferiorly, Close the rotator interval. Close the arthroscopic portals.

44. 4-Arthroscopic repair of posterior humeral avulsion of glenohumeral ligament. Place the patient in the lateral decubitus position. Three portals are used for posterior repair. A posterior portal, an anterosuperior portal, and a posterior 7-o’clock portal are normally necessary. Fully evaluate the shoulder for all pathologic entities. If it is determined that it is an isolated posterior avulsion of the glenohumeral ligament and capsular attachment and that the attachment to the glenoid is stable, then a humeral repair is undertaken. With the arthroscope in the anterosuperior portal, create two posterior portals and place a 6-mm plastic cannula in each portal. The posteroinferior portal is used for placement of an inferior suture anchor. Abrade the neck area. Place the anchor and retrieve the sutures through the posterosuperior portal. With a grasping instrument maintained in the superior portal to put tension on the capsule, visualize the approximate location of the anatomic attachment. Maintain tension on the capsule and place a penetrating retrieval device through the posteroinferior portal and through the capsule about 7 mm from its edge. Grasp the inferiormost suture and carry it into the inferior cannula. Use of a hand-off technique with an instrument from the superior portal can make this technique easier.

45. Use the same technique to grab the more superior of the sutures, once again separating it from the previously retrieved suture by about 7 mm. Place the penetrator through the capsule about 7 mm from its torn edge and retrieve the second suture and take it back out the inferior capsule. Once again, the superior portal is used to keep tension on the capsule and a hand-off technique is used to aid in retrieving the suture and pulling it back through the capsule. Tie the mattress sutures down snugly, securing the inferior portion of the tear to the neck. Use the inferior cannula to tie the arthroscopic SMC knots. Place a second anchor in the more superior part of the anatomic attachment of the capsule in the posterior part of the neck. Place the penetrating device through the capsule and grab the inferior suture and pass it back out through the cannula. Grab the superior suture and again pass it back out through the cannula. Tie the arthroscopic mattress suture through the superior portal to obtain excellent compression of the capsule to the neck to ensure adequate healing. If a side-to-side repair of the vertical component of the tear is achievable, a Spectrum with a crescent hook can be used to pass through the superior leaf of the tear. The suture can be retrieved with a penetrating device passed through the inferior leaf of the tear and then tied extracapsularly. On completion, check the stability and close the portals with Monocryl sutures. 4-Arthroscopic repair of posterior humeral avulsion of glenohumeral ligament.

46. 5-Arthroscopic repair of hill sachs lesion REMPLISSAGE The Hill-Sachs remplissage technique is similar to an arthroscopic repair of a partial-thickness, articular-surface rotator cuff tear. It consists of fixation of the infraspinatus tendon and posterior capsule to the abraded surface of the Hill-Sachs lesion (Fig. 52.27A). The addition of a remplissage procedure significantly reduces recurrence rates in contact athletes with Hill-Sachs lesions.

47. Place the patient in the lateral decubitus position and leaned back approximately 30 degrees. Enter the glenohumeral joint through a posterior portal that is placed at the lateral aspect of the convexity of the humeral head so that it is centered directly over the HillSachs lesion (Fig. 52.27B). While viewing from the anterosuperior portal, assess the Hill-Sachs lesion, glenoid bone loss, and anterior labral lesion, as well as the location of the posterior portal. Gently freshen the surface of the engaging Hill-Sachs lesion with a burr in reverse mode, taking care to remove a minimal amount of surface bone. While maintaining the camera in the anterosuperior portal, carefully withdraw the cannula in the posterior portal from the posterior capsule and infraspinatus tendon but not through the deltoid. The mouth of the cannula will be in the subdeltoid space. Place the first anchor in the inferior aspect of the Hill-Sachs lesion (Fig. 52.27C). Place a second anchor in the superior aspect of the Hill-Sachs lesion. Use a grasper penetrator in the same fashion to pass one suture limb 1 cm superior to the initial portal entry site (Fig. 52.27D). 5-Arthroscopic repair of hill sachs lesion

48. References Apley_s_System_of_Orthopaedics_and_ F ractures. Essentials of Musculoskeletal Care. Campbell's operative orthopedic ―volume four ―tenth edition. Abrams JS, Bradley JP, Angelo RL, et al.: Arthroscopic management of shoulder instabilities: anterior, posterior, and multidirectional, Instr Course Lect 59:141, 2010. Acid S, Le Corroller T, Aswad R, et al.: Preoperative imaging of anterior shoulder instability: diagnostic effectiveness of MDCT arthrography and comparison with MR arthrography and arthroscopy, AJR Am J Roentgenol 198:661, 2012. Ahmed I, Ashton F, Robinson CM: Arthroscopic Bankart repair and capsular shift for recurrent anterior shoulder instability: functional outcomes and identification of risk factors for recurrence, J Bone Joint Surg Am 94:1308, 2012. Bahk MS, Karzel RP, Snyder SJ: Arthroscopic posterior stabilization and anterior capsular plication for recurrent posterior glenohumeral instability, Arthroscopy 26:1172, 2010. Owens BD, Campbell SE, Cameron KL: Risk factors for anterior glenohumeral instability, Am J Sports Med 42:2591, 2014. Park MJ, Tjoumakaris FP, Garcia G, et al.: Arthroscopic remplissage with Bankart repair for the treatment of glenohumeral instability with HillSachs defects, Arthroscopy 27:1187, 2011. Wolf EM, Siparsky PN: Glenoid avulsion of the glenohumeral ligaments as a cause of recurrent anterior shoulder instability, Arthroscopy 26:1263, 2010

49. Thank you