Disclosure Royalities: Arthrex, Arthrosurface Consultant: - - PowerPoint PPT Presentation

Disclosure Royalities: Arthrex, Arthrosurface Consultant: Arthrex, Arthrosurface medi Bayreuth, Med Park Stock option:

• Research Support: Arthrex, DFG, AGA, Arthrosehilfe

Editorial Board: Arthroskopie, AJSM, AOTS, DZS, EJTrauma, JSES, KSSTA, OBEX, OOTR, Operative Techniques, Sportorthopädie, ZOU OpenAccess Journal Sports Medicine

2018

Why do they dislocate again?

Imhoff AB et al., Am J Sports Med 2010 Tischer & Imhoff, Oper Orthop Traumatol. 2007

n=190 (1996 - 2000)

• RTS at preinjury level in 80%
• Rowe, Constant, ASES increased
• no complications due to 5:30h
• verall 9% recurrence

Epidemiology: Age

Zacchilli, Owens, JBJS, 2010 Owens et al., AJSM, 2007

Overall incidence rate 23.9/100,000/year

Epidemiology: Gender

Leroux et al., AJSM, 2014 Zacchilli, Owens, JBJS, 2010 Kirkley et al., Arthroscopy, 2005 Flatow et al., Orthop Clin North Am, 2000

Incidence of first-time anterior dislocation varies from 11 – 23 / 100,000 / year Male : Female = 3:1 > 40% younger than 22 years High-risk sports

• Contact sports (football, rugby, handball, wrestling...)
• Boxing
• Climbing (subluxations)

First time anterior shoulder dislocation Why should we be concerned?

Natural History – Recurrence: Age

< 30 y.o. 30-40 y.o. > 40 y.o. Conservative < 18 a: ≈ 73% < 30 a: ≈ 50% Surgery < 18 a: ≈ 17 – 21% < 30 a: ≈ 7 – 13%

Recurrence rate is highest in the young (male) population! Contact and throwing sports as important risk factors! Secondary pathologies with recurrence!

Aboalata, Imhoff et al. 2017, Olds et al. 2015, Shymon et al. 2015, Longo et al. 2016, Privitera et al. 2014, Liavaag et al. 2011, Kim et al. 2009, Robinson et al. 2004, Hovelius et al. 1983, Imhoff et al. 2001

Conservative ≈ 20% Surgery ≈ 7 – 15% Conservative ≈ 10% Surgery ≈ 7 – 20%

Natural History - Arthropathy

Hovelius, Rahme, KSSTA, 2016

• „Almost half of all first-time

dislocations at the age of <25 years will have stabilising surgery“

• „Two- thirds will develop

different stages of arthropathy within 25 years“

• significant improvement in Rowe and Constant score

(pre-OP vs. post-OP)

• improvement independent of index procedure (Asc. vs.
• pen)
• 86% rated result as excellent or good
• no loss of external rotation or SSC-function after revision
• 80% achieved return to sports after mean of 9 months (5-

13 months)

• 76% returned to previous level with little or no limitation

Arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability.

Bartl C, Schumann K, Paul J, Vogt S, Imhoff AB. Am J Sports Med. 2011, 39:511-8.

Munich-Results after Revision Surgery 2011

5: 30h - portal

Coracoid Portal

x

Acromion

8-10 cm

• 1-2 cm lateral from the axilla
• through inferior SSC
• 2,4 cm to axillary nerve
• 1,4 cm to circumflex. post.

artery

De Simoni C, Burkart A, Imhoff AB. Arthroskopie. 2000

My VIP Concept for bipolar Lesions

Visitation Interpretation Procedure

Bipolar Lesions and On/ Off Track Concept Bipolar Lesions are not uncommon ! Number of bipolar defects increases with recurrence up to > 80%

The effect of bipolar bone loss = double trouble?!

Isolated anterior glenoid bone loss Isolated Hill-Sachs-Lesion

The effect of bipolar bone loss = double trouble?!

Known fact: Combined glenoid and humeral head defects have an additive and negative effect on glenohumeral stability!

Arciero AJSM 2015

• Hyper-Laxity ?
• Direction of Instability ?
• SLAP / Pulley-Lesion ?

Visitation and Physical Examination

Hyperlaxity?

Sulcus sign Gagey test (Hyperabduction)

Visitation and Physical Examination

Rule out rotator cuff tears (patients > 40 years!)

• Antero-superior / Postero-superior cuff tears!
• Boxing – missed punch
• Pseudoparalysis two weeks after dislocation!

Visitation and Physical Examination

Specific Imaging

RX (3 Plains) MRI

• To detect additional pathologies

(SLAP, HAGL, Cuff tears )

• First impression of possible Bone loss

CT (3D Reconstruction)

• To evaluate glenoidal/humeral bone loss
• Dysplasia, glenoid retroversion

New aspects of decision making

Pioneer work Burkhart and DeBeer Arthroscopy 2000

• Noted high risk of redislokation with anterior glenoid bone loss
• 61 % failure with inverted pear glenoids and Bankhart repairs

Sugaya JBJS 2003

• Checked 100 CT scans of patients with anterior shoulder instability
• 50% showed measurable anterior glenoid bone loss

Griffith AJR 2008 :

• Purporsed a correlation between number of dislocations and
• size of bone defect

Why should we all measure? History of the Bone Loss Concept

Burkhart and DeBeer, Arthroscopy 2000 first clinical data

• 194 Athlets treated with a bankart repair
• average 10.8% Failure rate
• 173 without measurable glenoid bone loss = 4% recurrence
• 21 with measurable glenoid bone loss = 67% recurrence
• Contact athletes with measurable glenoid bone loss = 89% recurrence

Conclusion: Patients with measurable anterior glenoid bone loss should not be treated with an isolated arthroscopic bankart repair!

Why should we all measure? History of the Bone Loss Concept

Biomechanical proof of concept Itoi (JBJS 2000) – glenoid defects >21% Could not be sufficient restored with a bankart repair CONCLUSION: glenoid defects >21% need additional reinforcement Originally a capsule shift with open bankart was recommended Today bone augmentation is preferred

Why should we all measure? History of the Bone Loss Concept

The quick and easy way ( Diameter-Method)

• S. BHATIA ET AL.

(8,00/29,2) x 100 = 27,3 %

How do I measure it ?

Not everything fits perfect into a box!

Problem of quick and dirty measurment – defect overestimation 2-5%!

There is way for everyone find the one that works best for you!

Sugaya Burkhart Baudi Sugaya Gerber Barchilon

There is way for everyone find the one that works best for you!

30 % glenoid bone loss:

• Contact area decreased a mean
• f 41%
• Contact pressure increased

nearly 100% .

• Today critical bone loss is set be

around 1 5 %

Greis et al., JSES 2002

Why we care about the glenoid ?

Hill-Sachs-defect and the On/ Off Track Concept

Di Giacomo et al., Curr Rev Musculoskelet Med, 2014 Yamamoto N et al. JSES 2007

bony glenoid defect vs. bony humeral defects

Hill-Sachs-defect and the On/ Off Track Concept

Di Giacomo et al., Curr Rev Musculoskelet Med, 2014 Yamamoto N et al. JSES 2007

• The importance of Hill-Sachs-lesion is much higher

than expected

• The relation between On Track vs.

Off Track should be calculated before surgery

• I f distance A > B

you should address the bony defect

A B

Mook & Millett et al. AJSM 2016

New aspects of asc. stab.: Glenoid track

• Arthroscopy. 2016

Risk factor: Off-track

n=100 recurrence at 22 months FU

Don’t use the same hammer for every nail!

Glenoid Defect? Humeral Defect? On/Off Track Lesions?

Glenoid options

• Asc. / Open Bankart
• Latarjet
• J-Span

Humeral options

• Remplissage
• posteromedial Capsule Plication
• Iliac crest / OATS
• Prosthesis

My preferred technique: glenoid bone loss

Glenoid defects > 15% , failed proper arthroscopic stabilization

• Latarjet
• J-Span
• Iliac crest for Revisions

Imhoff et al., Springer, 2012 Auffarth et al., AJSM 2008 Auffarth et al., OOTr 2011 Burkhart et al., Arthroscopy 2007 Edwards& Walch, Oper Tech Sports Med 2008

History of asc stabilization 4 years ago Traumatic re-dislocation by jumping into shallow water

Case 1 Glenoid# : 32y male

24% Glenoid Bone Loss On Track Hill Sachs

Case 1 Glenoid# : 32y male

• male, 40y
• traumatic shoulder luxation during ice skating on

10.02.2017

Case 2 Reverse Hill-Sachs

MRI – 27.02.2017

Case 2 Reverse Hill-Sachs

MRI – 27.02.2017

• Anterior engaging reverse Hill-Sachs-Lesion
• Post. Bankart
• Minimal post. glenoid Bone Loss

Case 2 Reverse Hill-Sachs

Case 2 Ant.Remplissage (McLaughlin )+ post. Bankart

Case 2 Ant.Remplissage (McLaughlin )+ post. Bankart

Case 2 Ant.Remplissage (McLaughlin )+ post. Bankart

Case 2 Ant.Remplissage (McLaughlin )+ post. Bankart

Case 2 Ant.Remplissage (McLaughlin )+ post. Bankart

Of Track lesions, intra operative engaging after glenoid repair

• Location lateral

– Remplissage

• Location more medial -

OATS/ Iliac crest

• Epileptic history

– consider CAP Prosthesis

Imhoff, et al., Springer, 2012 Connolly et al. Instr. Course Lect 1972 Purchase, Wolf et al. Arthroscopy 2008 Zhu et al. AJSM 2011

My preferred technique: Hill-Sachs lesion

Of Track lesions, intra operative engaging after glenoid repair

• Remplissage

Imhoff, et al., Springer, 2012 Connolly et al. Instr. Course Lect 1972 Purchase, Wolf et al. Arthroscopy 2008 Zhu et al. AJSM 2011

My preferred technique: Hill-Sachs lesion

Werner et al., 2017, AJSM

New aspects of asc. stab.: Posteromedial plication

In the lab no reduction

• f External Rotation

• Knots over 2 anchors
• Knots between 2 anchors

(double-pulley)

• 2 knotless anchors & tape

(Tape-bridge)

Purchase Arthroscopy 2008 Koo Arthroscopy 2009

Tan, Saier, Imhoff, Braun, BMC 2016

Techni que n Area

p- value

Knot 10 13% Pulley 10 16% n.s. Tape 10 27% .03

New aspects of asc. stab.: 3 techniques

Kropf und Sekiya Arthroscopy 2007 Shah et al. Arthroscopy 2011

Case 3: Glenoid defect & Hill-Sachs: OATS / Allograft

28y male soccer player several dislocations since 3 years Tx: filled HillSachs + Latarjet

Epileptic 34y, 2 x asc. Stabilization, new dislocation Tx: 2 step procedure

• 1. Asc, Hemicap
• 2. Latarjet

Case 4: Glenoid defect & Hill-Sachs: Partial Eclipse

11.11.15 30.03.16

Case 4: Glenoid defect & Hill-Sachs: Partial Eclipse

Knotless All-Suture (Soft) Anchor

New aspects of arthroscopic stabilsation

Advantage of ALL-Suture ( Soft) anchors:

• Minimal drill holes (1.4 - 2.0 mm)
• Flexible drills
• Curved guide instruments
• Positioning the anchors through

the guides

• Similiar pull out forces
• No osteolysis described

New aspects of asc. stab.: anchors

Case 16 y female Caroline professional swimmer (JWC) First dislocation – painful instability - MDI

Case 16 y female Caroline professional swimmer (JWC) First dislocation – painful instability - MDI

How good is the modern asc. bony bankart repair?

Owens et al. Curr Rev Musculoskelet Med 2017

Case 2: Jana G. 25 y female painful instability – MDI since 10 years, mainly inferior Video_006

Video_008 Case 2: 25 y female painful instability – MDI since 10 years, mainly inferior direction

Video_010 Case 2: 25 y female painful instability – MDI since 10 years, mainly inferior direction

Inclusion:

• Instability after traumatic dislocation
• Time to surgery > 12 months
• FU > 24 months

Exclusion:

• Bony deficiency glenoid > 20%
• Rotator cuff lesion
• OA (> I° Samilson)

Return to activity after arthroscopic bankart repair in chronic glenohumeral instability

Return to activity after arthroscopic bankart repair in chronic glenohumeral instability

• 66 / 81 patients with chronic instab. (> 12m)
• 2/ 2008-8/ 2010 / / FU: 43 months
• Tegner scale: 6,3 -> 6,1 ; DASH: 6,9
• Re-dislocation rate: 9%
• Return to same level
• verhead sports: 79%

contact-Sport: 82%

• No increase of frequency, time, level or

riskfactors (p> 0.05)

• Reasons:

59% - not associated by the shoulder 22% - afraid about redislocation/ no appreh. 19% - some pain or instability

Imhoff AB et al. Am J Sports Med. 2014

Return to activity after arthroscopic bankart repair in chronic glenohumeral instability

Subjective sport activity

• 66% - increased
• 26% - equal
• 8% - less

Increase of Low risk sports:

• Biking
• Hiking
• Fitness / Gym

Risk for osteoarthritis

Bankart: 12% OA (Plath, Imhoff AJSM 2015) Latarjet procedure: 25% osteoarthritis (Mizuno JSES 2014)

Quality of Life – 2y after asc. Bankart Repair

*preop vs 12m postop p<.001

Weighted sum score

[Reference: 65]

preop 66 6w 57 12w 62 6m 73 12m 78 24m 75

*

Quality of Life – 2y after asc. Bankart Repair

How satisfied are Patients with Asc. Bankart Repair? A 2y fup on Quality of Life outcome Saier T,.....Imhoff A., Arthroscopy 2017

Functional outcome (OIS & ASES)

*p<.001

OIS Mean Interpretation preop 26 “Fair” 6w 18* “Poor” 3m 25* “Fair” 6m 38* “Good” 12m 42* “Excellent” 24m 44 “Excellent” Significant improvement ASES (preop ø72, 2y postop ø90*) Significant correlation QoL & functional outcome (r .4, p<.05) Quality of Life – 2y after asc. Bankart Repair

• Operative reconstruction superior to

conservative therapy

• Excellent results in early arthroscopic Bankart

repair in young athletes

• Low re-dislocation rates
• Most of the athletes return to the same level

– overhead Sports: 79% – Contact Sport: 82%

• Sig. & high improvement of Quality-of-Life and

patient satisfaction following asc. Bankart repair (5: 30 portal)

Summary