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? n=190 (1996 - 2000) • RTS at preinjury level in 80% • Rowe, Constant, ASES increased • no complications due to 5:30h • overall 9% recurrence Imhoff AB et al., Am J Sports Med 2010 Tischer & Imhoff, Oper Orthop Traumatol. 2007
Epidemiology: Age Overall incidence rate 23.9/100,000/year Zacchilli, Owens, JBJS, 2010 Owens et al., AJSM, 2007
Epidemiology: Gender 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) Leroux et al., AJSM, 2014 Zacchilli, Owens, JBJS, 2010 Kirkley et al., Arthroscopy, 2005 Flatow et al., Orthop Clin North Am, 2000
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 Conservative Conservative < 18 a: ≈ 73% ≈ 20% ≈ 10% < 30 a: ≈ 50% Surgery Surgery Surgery < 18 a: ≈ 17 – 21% ≈ 7 – 15% ≈ 7 – 20% < 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
Natural History - Arthropathy „ 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“ Hovelius, Rahme, KSSTA, 2016
Munich-Results after Revision Surgery 2011 significant improvement in Rowe and Constant score (pre-OP vs. post-OP) improvement independent of index procedure (Asc. vs. open) 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.
5: 30h - portal De Simoni C, Burkart A, Imhoff AB. Arthroskopie. 2000 Coracoid Acromion Portal 8-10 cm x • 1-2 cm lateral from the axilla • through inferior SSC • 2,4 cm to axillary nerve • 1,4 cm to circumflex. post. artery
My VIP Concept for bipolar Lesions V isitation I nterpretation P rocedure
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 Isolated anterior glenoid bone loss 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
Visitation and Physical Examination - 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!
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
Why should we all measure? History of the Bone Loss Concept 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
How do I measure it ? The quick and easy way ( Diameter-Method) S. BHATIA ET AL. (8,00/29,2) x 100 = 27,3 %
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!
There is way for everyone find the one that works best for you! Sugaya Burkhart Baudi Sugaya Gerber Barchilon
Why we care about the glenoid ? 30 % glenoid bone loss: • Contact area decreased a mean of 41% • Contact pressure increased nearly 100% . • Today critical bone loss is set be around 1 5 % Greis et al., JSES 2002
Hill-Sachs-defect and the On/ Off Track Concept bony glenoid defect vs. bony humeral defects Di Giacomo et al., Curr Rev Musculoskelet Med, 2014 Yamamoto N et al. JSES 2007
Hill-Sachs-defect and the On/ Off Track Concept Di Giacomo et al., Curr Rev Musculoskelet Med, 2014 Yamamoto N et al. JSES 2007
New aspects of asc. stab.: Glenoid track • The importance of Hill-Sachs-lesion is much higher than expected • The relation between On Track vs. Off Track should be calculated before surgery B • I f distance A > B you should address A the bony defect Mook & Millett et al. AJSM 2016
Risk factor: Off-track Arthroscopy. 2016 n=100 recurrence at 22 months FU
Don’t use the same hammer for every nail! Humeral options Glenoid options • Remplissage • Asc. / Open Bankart • posteromedial Capsule Plication • Latarjet • Iliac crest / OATS • J-Span • Prosthesis Glenoid Defect? Humeral Defect? On/Off Track Lesions?
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
Case 1 Glenoid# : 32y male 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 2 Reverse Hill-Sachs • 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 • Anterior engaging reverse Hill-Sachs-Lesion • Post. Bankart • Minimal post. glenoid Bone Loss MRI – 27.02.2017
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
My preferred technique: Hill-Sachs lesion 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
New aspects of asc. stab.: Posteromedial plication In the lab no reduction of External Rotation Werner et al., 2017, AJSM
Recommend
More recommend
