Disclosure Royalities: Arthrosurface Consultant: medi Bayreuth, - - PowerPoint PPT Presentation

Disclosure Royalities: Arthrosurface Consultant: 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

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

Overall incidence rate 23.9/100,000/year

Epidemiology

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

< 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%

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

Specific Clinical Testing

Specific Imaging

• RX

(3 Plains)

• MRI

(i.a. Contrast)

• CT

(3D Reconstruction)

Woertler & Waldt, Eur Radiol, 2006

Bankart Lesion

SLAP V (Bankart- & SLAP-II-Lesion)

SLAP V (Bankart- & SLAP-II-Lesion)

SLAP V (Bankart- & SLAP-II-Lesion)

Woertler und Waldt (2006) Eur Radiol

Concomitant lesions of the capsular-labral complex

HAGL Perthes ALPSA GLAD

Imaging - MRI

Woertler, Waldt, Eur Radiol, 2006 Bui-Mansfield et al., AJSM, 2007

HAGL

Humeral avulsion of glenohumeral ligaments

Gold standard to detect capsulo-labral tears

• +/- contrast enhancement (not needed in the acute

phase – hemarthrosis)

Positioning of the 5: 30 - portal

Coracoid 5:30- portal

x

Acromion

8-10 cm

• Via the inferior third
• f the SSC
• 2,4 cm distance to

the axillary nerve

• 1,4 cm distance to

the circumflex artery

Tischer, Imhoff et al, OOT, 2007

17

Imhoff, Feucht, Atlas sportorthopädisch-sporttraumatologische Operationen, Springer 2013

19

Imhoff, Feucht, Atlas sportorthopädisch-sporttraumatologische Operationen, Springer 2013

• Ask. anteroinferiore Stabilisierung 1996 – 2000
• 190 patients; FU: 37,4 month; age at surgery: 28 y
• ROWE: 32,2  88
• High differences concerning redislocation in different anchors
•  best: 6,5% in Fastak (9/138/190)
• No complications due to the 5:30h portal
• Return to preop sporting level:

>95% leisure level 50% professional level 80% returned to the same level

Munich - Results 1996-2000

• 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.

Munich-Results after Revision Surgery 2011

Imaging - CT +/- CT-Arthrography

• To determine and evaluate glenoidal/humeral bone loss

(3D-CT!)

• Dysplasia, glenoid retroversion
• CT-A for cartilaginous lesions

Sizing CT (MRT)

• 20% = „small“
• > 20% = „large“

Saliken et al., BMC Musculoskeletal Disorders, 2015 Spiegl, Braun, Imhoff et al., Unfallchirurg 2014 Sugaya et al., JBJS Am 2003

Glenoid bone loss

Glenoid bone loss as small as 2-mm width of the anterior margin of the glenoid or average per cent bone loss

• f 7.5 % of the glenoid results in a significant decrease

in force prior to dislocation

Glenoid bone loss

Shin et al., KSSTA 2014

n=8 cadaveric shoulders

... glenoid

defects

• f

15%

• r

more should be considered the critical bone loss amount at which soft tissue repair cannot restore glenohumeral translation, restricts rotational range of motion, and leads to abnormal humeral head position.

Shin et al., Am J Sports Med. 2016

Glenoid bone loss

preoperative CT, A: parasagittal view glenoid defect (25%) Snowboarder 23 y first dislocation 2011, 2 x a‘scopic stabilisation 2011/13 Again dislocation while snowboarding 2014

Glenoid Defect - Latarjet

Glenoid Defect - Latarjet

Latarjet

Latarjet

Latarjet

Hill-Sachs-lesion

• 57,5% following index dislocation
• 94,5% following redislocation
• 77-100% following recurrent redislocation

Rowe et al., JBJS Am 1984 Burkhart et al., Arthroscopy 2000 Kim et al., AJSM 2010

Engaging Non-Engaging

Engaging or not ?

7 % engaging – indication for surgery

Imaging – MRI – (Bipolar) Bone Loss

Engaging Non-engaging

Burkhart, DeBeer, Arthroscopy, 2000 Imhoff, Feucht, Surgical Atlas of Sports Orthopaedics and Sports Traumatology, 2015

... the more medial, the more enganging ...

Localisation

Kurokowa et al., JSES 2013

Imaging – MRI – (Bipolar) Bone Loss

Locher, Imhoff et al., Arthroscopy, 2016; Gyftopolous et al, Am J Radiol, 2015, Di Giacomo, Arthroscopy, 2014

Off-track On-track

• Arthroscopy. 2016

Risk factor: Off-track

n=100 recurrence at 22 months FU

Glenoid defect & Hill-Sachs: Remplissage

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

Kropf und Sekiya Arthroscopy 2007 Shah et al. Arthroscopy 2011

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

Glenoid defect & Hill-Sachs: Partial Eclipse

11.11.15 30.03.16

Glenoid defect & Hill-Sachs: Partial Eclipse

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

13 y follow-up after Bankart Repair in 100 Sho.

• 21% recurrent dislocation
• 31% no signs OA, 41% mild signs, 16% moderate
• 12% severe OA – no correlation with Constant Sc.

Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Longterm Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13 years Follow-up Plath, Aboalata, Seppel, Juretzko, Waldt, Vogt, Imhoff Am J Sports Med. 2015: 1084-90

13 y follow-up after Bankart Repair in 100 Sho.

OA sig. associated with

• # of preop. disloc.
• Age at initial disloc.
• Age at surgery
• Number of anchors (= amount of primary trauma)

OA no significance

• Time between disloc. and surgery
• ER deficit at 0° and 90° ABD
• Recurrent dislocation

Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Longterm Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13 years Follow-up Plath, Aboalata, Seppel, Juretzko, Waldt, Vogt, Imhoff Am J Sports Med. 2015: 1084-90

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

*preop vs 12m postop p<.001

Weighted sum score

[Reference: 90]

preop 74 6w 60 12w 76 6m 88 12m 94 24m 93

*

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

• 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