arthroscopic stablization cherry blossom test 2009
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Benjamin Shaffer MD
Arthroscopic Stabilization in Anterior Instability
Indications, Pearls and Pitfalls
Arthroscopic stabilization has become
the “de facto” standard
In 2009…
Indications Contributory pathology Technology, instrumentation Technical skill
Improved outcomes likely due to:
“Ideal” Arthroscopic Indication
Post-traumatic Unidirectional Discrete Bankart Good tissue quality Overhead throwing
athlete
2009
Contraindications
1. HAGL
2009
Avulsion off humeral side
Index of suspicion Exposed subscap Best seen w/ 70° lens Easy to repair open
Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue
2009
Tissue Insufficient Revision Cases Soft tissue
augmentation
Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue3. Intra-capsular IGHL rupture
2009
Contraindications
1. HAGL2. Poor Quality Capsulolabral Tissue3. Intra-capsular IGHL rupture4. Revision Surgery
2009
Previous failed arthroscopic
Patient disappointed and/or hostile –need to do the surgery with the highest success rate
Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue3. Intra-capsular IGHL rupture4. Revision Surgery5. Significant Glenoid or Bony
Bankart Pathology
2009
Significant Glenoid Or Bony Bankart Lesion
~ 22% initial traumatic dislocations
up to 73% of recurrent cases
Good screening x-ray - Bernageau ViewArthroscopy Sept. 2003
Significant Glenoid Bone Loss
CT Scan 3-D Reconstructions
Significant Glenoid Bone Loss
Bone Loss With Inverted Pear
Failure rate ~ 60% with arthroscopic repair
(Lo, Burkhart Arthroscopy 2000)
↓ stability to ant transl w/ defect >21% glenoid width
Inferior
How to assess arthroscopically?
Glenoid Bare spot provides consistent reference point to quantify % bone loss of inferior
glenoid
Measure Radius (12.5mm)
Estimate Normal Diameter (25mm)
Measure Actual Diameter (20mm)
Bone Loss:
AB
CD
Bone loss
12.5mm25mm20mm
(25-20)/25 x100 = 20%
Calculate Bone Loss
>20 – 25% Loss: Bony (Open) Procedure
Significant Glenoid Bone Loss Treatment Options
AnatomicGlenoid Reconstruction
SalvageBristow-Laterjet
Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue3. Intra-capsular IGHL rupture4. Revision Surgery5. Significant Glenoid or Bony
Bankart Pathology6. Engaging Hill-Sachs Lesion
2009
Humeral Bone LossSignificant Hill-Sachs Lesion
25% w/ ant sublux 80% w/ 1º ant Disl Up to 100% w/
recurrent ant instability
Humeral Bone LossSignificant Hill-Sachs Lesion
Arthroscopic (Soft tissue) procedures cannot prevent Hill-Sachs lesion from engaging rim (articular arc deficiency)
Stryker Notch Apical Oblique View.
How to Asses Pre-Op
CT scan Measure length, width and depth > 25% of articular surface or depth > 15%
HHD may need tx
How to Asses Pre-Op
Treatment Options
“Engaging” Hill-Sachs Lesion
Anatomic Fill defect with
bone/substitute Repair defect
Treatment Options
“Engaging” Hill-Sachs Lesion
Non-anatomic Fill defect with soft
tissue Bristow
Miniaci ASES 2004 18 patients, defect > 25% of
humeral head Irradiated humeral head
allografts, anterior approach 50 month f/u No recurrences
Humeral Bone LossEngaging Hill-Sachs Lesion
OATS ALLOGRAFT
OATS AUTOGRAFT
Humeral Bone LossEngaging Hill-Sachs Lesion
Clinical Results Pending
BONE SUBSTITUTE plugs
Humeral Bone LossEngaging Hill-Sachs Lesion
12 pts arthroscopic grafting of the
engaging humeral head lesions.
No significant intra-operative complications
Clinical results pending
John Kelly MDArthroscopy abstract ’07
Multiple sizes Limited data OA, ON, focal
chondral defects
Humeral Bone LossEngaging Hill-Sachs Lesion
Prosthetic (HEMI-CAP)
Humeral Bone LossEngaging Hill-Sachs Lesion
Auto Body Technique w/ “transhumeral elevation and
allograft augmentation of the impacted head
fragment”
Humeral Bone LossEngaging Hill-Sachs Lesion
Arthroscopic technique limits engagement of defect
Remplissage (French: “To Fill”)
Humeral Bone LossEngaging Hill-Sachs Lesion
Remplissage
• In an unpublished review, only 2 of 24 patients (7%) had recurrent instability
• Both recurrences occurred after sig trauma.
• No sig complications or loss of ROM
Results
SalvageBristow-Latarjet
Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue3. Intra-capsular IGHL rupture4. Revision Surgery5. Significant Glenoid or Bony
Bankart Pathology6. Engaging Hill-Sachs Lesion7. Contact/Collision Sport Athlete
2009
Collision sports (football, hockey) Stability more important than full motion Cosmesis not a concern Can you afford failure in your high level athlete?
Higher failure rates in these athletes may be due to bone deficiency rather than
sport.
Another explanation…
Restore Stability Anatomic Repair Minimal Morbidity
Goals of Reconstruction
Instrumentation
Standard Scope, 30° and 70° Lenses
Periosteal elevator Suture Anchors Suture Passing Instruments Knot pusher/cutter Cannulae (and introducers)
which accommodate instrumentation
70°
30°
1. Position Patient2. Establish Portals3. Evaluate and Treat Pathology4. Prepare (and mobilize) opposing tissues5. Insert Anchors6. Pass Sutures7. Secure Fixation8. Address Capsular Patholaxity
Surgical Steps
1. Position Patient/EUA
In the beginning…
“Twin” anterior portals
High ASP Low AIP
2. Establish Portals
2. Establish Portals
3. Evaluate/Tx Pathology
4. Prepare Tissues
5. Insert Anchors
6. Pass Sutures
7. Secure Fixation
Complete the Repair
• Difficult to recognize• Occurs even w/
“isolated” Bankart pathology
• Addressed w/ apical stitch/plication
• RIGlenoid
IGHL
6
8. Address Capsular Patholaxity/Rotator Interval
3 wks immobilization Progressive ROM,
strength RTA 4-6 months
Post-op Rehabilitation
Year Author(s)#
ShouldersMean F/U (months)
Recurrence Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
2007 Thal 72 Min 2yr 6.9%13.5% <22yrs, 7.5% in
contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA
Arthroscopic Bankart Results
Year Author(s)#
ShouldersMean F/U (months)
Recurrence Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
2007 Thal 72 Min 2yr 6.9%13.5% <22yrs, 7.5% in
contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA
Arthroscopic Bankart Results
Year Author(s)#
ShouldersMean F/U (months)
Recurrence Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
2007 Thal 72 Min 2yr 6.9%13.5% <22yrs, 7.5% in
contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA
Arthroscopic Bankart Results
Year Author(s)#
ShouldersMean F/U (months)
Recurrence Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
2007 Thal 72 Min 2yr 6.9%13.5% <22yrs, 7.5% in
contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA
Arthroscopic Bankart Results
Caution
Recurrent instability Uncommon
Loss of Motion Implant-related problems Nerve Injury
Complications
Most instability surgery can be performed w/ scope.
Don’t do arthroscopic procedure in pts with deficient capsule and sig bone defects
Consider arthroscopic repair for revision cases, HAGL lesions and contact/collision sports athletes.
Practice makes perfect Good to excellent results in most cases.
Summary
Thank You
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