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