Surgical treatment of shoulder sports injuries

Mr Lee Van Rensburg

United Kingdom

Objectives

• Surgical options for shoulder instability

– Glenohumeral• Acute traumatic• Recurrent traumatic

30 YO male,Professional Rugby payer,

Surgical options

Hippocrates 400 BC

• method of reduction

• cauterisation of inferior capsule

Shoulder Instability

Bankart Lesion• Perthes 1906• Bankart 1938

– “essential lesion” of the capsulolabral complex

Uber operation bei habitueller schulterluxation. Perthes G. Dtsch Z Chir 1906

The pathology and treatment of recurrent dislocation of the shoulder joint. Bankart B Br J Surg 1938

Bankart Repair

• Bankart 1938• 1st procedure 1923 on his

former House Surgeon• re-attaching capsule to the

glenoid with transosseous sutures

• repairing subscapularis with NO overlap or shortening

The pathology and treatment of recurrent dislocation of the shoulder joint. Bankart A. Br J Surg 1938

Modified Open Bankart Repair

• Numerous modifications- capsular imbrication- suture anchors

• Multiple series published

• Accepted recurrence rate Open Bankart Repair 8 –12%

• Loss of ER

Arthroscopic Stabilisation

• Johnson 1982

- Arthroscopic Staple Capsulorrhaphy

- Metal Staple

- 106 patients

- > 18 mth F/U

- 21% recurrence

Early complications of acute anterior dislocation of the shoulder in middle-aged and elderly patients. Johnson JR et al. Injury 1982

Staple Capsulorrhaphy

Lane et al 1993

- 54 patients Staple Capsulorrhaphy

- >39 month F/U

- 18 (33%) re-dislocated

- 36 stable – 15 % loose staple + articular injury

- < 50 loss of ER

- Caution in considering Staple Capsulorrhaphy

- ROM & functional level well maintained

Arthroscopic staple capsulorrhaphy: A long term follow-up. Lane JG et al. Arthroscopy 1993

Transglenoid Stabilisation

• Caspari 1988

- Transglenoid arthroscopic stabilisation

- multiple sutures passed through

AI capsule

- transglenoid drill hole

- passed A to P through glenoid

- sutures tied onto infraspinatus

fascia

Arthroscopic reconstruction for anterior shoulder Arthroscopic reconstruction for anterior shoulder instability.instability. Caspari.Caspari. Tech OrthopTech Orthop 1988 1988

Transglenoid Stabilisation

• Torchia 1997

- 150 transglenoid stabilisation

- F/U > 2 yrs

- av age 29yrs (14 – 67)

- 11 dislocations (7.3%)

- areas of risk - P fixation

- < 25 yrs

Arthroscopic transglenoid multiple suture repair: 2- 8 year results in 150 patients. Torchia et al. Arthroscopy 1997

Transglenoid Stabilisation

• Soderlund 2008

- 455 army recruits (1992 – 2000) Questionaire

- 312 (68.5%) responded av 20yr (18-28)

- Av time from surg 6.4yrs (1-14)

- 177 (56%) re-dislocations

Long-term outcome of a transglenoid suture technique for anterior shoulder instability in young adults. Soderlund et al JBJS Br 2008

Bioabsorbable Tack Stabilisation

• Bioabsorbable Tack Stabilisation

Speer 1996

- 52 recurrent dislocators

- Suretac stabilisation

- > 2yr F/U (24 – 60 mth)

- 11 dislocations (21%)

- 7 of 8 open revision Bankart

healed with ‘patulous capsule’

An arthroscopic technique for anterior shoulder stabilisation of the shoulder using a bio-absorbable tack. Speer et al. J BJS Am. 1996

Arthroscopic Stabilisation

• Suture Anchor Stabilisation

- problems staple & transglenoid

fixation

- difficulty in capsule plication

with tacks

- improvements in suture anchor

design

- improvements in instrumentation

Arthroscopic washout

Arthroscopic Stabilisation v Arthroscopic Lavage

•2 yr f/u (1 lavage & 3 stabilisation – lost)

- Re-dislocation

- stab 3/42 ( 7%)

- lavage 16/42 (38%)

- Reduction in risk

- 76% re-disc & 82% instab

Primary arthroscopic stabilisation for a first-time anterior dislocation of the shoulder. Robinson JBJS Am 2008

Suture Anchor Stabilisation

• Metanalysis

Hobby 2007

- 20 suture anchor stabilisation studies

- 1030 patients

- recurrence as end point

- failure rates ranged from 0 – 30%

- most < 10%

Is arthroscopic surgery for chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations. Hobby et al. JBJS Br .2007

Surgical options summary

• Hot Poker in axilla• Open Bankart• Arthroscopic

– Staple– Transglenoid suture– Suture tacks– Arthroscopic washout– Suture anchors

Again?

• Age 30 continues to play what are chances it will happen again

Non-Operative Treatment

Prognosis: age at time of dislocation

12-22 yrs 23-29 yrs 30-40 yrs

Re dislocated 73% 56% 25%

x1 disloc 20% 18% 10%

Recurrence ( > x2)

no surgery 12% 10% 5%

surgery 40% 28% 10%

Non-operative treatment of primary anterior shoulder dislocation in patients forty years and younger. A prospective twenty-five-year follow-up. Hovelius et al JBJS Am 2008

Open Access Journal of Sports Medicine 2011:2 19–24

Diagnostic arthroscopy• Anaesthetic

– GA– Regional block – www.nerveblocks.co.uk

• Interscalene block• Supraclavicular +- Axillary nerve block

• Setup– Beach position– Lateral position

• Skin preparation– Alcohol/ chlorhexidine preparation

• Propriono bacterium acnes

• Prophylactic antibiotics– Implant surgery– P acnes

• Flucloxacillin _+- Gentamycin

• Alcohol and chlorhexidine, superior to povidone iodine

J Bone Joint Surg Am. 2009;91:1949-53

Diagnostic arthroscopy

• Equipment– Arthroscopy stack

• 30 degree scope– Fluid management system– High flow arthroscopy trocars– Radiofrequency probe– Arthroscopic shaver– Suture passers– Anchors

Diagnostic arthroscopy• Portals

– Posterior – viewing portal– Anterior- working portal (inside out, spinal needle)

• Procedure– Biceps anchor– Anterior labrum– MGHL– Subscapularis– SGHL (Pulley)– Biceps (tunnel)– Supraspinatus– Infraspinatus– Inferior recess– Articular surfaces

• Glenoid• Humeral head

• Closure– Subcuticular prolene

Portal Placement

• Anterior Portal – 2nd ‘working’ gleno-humeral portal

21

Arthroscopic Bankart

Diagnostic Arthroscopy

Suture Anchor Insertion

Knott Tying

Second Anchor

Arthroscopic stabilisation

Arthroscopic stabilisation

SLAP tears

1 Frayed

2 Superior A and P

32 + bucket handle

4Bucket into biceps

5 Assoc dislocation

62 with A or P labral flap

7Tear into MGHL

82 + P labrum

92 + Circumferential labrum

102 + P + Inf labrum

SLAP tears

• Options– Debridement

• Type 1

– Re attachment (SLAP repair)– Biceps tenotomy/ tenodesis

J Shoulder Elbow Surg (2011) 20, 326-332

Again?

• Recurrence rates– Arthroscopic (suture anchor) 8-11%– Open (Bankart) 0-11%

• Arthroscopic slightly better ROM

Sports Health. 2011 Jul;3(4):396-404.

Glenoid Bone Loss

• Re-Dislocation

- 194 arthroscopic stabilisations- 21 significant bone loss

- no bone loss 4% recurrence- inverted pear 61% recurrence

- “Inverted Pear” 25% of glenoid surface area

Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the glenoid’s “inverted pear” and the humeral “engaging Hills-Sachs lesion”. Burkhart & De Beer Arthroscopy 2000

• Glenoid• Concavity depression• De Beer – Inverted pear• Deficiency antero inferior diameter >25%

– Augment glenoid

• Humeral• Hills sachs lesion• Engaging Hill Sachs lesion

– Dx Arthroscopy– Address humerus

J Shoulder Elbow Surg (2009) 18, 317-328

Glenoid defects

• Eden Hybbinette ( 1918/ 1932)• Initially Tibia• Now iliac crest

• Bristow (Helfett 1958)• 1-2 cm Coracoid transfer distal to pectoralis minor• Single screw

• Latarjet (1954)• Larger 2-3 cm• Length ways 2 screws• Arthroscopic

Latarjet

• Massive Hill-Sachs lesion• >25% volume of the humeral

head• Management

- rotational osteotomy

- hemiarthroplasty

- infraspinatus transfer

- osteo-articular allograft

- arthroscopic remplissage

Humeral defects

Humeral Bone Loss

• Osteoarticular humeral head allograft

- 18 patients failed surgery

with >25% Hill-Sachs

- osteoarticular allograft

- 0 recurrence at 2 yrs

- early x-ray evidence of

allograft collapse

Recurrent anterior instability following failed surgical repair: Allograft reconstruction of large humeral defects. Miniaci, Tytherleigh-Strong. JBJS 2001

Arthroscopic Remplissage

• arthroscopic Bankart

• capsulodesis and infraspinatus tenodesis

SummaryYoung sports dislocation

1 week

- Plain x-ray

- CT

- CT recon

Bone loss

Practically

• Arthroscopic Bankart with anchors– 1st time dislocator– Recurrent with no bony defect

• Open Latarjet– Failed arthroscopic Bankart– Bony defects (glenoid)– Chronic dislocation

J Bone Joint Surg Am. 2009;91:966-78

The End