Arthroscopic Stablization Cherry Blossom Final 2009
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Arthroscopic Stablization Cherry Blossom Final 2009

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Arthroscopic Stablization Cherry Blossom Final 2009 Arthroscopic Stablization Cherry Blossom Final 2009 Presentation Transcript

  • Arthroscopic Stabilization in Anterior Instability Indications, Pearls and Pitfalls Benjamin Shaffer MD
    • Arthroscopic stabilization has become
    • the “de facto” standard
    In 2009…
    • Indications
    • Contributory pathology
    • Technology, instrumentation
    • Technical skill
    Improved outcomes likely due to:
    • Post-traumatic
    • Unidirectional
    • Discrete Bankart
    • Good tissue quality
    • Overhead throwing athlete
    “ Ideal” Arthroscopic Indication 2009
  • Contraindications 2009
    • 1. HAGL
    • 2. Poor Quality Capsulolabral Tissue
    • 3. Intra-capsular IGHL rupture
    • 4. Revision Surgery
    • 5. Significant Glenoid or Bony Bankart Pathology
    • 6. Engaging Hill-Sachs Lesion
    • 7. Contact/Collision Sport Athlete
    Contraindications 2009
    • 1. HAGL
    • 2. Poor Quality Capsulolabral Tissue
    • 3. Intra-capsular IGHL rupture
    • 4. Revision Surgery
    • 5. Significant Glenoid or Bony Bankart Pathology
    • 6. Engaging Hill-Sachs Lesion
    • 7. Contact/Collision Sport Athlete
    Contraindications 2009
    • 1. HAGL
    Contraindications 2009
    • Avulsion off humeral side
    • Index of suspicion
    • Exposed subscap
    • Best seen w/ 70 ° lens
    • Easy to repair open
  • Contraindications
    • 1. HAGL
    • 2. Poor Quality Capsulolabral Tissue
    Contraindications 2009
    • Tissue Insufficient
    • Revision Cases
    • Soft tissue augmentation
    • 1. HAGL
    • 2. Poor Quality Capsulolabral Tissue
    • 3. Intra-capsular
    • IGHL rupture
    Contraindications 2009
    • 1. HAGL
    • 2. Poor Quality Capsulolabral Tissue
    • 3. Intra-capsular IGHL rupture
    • 4. Revision Surgery
    Contraindications 2009
    • Previous failed arthroscopic
    • Patient disappointed and/or hostile –need to do the surgery with the highest success rate
    • 1. HAGL
    • 2. Poor Quality Capsulolabral Tissue
    • 3. Intra-capsular IGHL rupture
    • 4. Revision Surgery
    • 5. Significant Glenoid or Bony Bankart Pathology
    Contraindications 2009
    • ~ 22% initial traumatic dislocations
    • up to 73% of recurrent cases
    Significant Glenoid Or Bony Bankart Lesion
  • Contraindication: Bony Bankart
    • Good screening x-ray - Bernageau View Arthroscopy Sept. 2003
    Significant Glenoid Bone Loss
    • CT Scan
    • 3-D Reconstructions
    Significant Glenoid Bone Loss
  • REC: Preop Bilateral CT’s 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:
    A B C D Bone loss 12.5mm 25mm 20mm (25-20)/25 x100 = 20% Calculate Bone Loss
    • >20 – 25% Loss: Bony (Open) Procedure
    Significant Glenoid Bone Loss Treatment Options Anatomic Glenoid Reconstruction Salvage Bristow-Laterjet
    • 1. HAGL
    • 2. Poor Quality Capsulolabral Tissue
    • 3. Intra-capsular IGHL rupture
    • 4. Revision Surgery
    • 5. Significant Glenoid or Bony Bankart Pathology
    • 6. Engaging Hill-Sachs Lesion
    Contraindications 2009
    • 25% w/ ant sublux
    • 80% w/ 1 º ant Disl
    • Up to 100% w/ recurrent ant instability
    Humeral Bone Loss Significant Hill-Sachs Lesion
    • Presents the long axis of its defect parallel to anterior glenoid w/ shoulder in functional position of abd/er
    “ Engaging” Hill-Sachs Lesion
    • Arthroscopic (Soft tissue) procedures cannot prevent Hill-Sachs lesion from engaging rim (articular arc deficiency)
    Humeral Bone Loss Significant Hill-Sachs Lesion
  • “ Engaging” Hill-Sachs Lesion
    • Hx of multiple dislocations over many years
    • Hx of multiple failed surgeries
    When to Asses Pre-Op? Consider when…
    • 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 Loss Engaging Hill-Sachs Lesion OATS ALLOGRAFT
    • Arthroscopic Bankart
    • Posterior bone grafting
    • Usually staged (s/p scope repair w/ persistent HS engagement) to avoid unnecessary OA graft
    • 1 US Navy Seaman RTA @ 1 yr f/u
    Humeral Bone Loss Engaging Hill-Sachs Lesion
    • OATS AUTOGRAFT
    Humeral Bone Loss Engaging Hill-Sachs Lesion Clinical Results Pending
    • BONE SUBSTITUTE plugs
    Humeral Bone Loss Engaging Hill-Sachs Lesion
    • 12 pts
    • arthroscopic grafting of the engaging humeral head lesions.
    • No significant intra-operative complications
    • Clinical results pending
    John Kelly MD Arthroscopy abstract ’07
    • Multiple sizes
    • Limited data
    • OA, ON, focal chondral defects
    Humeral Bone Loss Engaging Hill-Sachs Lesion
    • Prosthetic (HEMI-CAP)
  • Humeral Bone Loss Engaging Hill-Sachs Lesion Auto Body Technique w/ “transhumeral elevation and allograft augmentation of the impacted head fragment”
  •  
  • Humeral Bone Loss Engaging Hill-Sachs Lesion Arthroscopic technique limits engagement of defect
    • Remplissage (French: “To Fill”)
  • Humeral Bone Loss Engaging 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
  • Salvage Bristow-Latarjet
    • 1. HAGL
    • 2. Poor Quality Capsulolabral Tissue
    • 3. Intra-capsular IGHL rupture
    • 4. Revision Surgery
    • 5. Significant Glenoid or Bony Bankart Pathology
    • 6. Engaging Hill-Sachs Lesion
    • 7. Contact/Collision Sport Athlete
    Contraindications 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
    • Standard Scope, 30° and 70° Lenses
    • Periosteal elevator
    • Suture Anchors
    • Suture Passing Instruments
    • Knot pusher/cutter
    • Cannulae (and introducers) which accommodate instrumentation
    Instrumentation 70° 30°
    • Position Patient
    • Establish Portals
    • Evaluate and Treat Pathology
    • Prepare (and mobilize) opposing tissues
    • Insert Anchors
    • Pass Sutures
    • Secure Fixation
    • 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
    • RI
    Glenoid IGHL 6 8. Address Capsular Patholaxity/Rotator Interval
    • Questions
    • How to know when it is deficient?
    • # sutures?
    • Mono or braided?
    • Arm Position?
    Rotator Interval
    • 3 wks immobilization
    • Progressive ROM, strength
    • RTA 4-6 months
    Post-op Rehabilitation
  • Arthroscopic Bankart Results Year Author(s) # Shoulders Mean 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) # Shoulders Mean 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) # Shoulders Mean 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) # Shoulders Mean 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
  • 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