Arthroscopic Stablization Cherry Blossom Final 2009

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  • Arthroscopic Stablization Cherry Blossom Final 2009

    1. 1. Arthroscopic Stabilization in Anterior Instability Indications, Pearls and Pitfalls Benjamin Shaffer MD
    2. 2. <ul><li>Arthroscopic stabilization has become </li></ul><ul><li>the “de facto” standard </li></ul>In 2009…
    3. 3. <ul><li>Indications </li></ul><ul><li>Contributory pathology </li></ul><ul><li>Technology, instrumentation </li></ul><ul><li>Technical skill </li></ul>Improved outcomes likely due to:
    4. 4. <ul><li>Post-traumatic </li></ul><ul><li>Unidirectional </li></ul><ul><li>Discrete Bankart </li></ul><ul><li>Good tissue quality </li></ul><ul><li>Overhead throwing athlete </li></ul>“ Ideal” Arthroscopic Indication 2009
    5. 5. Contraindications 2009
    6. 6. <ul><li>1. HAGL </li></ul><ul><li>2. Poor Quality Capsulolabral Tissue </li></ul><ul><li>3. Intra-capsular IGHL rupture </li></ul><ul><li>4. Revision Surgery </li></ul><ul><li>5. Significant Glenoid or Bony Bankart Pathology </li></ul><ul><li>6. Engaging Hill-Sachs Lesion </li></ul><ul><li>7. Contact/Collision Sport Athlete </li></ul>Contraindications 2009
    7. 7. <ul><li>1. HAGL </li></ul><ul><li>2. Poor Quality Capsulolabral Tissue </li></ul><ul><li>3. Intra-capsular IGHL rupture </li></ul><ul><li>4. Revision Surgery </li></ul><ul><li>5. Significant Glenoid or Bony Bankart Pathology </li></ul><ul><li>6. Engaging Hill-Sachs Lesion </li></ul><ul><li>7. Contact/Collision Sport Athlete </li></ul>Contraindications 2009
    8. 8. <ul><li>1. HAGL </li></ul>Contraindications 2009 <ul><li>Avulsion off humeral side </li></ul><ul><li>Index of suspicion </li></ul><ul><li>Exposed subscap </li></ul><ul><li>Best seen w/ 70 ° lens </li></ul><ul><li>Easy to repair open </li></ul>
    9. 9. Contraindications
    10. 10. <ul><li>1. HAGL </li></ul><ul><li>2. Poor Quality Capsulolabral Tissue </li></ul>Contraindications 2009 <ul><li>Tissue Insufficient </li></ul><ul><li>Revision Cases </li></ul><ul><li>Soft tissue augmentation </li></ul>
    11. 11. <ul><li>1. HAGL </li></ul><ul><li>2. Poor Quality Capsulolabral Tissue </li></ul><ul><li>3. Intra-capsular </li></ul><ul><li>IGHL rupture </li></ul>Contraindications 2009
    12. 12. <ul><li>1. HAGL </li></ul><ul><li>2. Poor Quality Capsulolabral Tissue </li></ul><ul><li>3. Intra-capsular IGHL rupture </li></ul><ul><li>4. Revision Surgery </li></ul>Contraindications 2009 <ul><li>Previous failed arthroscopic </li></ul><ul><li>Patient disappointed and/or hostile –need to do the surgery with the highest success rate </li></ul>
    13. 13. <ul><li>1. HAGL </li></ul><ul><li>2. Poor Quality Capsulolabral Tissue </li></ul><ul><li>3. Intra-capsular IGHL rupture </li></ul><ul><li>4. Revision Surgery </li></ul><ul><li>5. Significant Glenoid or Bony Bankart Pathology </li></ul>Contraindications 2009
    14. 14. <ul><li>~ 22% initial traumatic dislocations </li></ul><ul><li>up to 73% of recurrent cases </li></ul>Significant Glenoid Or Bony Bankart Lesion
    15. 15. Contraindication: Bony Bankart
    16. 16. <ul><li>Good screening x-ray - Bernageau View Arthroscopy Sept. 2003 </li></ul>Significant Glenoid Bone Loss
    17. 17. <ul><li>CT Scan </li></ul><ul><li>3-D Reconstructions </li></ul>Significant Glenoid Bone Loss
    18. 18. REC: Preop Bilateral CT’s Significant Glenoid Bone Loss
    19. 19. Bone Loss With Inverted Pear <ul><li>Failure rate ~ 60% with arthroscopic repair </li></ul><ul><li>(Lo, Burkhart Arthroscopy 2000) </li></ul><ul><li>↓ stability to ant transl w/ defect >21% glenoid width </li></ul>Inferior
    20. 20. How to assess arthroscopically? Glenoid Bare spot provides consistent reference point to quantify % bone loss of inferior glenoid
    21. 21. <ul><li>Measure Radius (12.5mm) </li></ul><ul><li>Estimate Normal Diameter (25mm) </li></ul><ul><li>Measure Actual Diameter (20mm) </li></ul><ul><li>Bone Loss: </li></ul>A B C D Bone loss 12.5mm 25mm 20mm (25-20)/25 x100 = 20% Calculate Bone Loss
    22. 22. <ul><li>>20 – 25% Loss: Bony (Open) Procedure </li></ul>Significant Glenoid Bone Loss Treatment Options Anatomic Glenoid Reconstruction Salvage Bristow-Laterjet
    23. 23. <ul><li>1. HAGL </li></ul><ul><li>2. Poor Quality Capsulolabral Tissue </li></ul><ul><li>3. Intra-capsular IGHL rupture </li></ul><ul><li>4. Revision Surgery </li></ul><ul><li>5. Significant Glenoid or Bony Bankart Pathology </li></ul><ul><li>6. Engaging Hill-Sachs Lesion </li></ul>Contraindications 2009
    24. 24. <ul><li>25% w/ ant sublux </li></ul><ul><li>80% w/ 1 º ant Disl </li></ul><ul><li>Up to 100% w/ recurrent ant instability </li></ul>Humeral Bone Loss Significant Hill-Sachs Lesion
    25. 25. <ul><li>Presents the long axis of its defect parallel to anterior glenoid w/ shoulder in functional position of abd/er </li></ul>“ Engaging” Hill-Sachs Lesion
    26. 26. <ul><li>Arthroscopic (Soft tissue) procedures cannot prevent Hill-Sachs lesion from engaging rim (articular arc deficiency) </li></ul>Humeral Bone Loss Significant Hill-Sachs Lesion
    27. 27. “ Engaging” Hill-Sachs Lesion
    28. 28. <ul><li>Hx of multiple dislocations over many years </li></ul><ul><li>Hx of multiple failed surgeries </li></ul>When to Asses Pre-Op? Consider when…
    29. 29. <ul><li>Stryker Notch </li></ul><ul><li>Apical Oblique View. </li></ul>How to Asses Pre-Op
    30. 30. <ul><li>CT scan </li></ul><ul><ul><li>Measure length, width and depth </li></ul></ul><ul><ul><li>> 25% of articular surface or depth > 15% HHD may need tx </li></ul></ul>How to Asses Pre-Op
    31. 31. <ul><li>Treatment Options </li></ul>“ Engaging” Hill-Sachs Lesion <ul><ul><li>Anatomic </li></ul></ul><ul><ul><ul><li>Fill defect with bone/substitute </li></ul></ul></ul><ul><ul><ul><li>Repair defect </li></ul></ul></ul>
    32. 32. <ul><li>Treatment Options </li></ul>“ Engaging” Hill-Sachs Lesion <ul><ul><li>Non-anatomic </li></ul></ul><ul><ul><ul><li>Fill defect with soft tissue </li></ul></ul></ul><ul><ul><ul><li>Bristow </li></ul></ul></ul>
    33. 33. <ul><li>Miniaci ASES 2004 </li></ul><ul><ul><li>18 patients, defect > 25% of humeral head </li></ul></ul><ul><ul><li>Irradiated humeral head allografts, anterior approach </li></ul></ul><ul><ul><li>50 month f/u </li></ul></ul><ul><ul><li>No recurrences </li></ul></ul>Humeral Bone Loss Engaging Hill-Sachs Lesion OATS ALLOGRAFT
    34. 34. <ul><li>Arthroscopic Bankart </li></ul><ul><li>Posterior bone grafting </li></ul><ul><li>Usually staged (s/p scope repair w/ persistent HS engagement) to avoid unnecessary OA graft </li></ul><ul><li>1 US Navy Seaman RTA @ 1 yr f/u </li></ul>Humeral Bone Loss Engaging Hill-Sachs Lesion
    35. 35. <ul><li>OATS AUTOGRAFT </li></ul>Humeral Bone Loss Engaging Hill-Sachs Lesion Clinical Results Pending
    36. 36. <ul><li>BONE SUBSTITUTE plugs </li></ul>Humeral Bone Loss Engaging Hill-Sachs Lesion <ul><li>12 pts </li></ul><ul><li>arthroscopic grafting of the engaging humeral head lesions. </li></ul><ul><li>No significant intra-operative complications </li></ul><ul><li>Clinical results pending </li></ul>John Kelly MD Arthroscopy abstract ’07
    37. 37. <ul><li>Multiple sizes </li></ul><ul><li>Limited data </li></ul><ul><li>OA, ON, focal chondral defects </li></ul>Humeral Bone Loss Engaging Hill-Sachs Lesion <ul><li>Prosthetic (HEMI-CAP) </li></ul>
    38. 38. Humeral Bone Loss Engaging Hill-Sachs Lesion Auto Body Technique w/ “transhumeral elevation and allograft augmentation of the impacted head fragment”
    39. 40. Humeral Bone Loss Engaging Hill-Sachs Lesion Arthroscopic technique limits engagement of defect <ul><li>Remplissage (French: “To Fill”) </li></ul>
    40. 41. Humeral Bone Loss Engaging Hill-Sachs Lesion
    41. 42. Remplissage <ul><li>In an unpublished review, only 2 of 24 patients (7%) had recurrent instability </li></ul><ul><li>Both recurrences occurred after sig trauma. </li></ul><ul><li>No sig complications or loss of ROM </li></ul>Results
    42. 43. Salvage Bristow-Latarjet
    43. 44. <ul><li>1. HAGL </li></ul><ul><li>2. Poor Quality Capsulolabral Tissue </li></ul><ul><li>3. Intra-capsular IGHL rupture </li></ul><ul><li>4. Revision Surgery </li></ul><ul><li>5. Significant Glenoid or Bony Bankart Pathology </li></ul><ul><li>6. Engaging Hill-Sachs Lesion </li></ul><ul><li>7. Contact/Collision Sport Athlete </li></ul>Contraindications 2009
    44. 45. <ul><li>Collision sports (football, hockey) </li></ul><ul><ul><li>Stability more important than full motion </li></ul></ul><ul><ul><li>Cosmesis not a concern </li></ul></ul><ul><ul><li>Can you afford failure in your high level athlete? </li></ul></ul>
    45. 46. <ul><li>Higher failure rates in these athletes may be due to bone deficiency rather than sport. </li></ul>Another explanation…
    46. 47. <ul><li>Restore Stability </li></ul><ul><li>Anatomic Repair </li></ul><ul><li>Minimal Morbidity </li></ul>Goals of Reconstruction
    47. 48. <ul><li>Standard Scope, 30° and 70° Lenses </li></ul><ul><li>Periosteal elevator </li></ul><ul><li>Suture Anchors </li></ul><ul><li>Suture Passing Instruments </li></ul><ul><li>Knot pusher/cutter </li></ul><ul><li>Cannulae (and introducers) which accommodate instrumentation </li></ul>Instrumentation 70° 30°
    48. 49. <ul><li>Position Patient </li></ul><ul><li>Establish Portals </li></ul><ul><li>Evaluate and Treat Pathology </li></ul><ul><li>Prepare (and mobilize) opposing tissues </li></ul><ul><li>Insert Anchors </li></ul><ul><li>Pass Sutures </li></ul><ul><li>Secure Fixation </li></ul><ul><li>Address Capsular Patholaxity </li></ul>Surgical Steps
    49. 50. 1. Position Patient/EUA
    50. 51. <ul><li>In the beginning… </li></ul><ul><li>“ Twin” anterior portals </li></ul><ul><li>High ASP </li></ul><ul><li>Low AIP </li></ul>2. Establish Portals
    51. 52. 2. Establish Portals
    52. 53. 3. Evaluate/Tx Pathology
    53. 54. 4. Prepare Tissues
    54. 55. 5. Insert Anchors
    55. 56. 6. Pass Sutures
    56. 57. 7. Secure Fixation
    57. 58. Complete the Repair
    58. 59. <ul><li>Difficult to recognize </li></ul><ul><li>Occurs even w/ “isolated” Bankart pathology </li></ul><ul><li>Addressed w/ apical stitch/plication </li></ul><ul><li>RI </li></ul>Glenoid IGHL 6 8. Address Capsular Patholaxity/Rotator Interval
    59. 60. <ul><li>Questions </li></ul><ul><li>How to know when it is deficient? </li></ul><ul><li># sutures? </li></ul><ul><li>Mono or braided? </li></ul><ul><li>Arm Position? </li></ul>Rotator Interval
    60. 61. <ul><li>3 wks immobilization </li></ul><ul><li>Progressive ROM, strength </li></ul><ul><li>RTA 4-6 months </li></ul>Post-op Rehabilitation
    61. 62. 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
    62. 63. 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
    63. 64. 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
    64. 65. 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
    65. 66. Caution
    66. 67. <ul><li>Recurrent instability </li></ul><ul><li>Uncommon </li></ul><ul><ul><li>Loss of Motion </li></ul></ul><ul><ul><li>Implant-related problems </li></ul></ul><ul><ul><li>Nerve Injury </li></ul></ul>Complications
    67. 68. <ul><li>Most instability surgery can be performed w/ scope. </li></ul><ul><li>Don’t do arthroscopic procedure in pts with deficient capsule and sig bone defects </li></ul><ul><li>Consider arthroscopic repair for revision cases, HAGL lesions and contact/collision sports athletes. </li></ul><ul><li>Practice makes perfect </li></ul><ul><li>Good to excellent results in most cases. </li></ul>Summary
    68. 69. Thank You

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