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New developments in shoulder arthroscopy

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New developments in shoulder arthroscopy

  1. 1. www.shoulder.grwww.shoulder.gr Manos Antonogiannakis Head B’ Orthopaedics Dept - Center for Shoulder Arthroscopyr IASO GENERALHospital New Developments in Arthroscopic Surgery of the Shoulder
  2. 2. www.shoulder.grwww.shoulder.gr Bones and Joints of the Shoulder Girdle
  3. 3. Labrum www.shoulder.gr
  4. 4. Arthroscopic Shoulder Surgery can adress a wide spectrum of shoulder pathology regarding the painfull shoulder the unstable shoulder
  5. 5. Painful Shoulder may include  Subacromial Impingement  Rotator Cuff Tears  Biceps Tendinosis - Instability - Tear  Calcific Tendinitis  Frozen Shoulder  SLAP lesions  Synovitis, Arthritis of the glenohumeral Joint  AC arthritis, tear of the intraarticular meniscus  Suprascapular Nerve Entrapment  Atraumatic Shoulder Instability - Internal Impingement
  6. 6. Unstable Shoulder  Anterior Glenohumeral Instability  Posterior Glenohumeral Instability  Multidirectional
  7. 7. SUBACROMIAL IMPIGEMENT Muscle imbalance loss of centralization of the humeral head
  8. 8. A Hooked Acromion Predisposes to impingement
  9. 9. SUBACROMIAL IMPIGEMENT
  10. 10. www.shoulder.grwww.shoulder.gr Acromioplasty
  11. 11. Painfull structures around the glenohumeral joint Long Head of Biceps Pathology Tendinitis
  12. 12. Biceps tenodesis or tenotomy
  13. 13. Radiographs
  14. 14. Arthroscopic Removal
  15. 15. Normal Shoulder
  16. 16. Frozen Shoulder
  17. 17. Painfull structures around the shoulder A.C. Joint Arthritis
  18. 18. Removal of Distal Clavicular End
  19. 19. www.shoulder.gr
  20. 20. Normal Rotator Cuff Rotates and stabilize the humeral head Side View
  21. 21. Anchor Repair
  22. 22. www.shoulder.grwww.shoulder.gr Partial Thickness Tear  Bursal side tears  Articular side tears  Intratendinus tears Partial tear classification by Ellman  Grade I <3mm deep  Grade II 3-6mm deep  Grade III>6mm deep (i.e. >50% thickness)
  23. 23. www.shoulder.grwww.shoulder.gr Partial Tears Treatment Options 1. Debride partial tear only 2. In-situ Repair 3. Convert to full thickness, Debride, Repair Etiology makes the decision!!!  Because most tears are degenerative, option 3 should be the best for most cases  Trauma or young athletes are candidates for in-situ repair  If partial tear causes significant pain then debridement alone [Yamaguch K, 2006 Nice Shoulder Course] www.shoulder.gr
  24. 24. www.shoulder.grwww.shoulder.gr Partial Tears In situ repair
  25. 25. www.shoulder.grwww.shoulder.gr COMPLETE TEARS  Small 1cm  Medium 2-3cm  Large 3-5 cm  Massive >5cm Cofield et all
  26. 26. www.shoulder.grwww.shoulder.gr Type Description Preoperative MRI Findings Treatment Prognosis 1 Crescent Short and wide tear End-to- bone repair Good to excellent 2 Longitudinal (L or U) Long and narrow tear Margin convergence Good to excellent 3 Massive contracted Long and wide > (2 x 2 cm) Interval slides or partial repair Fair to good 4 Cuff tear arthropathy Cuff tear arthropathy Arthroplast y Fair to good.
  27. 27. www.shoulder.grwww.shoulder.gr Patient Position Lateral decubitus my preferred position
  28. 28. www.shoulder.grwww.shoulder.gr Joint Side Inspection
  29. 29. www.shoulder.grwww.shoulder.gr Bursal Side Inspection-Bursectomy
  30. 30. www.shoulder.grwww.shoulder.gr Recognize the Tear Pattern Tears must be repaired in the direction of greatest mobility -> minimal strain The muscle-tendon junction must be 2-3 mm medial of the edge of the cartilage at the tuberosity after the repair
  31. 31. www.shoulder.grwww.shoulder.gr Tear Patterns  Crescent shaped  U-Shaped  L-shaped (or reverse L)  Massive Contracted Immobile tears S.S. Burkhart
  32. 32. www.shoulder.grwww.shoulder.gr Crescent-Shaped Tears Repair to bone with increased points of fixation  Double row repair ?  Single row triple loadead anchors  Mc Stitch configuration
  33. 33. www.shoulder.grwww.shoulder.gr
  34. 34. www.shoulder.gr
  35. 35. www.shoulder.grwww.shoulder.gr Double Row Fixation Restoration of the footprint
  36. 36. Medial Row - Matress Sutures - 2 anchors www.shoulder.gr
  37. 37. Lateral Row - Simple Sutures - 2 anchors www.shoulder.gr
  38. 38. www.shoulder.grwww.shoulder.gr Suture Bridge double row
  39. 39. www.shoulder.grwww.shoulder.gr L-Shaped & U-Shaped Tears  Side to side sutures from medial to lateral  Progressively converge the margin of the tear lateral to the bone bed  Closing 50% of a U-Shaped tear -> reduces strain at converge margin by a factor of 6 [S. S .Burkhart]
  40. 40. www.shoulder.grwww.shoulder.gr  Large U-shaped cuff tear extending to glenoid  Margin convergence  The free margin of the cuff is repaired to bone with suture anchors
  41. 41. www.shoulder.grwww.shoulder.gr U-Shaped tear: Margin covergence with side to side sutures
  42. 42. www.shoulder.grwww.shoulder.gr Massive Contracted Immobile Tears  No mobility from medial to lateral or from anterior to posterior  Represent 9.6% of massive tears [S.Burkhart]
  43. 43. www.shoulder.grwww.shoulder.gr Complete loss of active external rotation (external rotation lag ) is a bad prognostic factor Superior migration of the humeral head in contact with the acromion – repair attempt is going to be a failure Rotator Cuff Arthropathy What are the limits?
  44. 44. Latissimus Dorsi Transfer  The goal of the transfer is to use an internal rotator as an external rotator of the shoulder Subscapularis Lat. Dorsi
  45. 45. Latissimus Dorsi Transfer Indications  Intact Subscpularis  Intact Deltoid  No Stiffness
  46. 46. Arthroscopic Preparation
  47. 47. Surgical Field
  48. 48. Tendon preparation 3
  49. 49. Passage to subacromial space
  50. 50. Graft passage & fixation
  51. 51. Results - Literature  Pain relief with latissimus dorsi transfer found to be very satisfactory in all studies  Excellent or good results in about two-thirds of patients, provided subscapularis intact Aoki et al. JBJS (Br) 1996; 78: 761-766 Gerber et al. J Bone Joint Surg (Am) 2006; 88: 113-120 Iannotti et al. JBJS (Am) 2006; 88: 342-348
  52. 52. Other Options prior to RSA? Arthroscopic Implantation of inspace Baloon Biodegradable implant comprised of a co- polymer of poly-L_lactide- co-ε-caprolactone
  53. 53. Goal is to achieve painless ROM avoiding superior migration of the humeral head. Provides sufficient lever and tension to the Deltoid to produce forward flexion and abduction
  54. 54. Arthroscopic Implantation of Orthospace Baloon
  55. 55. Arthroscopic Implantation of Orthospace Baloon
  56. 56. Arthroscopic Implantation of Orthospace Baloon
  57. 57. Excessive motion Anterior Instability
  58. 58. Labrum & Ligaments Static stabilizers of the joint
  59. 59. Bankart Lesion
  60. 60. Engaging Non Engaging Burkhart SS, De Beer JF : Arthroscopy 2003;19 : 732–739 Hill-Sachs lesion Engaging Hill-Sachs Lesion
  61. 61. Bankart Lesion
  62. 62. AS portal view
  63. 63. Large Hill-Sachs
  64. 64. Glenoid ShapeGlenoid Shape The inferior 2/3 of the glenoid is nearly a perfect circleThe inferior 2/3 of the glenoid is nearly a perfect circle with avg diameter 24mmwith avg diameter 24mm Huysman et al. JSES 2006Huysman et al. JSES 2006
  65. 65. Normal Glenoid inverted pear Bony Bankart pear loss of anterior rim Compression Bankart
  66. 66. Critical LimitCritical Limit 6.8 mm width of resection 21% to total length of the6.8 mm width of resection 21% to total length of the glenoid - substantial loss of stabilityglenoid - substantial loss of stability Cadaveric biomechanical studyCadaveric biomechanical study Itoi et al. JBJS 2000Itoi et al. JBJS 2000
  67. 67. Quantification of Glenoid BoneQuantification of Glenoid Bone lossloss  Glenoid Index in 3D CT scan of both shouldersGlenoid Index in 3D CT scan of both shoulders  Critical Limit Glenoid index 0.75Critical Limit Glenoid index 0.75 SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382
  68. 68. What is the critical limit of GlenoidWhat is the critical limit of Glenoid Bone loss?Bone loss? Piasecki et al. AAOS J17 (8): 482. (2009) Bone loss <15% (0-3.5mm) of ap width Soft tissue repair incorporating the bone fragment if possible
  69. 69. What is the critical limit of GlenoidWhat is the critical limit of Glenoid Bone loss?Bone loss? >25 – 30% bone loss 6.5 – 8.6mm ap width Bone block procedures Piasecki et al. AAOS J17 (8): 482. (2009)
  70. 70. Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repairs: Significance of the Inverted-Pear Glenoid and the Humeral Engaging Hill-Sachs Lesion S.S. Burkhart and J. F. De Beer, M.D. Arthroscopy,October 2000
  71. 71.  Glenoid Bone Loss >25-30% Arthroscopic Latarjet procedure L. Lafosse Arthroscopic shoulder stabilization with a bone block E. Taverna Limitations of the Arthroscopic Techniques
  72. 72. New concepts in managing combined bone loss
  73. 73. Arthroscopy 2014
  74. 74.  Engaging Hill-Sachs-glenoid bone loss Limitations of the Arthroscopic Techniques Hill- Sachs Remplisage: An arthroscopic surgical solution for the engaging Hill-Sachs E.M. Wolf
  75. 75. Hill- Sachs Remplisage
  76. 76.  RemplissageRemplissage for large Hill-Sachsfor large Hill-Sachs
  77. 77. Arthroscopic LatarjetArthroscopic Latarjet Lafosse L, Arthroscopy, Vol 23, No 11 (November), 2007: pp 1242.e1-1242.e5 www.shoulder.gr
  78. 78. Arthroscopic Bone BlockArthroscopic Bone Block E.Taverna, et.al,Knee Surg Sports Traumatol Arthrosc (2008) 16:872–875
  79. 79. Arthroscopic Bone BlockArthroscopic Bone Block
  80. 80. Arthroscopic Bone Block combined withArthroscopic Bone Block combined with arthroscopic repair – Bankart -arthroscopic repair – Bankart - RemplissageRemplissage
  81. 81. www.shoulder.grwww.shoulder.gr Conclusions Evolution of Shoulder Arthroscopy Techniques and Materials provide solutions for the management of Shoulder Pathologies that could not be dealt with arthroscopy in the past. Nowadays the majoritry of shoulder pathology can be treated with the arthroscope It is not just a revolutionary technique It is a whole new concept of management of shoulder pathology a paradigm shift
  82. 82. www.shoulder.grwww.shoulder.gr Thank you for your attention
  83. 83. SLAP II SLAP IV

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