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αρθροσκοπική αποκατάσταση οστικών ελλειμμάτων τελικο

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αρθροσκοπική αποκατάσταση οστικών ελλειμμάτων τελικο

  1. 1. www.shoulder.gr Αρθροσκοπική αποκατάσταση οστικών ελλειμμάτων ωμογλήνης με λαγόνιο μοσχευμα Μάνος Αντωνογιαννακης Ορθοπαιδικός Χειρουργός Διευθυντής Γ΄Ορθοπαιδικής Κλινικής - Κέντρου Αρθροσκόπησης & Χειρουργικής Ώμου Γενικό Νοσοκομείο Υγεία
  2. 2. www.shoulder.gr Shoulder dislocation With Bone Defects Disclosures Zimmer Biomet SportsMed course - Invited Speaker 7th Balkan Congress of Arthroscopy, Sports, Traumatology & Knee Surgery Thessaloniki 2016 .
  3. 3. www.shoulder.gr The Shoulder  Greatest Range of Motion in the Body  Motion in all 3 planes of movement  Prone to instability Sacrifices stability for mobility
  4. 4. www.shoulder.gr What is Instability  Biomechanical Dysfunction  Failure of static and dynamic stabilizers  Ranges from mild subluxation to traumatic dislocation
  5. 5. www.shoulder.gr Contributors to stability Static stabilizers 1. ligamentous structures labrum and capsule 2. bony configuration of glenoid and humeral head Dynamic stabilizers 1. rotator cuff 2. scapula muscles
  6. 6. www.shoulder.gr Bone Defects  Glenoid side  Humeral side
  7. 7. www.shoulder.gr Humeral Bone Defects Hill-Sachs lesion
  8. 8. www.shoulder.gr Humeral Bone Defects Engaging Non Engaging
  9. 9. www.shoulder.gr Engaging Hill Sachs
  10. 10. www.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart A.Three-dimensional CT scan with en face view of a normal glenoid, with subtraction of the humeral head The width of the glenoid track without a glenoid defect is 83% of the glenoid width. B. Relation of glenohumeral joint in abduction and external rotation. The distance from the medial margin of the contact area (M) to the medial margin of the cuff footprint (F) is 83%±14% of the glenoid width: F - M = 83% of glenoid width = glenoid track.
  11. 11. www.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart A. 3D CT scan with en face view of a glenoid with bone loss of width d. In such a case with glenoid bone loss, the glenoid track will be 83% of the normal glenoid width minus d. B. Relation of glenohumeral joint in abduction and external rotation. One should note the loss of contact of the intact humeral articular surface with the articular surface of the glenoid. In this case the large Hill-Sachs interval (i.e., distance from posterior rotator cuff attachments to medial margin of Hill- Sachs lesion) is wider than the glenoid track, whose width has been reduced because of the glenoid bone loss.
  12. 12. www.shoulder.gr From engaging Hill Sachs to On-track & Off-track lesions No Bone Loss Arthroscopic Bankart Repair Glenoid Bone Loss > 25% Arthroscopic Bankart Repair + Bone grafting procedure What happens in between? It is the combination of the existing lesions Large Hill-Sachs lesion + No glenoid bone loss = Small Hill-Sachs lesion + 15% -20% glenoid bone loss
  13. 13. www.shoulder.gr Hill- Sachs Remplisage: An arthroscopic surgical solution for the engaging Hill-Sachs E.M. Wolf Remplissage
  14. 14. www.shoulder.gr
  15. 15. www.shoulder.gr
  16. 16. www.shoulder.gr Glenoid Bone Defects
  17. 17. www.shoulder.gr The inferior 2/3 of the glenoid is nearly a perfect circle with avg diameter 24mm Huysman et al. JSES 2006
  18. 18. www.shoulder.gr Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim
  19. 19. www.shoulder.gr Loss of 8.6mm of anterior radius of glenoid at the level of the bare spot corresponds to 35% of the normal anteroposterior width Lo, Burkhart Arthroscopy 2004
  20. 20. www.shoulder.gr >25 – 30% bone loss 6.5 – 8.6mm AP width Inverted pear appearance Bone block procedures Piasecki et al. AAOS J17 (8): 482. (2009)
  21. 21. www.shoulder.gr  Glenoid Index in 3D CT scan of both shoulders SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382
  22. 22. www.shoulder.gr  Taverna et al. Pico Method 2D CT – measurement of glenoid surface Critical Limit 25% loss of glenoid surface
  23. 23. www.shoulder.gr Our practice The percentage of the glenoid defect was evaluated on the en face reconstructed view with the humeral head eliminated Sugaya et al (2005) Joint Surg Am
  24. 24. www.shoulder.gr Glenoid Bone Loss >25% Arthroscopic Latarjet procedure L. Lafosse Arthroscopic shoulder stabilization with a bone block E. Taverna
  25. 25. www.shoulder.gr
  26. 26. www.shoulder.gr E.Taverna, et.al,Knee Surg Sports Traumatol Arthrosc (2008) 16:872–875
  27. 27. www.shoulder.gr
  28. 28. www.shoulder.gr
  29. 29. www.shoulder.gr
  30. 30. www.shoulder.gr
  31. 31. www.shoulder.gr
  32. 32. www.shoulder.gr
  33. 33. www.shoulder.gr
  34. 34. www.shoulder.gr Arthroscopic Bone Block combined with Remplissage
  35. 35. www.shoulder.gr 3 months Post-op
  36. 36. www.shoulder.gr
  37. 37. www.shoulder.gr 3 months Post-op
  38. 38. www.shoulder.gr 3 months Post-op
  39. 39. www.shoulder.gr  6 months Post-op
  40. 40. www.shoulder.gr OUR EXPERIENCE 23 cases Impressive early outcomes
  41. 41. www.shoulder.gr OUR RESULTS 23 patients (22M, 1F)  Average age: 32.87 (range 18-51)  Average fu: 6,8 months (range 2-24)  Dominant side : 60.87% (14/23)  21 sport, (17 recreational, 4 competition)  General laxity: 15/24  Average glenoid bone loss : 10,5 %  Average Hill-Sachs : 2,25 cm
  42. 42. www.shoulder.gr FUNCTIONAL RESULTS Recurrence Rate 0% Walch-Duplay Score (max 100 points) 94,2 ± 4 ,3 SD (range 85 – 100) Rowe Score (max 100 points) 84,2 ± 6,4 SD (range 70 – 100) ASES ( max 100 points ) 87,8 ± 12,1 SD (range 83 – 100) SD: Standard Deviation
  43. 43. www.shoulder.gr 76 78 80 82 84 86 88 ASESPRE ASESPOST 81 87,8
  44. 44. www.shoulder.gr 0 10 20 30 40 50 60 70 80 90 ROWEPRE ROWEPOST 45,2 84,2
  45. 45. www.shoulder.gr 0 5 10 15 20 25 30 35 40 OXFPRE OXFPOST 25,7 39,3
  46. 46. www.shoulder.gr 0 10 20 30 40 50 60 70 80 90 100 WALCHPRE WALCHPOST 54,5 94,2
  47. 47. www.shoulder.gr 170 172 89 78 82 73 0 20 40 60 80 100 120 140 160 180 200 FF PRE-OP FF POST- OP EXT90 PRE-OP EXT90 POST-OP EXT0 PRE- OP EXT0 POST-OP
  48. 48. www.shoulder.gr Preliminary outcomes  Impressive outcomes  BUT Mean follow up 6.8 months  Pain free full ROM after 4 months ( 2 pts with stiffness resolution at 5 & 6 months respectively)
  49. 49. www.shoulder.gr Complications  2 haematoma at the incision for the bone graft self -resolution between 3-6 weeks after surgery  2 fractures of bone , stabilized with 1 button but healed in proper position  No bone block absorption
  50. 50. www.shoulder.gr Bone Block VS Soft Tissue Repair • Lower Recurrence Rate • Anatomic Reconstruction of boney and soft tissue lesions
  51. 51. www.shoulder.gr Bone Block VS Bristow-Latarjet • Anatomical Procedure • No tendineous transfer • No Subscapularis split • Perfect position of the glenoid boney tunnels thanks to the guide
  52. 52. www.shoulder.gr Bone Block VS Bristow-Latarjet • No complications due to hardware (use of screws) • No major neurovascular complications • Βridges are not burned in case of reccurence
  53. 53. www.shoulder.gr Bone Block Technique: limits BB weak point: Capsular-labrum- ligaments Inconsinstency. Bone defects Arthroscopically assisted Latarjet procedure Conversion to
  54. 54. www.shoulder.gr
  55. 55. www.shoulder.gr 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
  56. 56. www.shoulder.gr  Total group: 194 patients  173 pt without significant bone defects : 7 pt sustained a recurrence (4%)  21 pt with significant bone defects: 14 pt developed rec instability (67%)
  57. 57. www.shoulder.gr 23 pt active military personel, 25y mean age 20-30% bone loss 7mm of ap width 34months mean fu, 14.2% rec rate Mologne et al. AJSM 2007

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