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Traumatic glenohumeral instability final

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Traumatic glenohumeral instability final

  1. 1. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar, Scapular Dyskinesis related to shoulder pathology Athens, 9&10 June 2017 . Manos Antonogiannakis Orthopaedic Surgeon Director of 3rd Orthopaedic Department Centre for Arthroscopy & Shoulder Surgery Hygeia General Hospital Traumatic glenohumeral instability
  2. 2. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 The Shoulder  Greatest Range of Motion in the Body  Motion in all 3 planes of movement  Prone to instability Sacrifices stability for mobility
  3. 3. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 What is Instability  Biomechanical Dysfunction  Failure of static and dynamic stabilizers  Ranges from mild subluxation to traumatic dislocation
  4. 4. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 T.U.B.S. Traumatic Unidirectional Bankart lesion Surgery A.M.B.R.I. Atraumatic Multidirectional Bilateral Rehabilitation Inferior capsular shift A.I.O.S. Acquired Instability Overstress Surgery Instability Profiles
  5. 5. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 The most common presentation A patient with some degree of laxity genetically controlled dislocates his shoulder after a minor or major accident
  6. 6. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 History: degree of violence Level of athletic participation number of dislocations Age of the patient Clinical examination: Generalized joint laxity direction of apprehension dictates treatment
  7. 7. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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
  8. 8. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 So what makes a shoulder unstable Degree of trauma and anatomic damage Muscular dysfunction Level of athletic activity We must act in all of them
  9. 9. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Bone Defects  Glenoid side  Humeral side
  10. 10. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Humeral Bone Defects Hill-Sachs lesion
  11. 11. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 The combination of the lesions No Bone Loss Arthroscopic Bankart Repair Glenoid Bone Loss > 25% Arthroscopic Bankart Repair + Bone grafting procedure
  12. 12. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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?
  13. 13. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Humeral Bone Defects Engaging Non Engaging
  14. 14. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Engaging Hill Sachs
  15. 15. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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
  16. 16. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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 Group Glenoid Defect Hill-Sachs Lesion Recommended Treatment 1 <25% On track Arthroscopic Bankart repair 2 <25% Off track Arthroscopic Bankart repair plus remplissage 3 >25% On track Latarjet procedure 4 >25% Off track Latarjet procedure with or without humeral sided procedure (humeral bone graft or remplissage), depending on engagement of Hill-Sachs lesion after Latarjet procedure
  17. 17. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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 a 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.
  18. 18. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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.
  19. 19. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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 How to Determine Whether Hill-Sachs Lesion Is “On Track” or “Off Track” 1. Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from 3D CT scan 2. Determine the width of the anterior glenoid bone loss (d). 3. Calculate the width of the glenoid track (GT) by the following formula: GT = 0.83 D - d. 4. Calculate the width of the HSI, which is the width of the Hill-Sachs lesion (HS) plus the width of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the Hill-Sachs lesion: HSI=HS + BB. 5. If HSI > GT, the HS is off track, or engaging. If HSI < GT, the HS is on track, or non-engaging.
  20. 20. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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
  21. 21. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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
  22. 22. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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
  23. 23. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Hill- Sachs Remplissage: An arthroscopic surgical solution for the engaging Hill-Sachs E.M. Wolf Remplissage
  24. 24. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Remplissage
  25. 25. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 From January 2007 to December 2010 (4 years) 48 patients Average age: 28.9 ± 7.8 years Average fu: 37.2 ± 9.9 months Recurrence percentage: 6.3%
  26. 26. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  27. 27. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Inclusion criteria  Traumatic unidirectional anterior shoulder instability  Hill-Sachs lesion of the humeral head  Evidence of engaging Hill-Sachs lesion during dynamic evaluation under arthroscopy  Arthroscopic Bankart repair in conjunction with arthroscopic remplissage  Follow-up period longer than 2 years Exclusion criteria  Anterior glenoid rim defect or fracture exceeding 25% of the inferior glenoid diameter confirmed intra-operatively  Humeral avulsion of the glenohumeral ligaments (HAGL) detected intra-operatively  Psychological disease or epilepsy
  28. 28. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Parameter Pre-operatively Latest Follow-up Difference P value Active forward flexion mean value ± standard deviation 170 ± 25.8 degrees 179 ± 3.1 degrees + 9 degrees n.s. External rotation beside the body mean value ± standard deviation 73.6 ± 23.0 degrees 78.1 ± 13.1 degrees + 4.5 degrees n.s. External rotation at 90 degrees of abduction mean value ± standard deviation 89.2 ± 25.9 degrees 85.4 ± 9.3 degrees - 3.8 degrees n.s. Internal rotation median value, range T10 level (range, T6-L2) T10 level (range, T7-T12) Same level n.s. Mean ASES score mean value ± standard deviation 67.7 ± 21.5 90.8 ± 21.7 + 23.1 p<0.01 Mean Rowe-Zarins score mean value ± standard deviation 38 ± 17.3 93.8 ± 14.5 + 55.8 p<0.001 Mean Oxford Instability score mean value ± standard deviation 27.6 ± 11.1 45.1 ± 8.3 + 17.5 p<0.01
  29. 29. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  30. 30. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 The outcome of the enhancement of the classic Bankart repair with tenodesis of the infraspinatus and posterior capsular plication is very good as far as the management of recurrent anterior shoulder instability is concerned, without significantly influencing the range of motion of the shoulder
  31. 31. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Glenoid Bone Defects
  32. 32. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 The inferior 2/3 of the glenoid is nearly a perfect circle with avg diameter 24mm Huysman et al. JSES 2006
  33. 33. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim
  34. 34. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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
  35. 35. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 >25 – 30% bone loss 6.5 – 8.6mm AP width Inverted pear appearance Bone block procedures Piasecki et al. AAOS J17 (8): 482. (2009)
  36. 36. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Bone loss <15% (0-3.5mm) of AP width Soft tissue repair incorporating the bone fragment if possible Piasecki et al. AAOS J17 (8): 482. (2009)
  37. 37. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017  Glenoid Index in 3D CT scan of both shoulders  Critical Limit Glenoid index 0.75 SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382
  38. 38. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017  Taverna et al. Pico Method 2D CT – measurement of glenoid surface Critical Limit 25% loss of glenoid surface
  39. 39. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  40. 40. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017  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
  41. 41. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Sugaya et al. JBJS Am 2005
  42. 42. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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
  43. 43. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017  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%)
  44. 44. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 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
  45. 45. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Glenoid Bone Loss >25% Arthroscopic Latarjet procedure L. Lafosse Arthroscopic shoulder stabilization with a bone block E. Taverna
  46. 46. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  47. 47. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  48. 48. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 E.Taverna, et.al,Knee Surg Sports Traumatol Arthrosc (2008) 16:872–875
  49. 49. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  50. 50. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  51. 51. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  52. 52. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 3 months Post-op
  53. 53. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  54. 54. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 3 months Post-op
  55. 55. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 3 months Post-op
  56. 56. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Arthroscopic Bone Block combined with Remplissage
  57. 57. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Our Results 15 cases Impressive early outcomes
  58. 58. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Bushnell BD, Creighton RA, Herring MM. Hybrid treatment of engaging Hill-Sachs lesions: Arthroscopic capsulolabral repair and limited posterior approach for bone-grafting. Tech Shoulder Elbow Surg 2007;8:194-203.
  59. 59. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Humeral head resurfacing for fixed anterior glenohumeral dislocation. Int Orthop 2007 Dec 19 [Epub ahead of print]
  60. 60. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Posterior instability clinical presentation 1. Sense of insecurity and feeling of instability in forward flexion and internal rotation 2. Locked posterior dislocation with loss of external rotation
  61. 61. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Locked posterior dislocation is easily missed
  62. 62. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  63. 63. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  64. 64. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017
  65. 65. www.shoulder.gr Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Athens Seminar - Scapular Dyskinesis related to shoulder pathology E. Antonogiannakis 09.06.2017 Thank you for your attention!!! Save the date: 1-3 February 2018

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