Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Arthroscopic Stablization Cherry Blossom Final 2009

1,082 views

Published on

Published in: Health & Medicine, Technology
  • Be the first to comment

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

×