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Shoulder Instability Sports - Decision Making

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Clinical and radiological assessment and decision making in the sporting shoulder.

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Shoulder Instability Sports - Decision Making

  1. 1. Lennard Funk Shoulder Instability in the Athlete Clinical & Radiological Assessment lenfunk@shoulderdoc.co.uk
  2. 2. www.wrightington.com My brief (10-15min): Clinical assessment of complex anterior and posterior instability. - with Video Radiological assessment of glenoid 
 and humeral bone loss. Management strategies 
 and decision making !2
  3. 3. www.wrightington.com !3 1 Sports Injuries of the Shoulder Lennard Funk Mike Walton Adam C. Watts Mike Hayton Chye Yew Ng Editors 1239 783030 230289 ISBN 978-3-030-23028-9 SportsInjuriesoftheShoulder This book provides a practical guide detailing the aetiology, diagnosis, relevant pathology, management principles, and out- comes of a variety of injuries to the shoulder including rotator cuff disorders, glenoid bone loss, and pectoralis major ruptures in both elite and non-elite athletes. Each chapter features clinical pearls and a question and answer section to emphasize key points. Sports Injuries of the Shoulder is an essential book for those seeking an up-to-date resource. It is aimed at sports doctors and musculoskeletal doctors; senior orthopedic trainees with an interest in upper limb and those preparing for the FRCSOrth exam and similar international exams, as well as surgeons with a particular interest in shoulder conditions. Lennard Funk · Mike Walton · Adam C. Watts · Mike Hayton Chye Yew Ng Editors Sports Injuries of the Shoulder Funk·Walton·Watts Hayton·YewNgEds.
  4. 4. www.wrightington.com Factors affecting RTP & Recurrence Age Type of Sport Level of Sport Laxity Pathology: Bone Loss ALPSA / HAGL !4
  5. 5. www.wrightington.com Clinical Assessment History: 1. Age; Level of sport; Position 2. Mechanism of Injury 3. Dislocation / Subluxation 4. Return to play? 5. Able to play? 6. Time of Season 7. Goals & Targets
  6. 6. www.wrightington.com Generalised Hypermobility Beighton Score Normal for young adult = 4-6. > 6 = hypermobility 1+2 3+4 5+6 7+8 9
  7. 7. www.wrightington.com !7 Anterior Instability 1. Apprehension • Position 2. Ant-Inf. Apprehension Sulcus
  8. 8. www.wrightington.com !8 Posterior Instability
  9. 9. www.wrightington.com !9 Posterior Instability
  10. 10. www.wrightington.com !10 Posterior Instability - Modifications
  11. 11. www.wrightington.com !11 1. Posterior Drawer • Position 2. WPIT / Modified O’Brein’s • Position 3. Kim’s Test • Position 4. Modifications Posterior Instability
  12. 12. www.wrightington.com Investigations X-Rays Bony Lesions- Bony Bankart, Hill-Sachs MR Arthrogram All lesions CT Scan Accurate assessment of: Bony deficiency Hill Sachs size CT Arthrogram Previous Surgery
  13. 13. www.wrightington.com MR Arthrogram Bone enhancing ABER in selected patients Radial Sequences !13
  14. 14. www.wrightington.com Radial Sequences !14 Cartesian (Rectilinear) Radial Sampling
  15. 15. www.wrightington.com How much glenoid loss 
 for Bony Reconstruction? 1. 10% 2. 15% 3. 20% 4. 25%
  16. 16. www.wrightington.com What is a significant Hill-Sachs Lesion? 1. 4cm long 2. 20% humeral head surface 3. 40% humeral head surface 4. Engaging at Arthroscopy
  17. 17. www.wrightington.com Balance Stability Angle - Matsen Effective Glenoid Arc = the area of the glenoid’s articular surface available for humeral head compression Balance Stability Angle = the angle between the centre of the glenoid and the end of the effective glenoid arc in any direction (18 degrees anterior) !17
  18. 18. www.wrightington.com Largest Track (contact) found in full ABER = 84% of glenoid width !18 ‘Glenoid Track’
  19. 19. www.wrightington.com Glenoid: Best fit circle (Huysmans) !19 Humerus: Hill-Sachs on coronal GT = 0.84xD-d HS D d 1.If HS > GT, the HS is ‘off track’, or engaging. 2.If HS < GT, the HS is ‘on track’, or non-engaging. Simplified: Not validatedTokish et al. 2015
  20. 20. www.wrightington.com Two year period of 57 Bankart repairs On-track (49) - recurrence 4% Off-track (8) - recurrence 75% PPV for Glenoid Track = 75% PPV for Glenoid loss >20% = 43% !20
  21. 21. www.wrightington.com My Approach - Glenoid !21
  22. 22. www.wrightington.com My Approach - Humerus Funky Pizza Method !22
  23. 23. www.wrightington.com !23
  24. 24. www.wrightington.com MR Arthrogram Six-series: Bone enhancing T1 + FS (Axial & coronal) !24 GLENOID HILL-SACHS No bony lesion < 12.5% Arthroscopic repair No bony lesion > 12.5% Arth repair & Remplissage Any bony lesion < 25% Latarjet Any bony lesion > 25 - 40% Latarjet & Remplissage Any bony lesion > 40% Latarjet & Allograft
  25. 25. Physician Experience Facilities Evidence Preference www.wrightington.com Decision Making !25 Profession Time of Season Career Targets Economics Social Factors Pathology Glenoid Loss Hill-Sachs HAGL Cuff Tear Player Position Preference Previous Injuries Age
  26. 26. www.wrightington.com My brief: Clinical assessment of complex anterior and posterior instability. - with Video History; Exam (positions) Radiological assessment of glenoid and humeral bone loss. MRA vs CTA: Radials Assessing Bone Loss Management strategies and decision making 1. Patient 2. Profession 3. Pathology 4. Physician !26
  27. 27. www.wrightington.com !27 “Soap and water 
 and common sense are the best disinfectants” William Osler

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