give current concept in management of shoulder dislocation,take refernce of reviews article

1. CURRENT CONCEPT IN
SHOULDER
DISLOCATION
DR CHANDU
JUNIOR RESISDENT
DEPARTMENT OF ORTHOPEDICS JIPMER ,PUDDUCHERY

2. OBJECTIVES
• GLENOID TRACK : SIGNIFICANCE
• RECENT REVIEWS ON SURGICAL TECHNEQUES AND SUCCESS RATE
• MODIFICATION IN CLASSIC LATERJET AND EDEN HYBINETTE SURGERY
• ROLE OF 3D PRINTING IN SHOULDER INSTABILITY
• ? DISTANCE TO DISLOCATION

3. GLENOID TRACK AND ITS ROLE IN EVALUATING
BONE LOSS
• Studies have shown that glenoid- and humeral-sided bone loss may be present in
up to 73-93% of individuals with recurrent anterior shoulder instability.
• As the amount of bone loss drives surgical decision making and influences
outcomes. Methods to describe and measure bone loss have changed over time.
Originally, glenoid and humeral bone loss were viewed separately.
• However, the concepts of bipolar bone loss, the glenoid track (GT), and "on/off-
track" lesions arose, highlighting the interplay between the two entities in
contributing to recurrent instability.

4. • important evolving concept in the management of shoulder instability is bipolar
bone loss
• both the glenoid and humeral head act synergistically to increase risk of
recurrence
• The concept of the glenoid track was defined in 2007 by Yamamoto et al.
• zone of contact between the glenoid and humeral head when the arm is elevated
along a “track” from the inferomedial to the superolateral aspect of the posterior
articular surface of the humeral head

5. • This track consists of approximately 83% of the glenoid width
• important consideration when evaluating the size and location of Hill-Sachs
lesions
• ON TRACK /Non engaging : if HILL-SACHS lesion fall within glenoid track
• OFF TRACK/ engaging : if Hill-sachs lesion fall out off track
• supported by meny studies eg Shaha et al. ( isolated bankard repair ) , Locher et
al.

6. CALCULATION ( GLENOID TRACT ,HILL SACHS
INTERVAL
• GT = 0.83D − d
• HIS = HS + BB
( D = glenoid diameter around inferior circular portion
d= anterior bone loss
HS = hill-sachs
BB = bony bridge
GT > HIS = ON TRACK
GT < HIS =OFF TRACK

8. CALCULATIONS

12. ARTHROSCOPIC BANKART REPAIR WITH CAPSULAR
SHIFT (BR)
• According to recent surveys, 90% of surgeons would use BR as the initial repair
procedure in Germany, the Netherlands and Great Britain
• arthroscopic Bankart repair was the treatment of choice for 93% of survey
participants in 2016 compared to 66% in a survey in 2001
• High patient satisfaction and Return to sport have been documented after BR
but there is evidence of a high recurrent dislocation rate over time associated
with risk factors

14. TECHNIQUE
• The arthroscopic technique is performed by releasing the capsuloligamentous
complex and freshening up the insertion of the labrum.
• Capsule and labrum are then repaired with suture anchors to create an
anatomical reconstruction
• Position preferred : lateral

15. ARTHROSCOPIC BANKART WITH HILL–SACHS
REMPLISSAGE (BR+R)
• Wolf described the arthroscopic remplissage as a solution for the difficult
problem of an engaging Hill–Sachs lesion by adding a Hill–Sachs remplissage
procedure to a standard arthroscopic Bankart repair.
• Techneque :
• The postero-superior capsule and the infraspinatus tendon are anchored and
sutured in the Hill–Sachs lesion which is transformed into an extraarticular lesion
preventing it from engaging at the anteroinferior glenoid rim.

16. • A systematic review in 2020 compared BR+R with bone block augmentation
(Latarjet) in patients with bipolar bone loss.
• 10–15% of mean glenoid bone loss, there was an increased rate of recurrent
instability for BR+R (6.1–13.2%) compared to bony augmentation (0–8.2%).
• The authors conclude that BR+R should be reserved for engaging Hill–Sachs
lesions (off-track) associated with glenoid bone loss of less than 10%

17. • A meta-analysis in 2018 concluded that isolated BR was significantly inferior to
BR+R for recurrence of instability and redislocation.
• In a retrospective cohort study, Feng et al. found a significantly higher RTS (100
vs 84.2%) and a return to the same level of sport rate (77.8 vs 50%) for patients
who underwent arthroscopic Bankart repair with the addition of a remplissage
procedure compared to patients with a Bankart repair alone.

18. • In 2020, Mac Donald et al. reported the results of a randomized controlled trial
comparing arthroscopic Bankart repair with or without a remplissage for patients
with a Hill–Sachs lesion of any size with glenoid bone loss of less than 15%, with
a minimum follow-up of 2 years .
• Conclusion : Adding a remplissage significantly decreased the risk for recurrent
dislocation from 18 to 4%.

19. • Bah et al. compared patients with chronic instability and significant Hill–Sachs
lesions treated with either BR+R or an open Latarjet procedure. There was no
significant difference in recurrent instability but decreased external rotation (ER)
and increased residual pain in the Bankart + Remplissage group .
• Therefore, BR + Remplisage is not recommended in throwers requiring maximal
ER.

20. • There is evidence that the addition of a remplissage increases the stability,
reducing the risk of recurrence after an arthroscopic Bankart repair. Return to any
sport and return to the same level of sport are also higher with the addition of a
remplissage.
• There may be increased post-operative pain and stiffness with decreased
rotation. When comparing BR+R to the Latarjet procedure, some authors
recorded a lower number of postoperative complications for BR+R, but this may
be biased by experience and expertise with the Latarjet procedure.

21. FREE BONE BLOCK PROCEDURE
• Resch’s group from Salzburg, Austria, popularized the J-bone graft for anatomical glenoid
reconstruction in recurrent posttraumatic anterior shoulder dislocation with bone loss.
• Techneque :
The J-graft is harvested from the iliac crest.
A shoulder arthrotomy and tenotomy of the subscapularis tendon
an osteotomy 5 mm medial to the glenoid rim and angled 30° to the glenoid plane with a 15 mm
wide chisel
impacting the J-graft
Give : primary stability in most cases (94%) without an additional screw

22. • Moroder et al. published the long-term follow-up (minimum of 15 years) of 35
shoulders with excellent stability (1 dislocation), but 23% of patients had
persistent apprehension. There was no instability arthropathy in 24 shoulders
(69%), mild arthropathy in 23%, moderate arthropathy in 6% and severe
arthropathy in 1 shoulder.
• A randomized controlled trial did not show a clinically relevant difference
between a standardized open Latarjet procedure and the J-bone graft technique
for a short follow-up time of a minimum of 2 years

23. • Frank et al. reported similar clinical outcomes for their technique using fresh
distal tibial allograft to a Latarjet procedure in a cohort study of 100 patients.

24. LATARJET–PATTE WITH WALCH’S TECHNIQUE
• After 40 years of clinical practice with over 4000 procedures and publication of
excellent long-term outcomes for different patient cohorts, the open Latarjet–Patte
with Walch’s technique can be considered the most standardized of Latarjet
procedures.
• Techneque :
subscapularis split and coracoid transfer
corocoid placed flat on the anterior surface of the scapula with its broad flattened
under surface and fixed with two screws.
The coracoacromial ligament stump is repaired to the vertical anterior capsulotomy in
ER of the arm

25. TRIPLE EFFECT FIRST
DESCRIBED BY PATTE
(i) Bone augmentation by the coracoid process
(ii) Sling effect by the conjoint tendon and
hammock effect of the lower portion of the
subscapularis and
(iii) Capsular repair with the coracoacromial
ligament stump

26. • The procedure was modified by Walch who used a subscapularis split and two
screws allowing for rotationally stable fixation of the bone block and immediate
postoperative range of motion in ER.
• A capsular shift and labral repair are not required . Capsular repair to the glenoid
or directly to the bone block has been advocated but may reduce ER.

27. • In 2000, Walch published a recurrent dislocation rate of 1% in a series of 126 patients
with a 3-year follow-up . In 2011, the same recurrence rate for dislocations of 1% in
over 2000 patients was reported for his patients . The RTS rate was 83%. Good or
excellent satisfaction was reported for 98% of patients who self-rated their results.
According to the modified Rowe score, 76% of patients achieved good or excellent
results.
• Gerber’s group used the Latarjet technique described by Walch and reported a 1%
dislocation recurrence at a minimum follow-up of 6 years . Gerber’s patients were
equally satisfied as Walch’s patients with an SSV of 96.8 and 98%, respectively, and it
has been shown that these results can be reproduced after fellowship training and
meticulous standardization of the technique.

28. REVISION OF FAILED INSTABILITY SURGERY
• In 2020, Lau et al. performed a systematic review of revision surgery after failed
instability surgery including 1110 revision cases over several studies
Surgery Instability recurrence
Laterjet 3.8%
Open repair 13.4%
Arthroscopic bankart revision 16%
Bone block revisions 20.8
Capsular recontruction 31%

29. • Additional revision surgery was performed in 23% of cases after capsular
reconstruction, 9% after BR and 9% after open repair compared to 0.02% after
Latarjet revision cases.
• The data underline that recurrent instability is a problem in instability revision
surgery if not performed by a Latarjet procedure, which outperformed all other
techniques.
• this study also saw that There is no evidence for differences in osteoarthritis rates
between BR and the Latarjet

30. SUMMARY
• in patients with risk factors, BR has higher failure rates than BR+R, BR with bone
grafts and the Latarjet procedure.
• Patients at the highest risk of failure are young patients and those with bone loss and
The amount of bone loss
• Recurrence rates are higher in BR and RTS may be quicker with the Latarjet.
• Instability arthropathy is associated with the number of previous dislocations as well
as surgical technique.
• Latarjet procedures do not seem to increase the risk of osteoarthritis if the bone
block is not lateralized.

35. LATERJET
• Congruent Arc Latarjet (in which the coracoid is rotated 90°, placing its inferior
surface parallel to the surface of the glenoid) corrects glenoid defects upto 40%
compare to the classic Latarjet corrects glenoid defects from 10 to 25%.

37. ILIAC CREST BONE GRAFT(EDEN HYBINETTE)
• Proponents of the Latarjet consider that the additional dynamic sling effect of the
conjoint tendon and the requirement of not having to use an iliac crest autograft
are favorable aspects over an Eden-Hybinette procedure.
• recent development of a suture-button fixation technique using a posterior drill
guide system that allows for accurate drill tunnel placement and can be used
both open and arthroscopically has revived interest in the Eden-Hybinette
procedure.

38. • The arthroscopic procedure has the advantage over both an open and
arthroscopic Latarjet procedure as, due to the flexibility of sutures, it can be
undertaken as a purely intra-articular procedure through the rotator interval
without compromising subscapularis.
• Similar techniques using suture tape cerclage to secure the bone block, avoiding
the use of any metalwork, have also been described .
• Additionally, human allograft and equine xenograft bone blocks have also been
used to avoid donor site morbidity .

41. • A study in 2018 described the results of 26 patients with recurrent anterior
instability with bone loss that underwent an arthroscopic Eden-Hybinette
procedure using suture-button fixation . At an average follow-up of 29.6 months
(range 24–30) none of the patients had had a re-dislocation with an average
Rowe score of 96.4 (SD 6.5) and Walch-Duplay of 93.2 (SD 7.8). The average loss
of external rotation, compared to the non-operated side, was 4.40 (SD 8.70), and
92.3% of the grafts had healed on CT scan.

42. • In the revision setting, when using the Eden-Hybinette procedure for a failed coracoid
transfer, the guided suture-button fixation system has some advantages over the
more traditional screw fixation.
• By undertaking an arthroscopic procedure through the rotator interval only, no
dissection of the anterior surface of the subscapularis, where the anatomy will be
distorted, or a further split of the subscapularis, which may compromise its function,
are required.
• Additionally, if there is any retained hardware in the glenoid, a “safe trajectory” for
the drill-guide and drill holes, which are of a smaller diameter than screws, can be
pre-planned to avoid the hardware.

44. • With the evolutions to these recent Eden-Hybinette procedure , there is an
increase in its use to treat primary anterior glenoid bone loss.
• While suture-button fixation can be used for both a Latarjet and an Eden-
Hybinette procedure, the ability to undertake the Eden-Hybinette procedure
arthroscopically through the rotator interval, without compromising
subscapularis or distorting the anatomy, are a significant advantage.

45. 3D printing in the treatment of
glenohumeral instability
• Surgeons are used to working with X-rays, 2D CT scans , and
magnetic resonance images to evaluate patients’ anatomy.
• With emerging 3D renderings improve the diagnostic of some
pathologies and deformities
• .

46. • They allow the surgeon to define the optimal implant location better
and accurately execute the surgical plan decreasing errors related to
implant malposition .
• Three-dimensional printing will undoubtedly become an essential
tool to achieve the best results in glenohumeral instability surgery.

47. 3D PRINTED MODEL OF A HUMERAL HEAD DEFECT

48. 3D PRINTED MODEL OF A GLENOID WITH THE
LOCATION FOR SCREWS AND A 3D PRINTED
MODEL OF A PATIENT-SPECIFIC GUIDE TO
POSITION THE SCREW

50. DISTANCE TO DISLOCATION (DTD)
GT > HIS = ON TRACK
GT < HIS =OFF TRACK
GT =HIS : ????

52. DISTANCE TO DISLOCATION (DTD)
• Classically, "off-track" lesions have been described as those Hill-Sachs interval
(HSI) greater than the GT, and have been shown to result in higher rates of re-
instability when addressed nonoperatively or with Bankart repair alone.
• More recently, further attention has been given to "on-track" lesions (HSI < GT).
The new concept of "distance to dislocation" (DTD) has gained popularity.
• DTD is calculated as the difference between the GT and HSI, and literature
evaluating DTD suggests that not all "on-track" lesions should be treated in the
same manner.
• On track lesion < 8mm of GT consider as off track lesion

54. BANKART VARIANTS

57. REFERENCES
• 1. Moya D, Aydin N, Yamamoto N, Simone JP, Robles PP, Tytherleigh-Strong G, et al. Current concepts in anterior
glenohumeral instability: diagnosis and treatment. SICOT-J. 2021;7:48.
• 2. DeFroda SF, Perry AK, Bodendorfer BM, Verma NN. Evolving Concepts in the Management of
Shoulder Instability. Indian J Orthop. 2021 Apr;55(2):285.
• 3. S B, P C, Ma Z, L N, Wg B. Current concepts in chronic traumatic anterior shoulder instability. EFORT Open Rev
[Internet]. 2023 Jun 8 [cited 2024 May 8];8(6). Available from: https://pubmed.ncbi.nlm.nih.gov/37289134/
• 4. Zj H, Em N, L K, Rp R, M C, Jd H, et al. Bipolar bone loss and distance to dislocation. Ann Jt [Internet]. 2024 Jan
5 [cited 2024 May 7];9. Available from: https://pubmed.ncbi.nlm.nih.gov/38529290/

58. • THANKS