Transcript Shoulder instability 2 - Cambridge Orthopaedics

Surgical treatment of shoulder
sports injuries
Mr Lee Van Rensburg
United Kingdom
Objectives
• Surgical options for shoulder instability
– Glenohumeral
• Acute traumatic
• Recurrent traumatic
30 YO male,Professional Rugby payer,
Surgical options
Shoulder Instability
Hippocrates 400 BC
• method of reduction
• cauterisation of inferior
capsule
Bankart Lesion
• Perthes 1906
• Bankart 1938
– “essential lesion” of the capsulolabral complex
Uber operation bei habitueller
schulterluxation. Perthes G.
Dtsch Z Chir 1906
The pathology and treatment of recurrent
dislocation of the shoulder joint. Bankart B
Br J Surg 1938
Bankart Repair
• Bankart 1938
• 1st procedure 1923 on his
former House Surgeon
• re-attaching capsule to the
glenoid with transosseous
sutures
• repairing subscapularis
with NO overlap or
shortening
The pathology and treatment of recurrent dislocation
of the shoulder joint. Bankart A. Br J Surg 1938
Modified Open Bankart Repair
• Numerous modifications
- capsular imbrication
- suture anchors
• Multiple series published
• Accepted recurrence rate
Open Bankart Repair 8 –12%
• Loss of ER
Arthroscopic Stabilisation
• Johnson 1982
- Arthroscopic Staple Capsulorrhaphy
- Metal Staple
- 106 patients
- > 18 mth F/U
- 21% recurrence
Early complications of acute anterior dislocation of the
shoulder in middle-aged and elderly patients. Johnson
JR et al. Injury 1982
Staple Capsulorrhaphy
Lane et al 1993
- 54 patients Staple Capsulorrhaphy
- >39 month F/U
- 18 (33%) re-dislocated
- 36 stable – 15 % loose staple + articular injury
- < 50 loss of ER
- Caution in considering Staple Capsulorrhaphy
- ROM & functional level well maintained
Arthroscopic staple capsulorrhaphy: A long term followup. Lane JG et al. Arthroscopy 1993
Transglenoid Stabilisation
• Caspari 1988
- Transglenoid arthroscopic stabilisation
- multiple sutures passed through
AI capsule
- transglenoid drill hole
- passed A to P through glenoid
- sutures tied onto infraspinatus
fascia
Arthroscopic reconstruction for anterior shoulder
instability. Caspari. Tech Orthop 1988
Transglenoid Stabilisation
• Torchia 1997
- 150 transglenoid stabilisation
- F/U > 2 yrs
- av age 29yrs (14 – 67)
- 11 dislocations (7.3%)
- areas of risk - P fixation
- < 25 yrs
Arthroscopic transglenoid multiple
suture repair: 2- 8 year results in 150
patients. Torchia et al. Arthroscopy
1997
Transglenoid Stabilisation
• Soderlund 2008
- 455 army recruits (1992 – 2000) Questionaire
- 312 (68.5%) responded av 20yr (18-28)
- Av time from surg 6.4yrs (1-14)
- 177 (56%) re-dislocations
Long-term outcome of a transglenoid suture technique
for anterior shoulder instability in young adults.
Soderlund et al JBJS Br 2008
Bioabsorbable Tack Stabilisation
• Bioabsorbable Tack Stabilisation
Speer 1996
- 52 recurrent dislocators
- Suretac stabilisation
- > 2yr F/U (24 – 60 mth)
- 11 dislocations (21%)
- 7 of 8 open revision Bankart
healed with ‘patulous capsule’
An arthroscopic technique for anterior shoulder
stabilisation of the shoulder using a bio-absorbable tack.
Speer et al. J BJS Am. 1996
Arthroscopic Stabilisation
• Suture Anchor Stabilisation
- problems staple & transglenoid
fixation
- difficulty in capsule plication
with tacks
- improvements in suture anchor
design
- improvements in instrumentation
Arthroscopic washout
Arthroscopic Stabilisation v Arthroscopic Lavage
•2 yr f/u (1 lavage & 3 stabilisation – lost)
- Re-dislocation
- stab
- lavage
3/42 ( 7%)
16/42
(38%)
- Reduction in risk
- 76% re-disc & 82% instab
Primary arthroscopic stabilisation for a first-time anterior dislocation of the shoulder.
Robinson JBJS Am 2008
Suture Anchor Stabilisation
• Metanalysis
Hobby 2007
- 20 suture anchor stabilisation studies
- 1030 patients
- recurrence as end point
- failure rates ranged from 0 – 30%
- most < 10%
Is arthroscopic surgery for chronic shoulder instability as
effective as open surgery? A systematic review and metaanalysis of 62 studies including 3044 arthroscopic
operations. Hobby et al. JBJS Br .2007
Surgical options summary
• Hot Poker in axilla
• Open Bankart
• Arthroscopic
– Staple
– Transglenoid suture
– Suture tacks
– Arthroscopic washout
– Suture anchors
Again?
• Age 30 continues to play what are chances it
will happen again
Non-Operative Treatment
Prognosis: age at time of dislocation
12-22 yrs
23-29 yrs
30-40 yrs
Re dislocated
73%
56%
25%
x1 disloc
20%
18%
10%
no surgery
12%
10%
5%
surgery
40%
28%
10%
Recurrence ( > x2)
Non-operative treatment of primary anterior shoulder dislocation in
patients forty years and younger. A prospective twenty-five-year followup. Hovelius et al JBJS Am 2008
Open Access Journal of Sports Medicine 2011:2 19–24
Diagnostic arthroscopy
• Anaesthetic
– GA
– Regional block – www.nerveblocks.co.uk
• Interscalene block
• Supraclavicular +- Axillary nerve block
• Setup
– Beach position
– Lateral position
• Skin preparation
– Alcohol/ chlorhexidine preparation
• Propriono bacterium acnes
• Prophylactic antibiotics
– Implant surgery
– P acnes
• Flucloxacillin _+- Gentamycin
• Alcohol and chlorhexidine, superior to povidone
iodine
J Bone Joint Surg Am. 2009;91:1949-53
Diagnostic arthroscopy
• Equipment
– Arthroscopy stack
• 30 degree scope
– Fluid management system
– High flow arthroscopy trocars
– Radiofrequency probe
– Arthroscopic shaver
– Suture passers
– Anchors
Diagnostic arthroscopy
•
Portals
– Posterior – viewing portal
– Anterior- working portal (inside out, spinal needle)
•
Procedure
–
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–
–
–
–
–
–
–
–
Biceps anchor
Anterior labrum
MGHL
Subscapularis
SGHL (Pulley)
Biceps (tunnel)
Supraspinatus
Infraspinatus
Inferior recess
Articular surfaces
•
•
•
Glenoid
Humeral head
Closure
– Subcuticular prolene
Portal Placement
• Anterior Portal – 2nd
2
1
‘working’ gleno-humeral portal
Arthroscopic Bankart
Diagnostic Arthroscopy
Suture Anchor Insertion
Knott Tying
Second Anchor
Arthroscopic stabilisation
Arthroscopic stabilisation
SLAP tears
1
Frayed
6
2 with A or P labral flap
2
Superior A and P
7
Tear into MGHL
3
2 + bucket handle
8
2 + P labrum
4
Bucket into biceps
5
Assoc dislocation
9
10
2 + Circumferential labrum 2 + P + Inf labrum
SLAP tears
• Options
– Debridement
• Type 1
– Re attachment (SLAP repair)
– Biceps tenotomy/ tenodesis
J Shoulder Elbow Surg (2011) 20, 326-332
Again?
• Recurrence rates
– Arthroscopic (suture anchor) 8-11%
– Open (Bankart) 0-11%
• Arthroscopic slightly better ROM
Sports Health. 2011 Jul;3(4):396-404.
Glenoid Bone Loss
• Re-Dislocation
- 194 arthroscopic stabilisations
- 21 significant bone loss
- no bone loss
- inverted pear
4% recurrence
61% recurrence
- “Inverted Pear” 25% of glenoid surface area
Traumatic glenohumeral bone defects and their relationship to failure of
arthroscopic Bankart repairs: significance of the glenoid’s “inverted
pear” and the humeral “engaging Hills-Sachs lesion”. Burkhart & De Beer
Arthroscopy 2000
• Glenoid
• Concavity depression
• De Beer – Inverted pear
• Deficiency antero inferior diameter >25%
– Augment glenoid
• Humeral
• Hills sachs lesion
• Engaging Hill Sachs lesion
– Dx Arthroscopy
– Address humerus
J Shoulder Elbow Surg (2009) 18, 317-328
Glenoid defects
• Eden Hybbinette ( 1918/ 1932)
• Initially Tibia
• Now iliac crest
• Bristow (Helfett 1958)
• 1-2 cm Coracoid transfer distal to pectoralis minor
• Single screw
• Latarjet (1954)
• Larger 2-3 cm
• Length ways 2 screws
• Arthroscopic
Latarjet
Humeral defects
• Massive Hill-Sachs lesion
• >25% volume of the humeral
head
• Management
- rotational osteotomy
- hemiarthroplasty
- infraspinatus transfer
- osteo-articular allograft
- arthroscopic remplissage
Humeral Bone Loss
• Osteoarticular humeral head allograft
- 18 patients failed surgery
with >25% Hill-Sachs
- osteoarticular allograft
- 0 recurrence at 2 yrs
- early x-ray evidence of
allograft collapse
Recurrent anterior instability following failed surgical
repair: Allograft reconstruction of large humeral defects.
Miniaci, Tytherleigh-Strong. JBJS 2001
Arthroscopic Remplissage
• arthroscopic Bankart
• capsulodesis and infraspinatus
tenodesis
Summary
Young sports dislocation
1 week
Bone loss
- Plain x-ray
- CT
- CT recon
Practically
• Arthroscopic Bankart with anchors
– 1st time dislocator
– Recurrent with no bony defect
• Open Latarjet
– Failed arthroscopic Bankart
– Bony defects (glenoid)
– Chronic dislocation
J Bone Joint Surg Am. 2009;91:966-78
The End