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MANAGEMENT OF ANTERIOR INSTABILITY

WITH AND WITHOUT BONE LOSS

Josh Dines, MDSports Medicine and Shoulder Service

FORE Current Solutions in Shoulder & Elbow Surgery

Tampa FL; Feb 5-7, 2016

HISTORY

How it occurred?

How was it put back in?

How many times?

Goals of the patient?

Age at first dislocation?

PHYSICAL EXAM

1. Generalized Laxity

2. Unstable at Midrange motions• Apprehension (+) at lower degrees of Abduction

and decreased ER

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• X-rays– Hill - Sachs

– Bony Bankart

– Head Centered

• MRI – If > 40 to r/o rotator cuff

tear

– If surgery considered

• CT – If concerned with bone loss

IMAGING

OPERATIVE VS NON-OPERATIVE

Systematic Review

Study Con Surg Con Surg Con Surg Con Surg

Arciero 15 21 19.5 20.5 23 32 80 20

Bottoni 12 9 23 21.6 37 36 75 11

Kirkley 15 16 22.7 23.3 79 79 60 20

Kirkley 21 19 22.8 22.1 36 32 47 16

Jakobsen 39 37 20 23 120 120 62 8

Yannmis 32 30 22 21 40 33 38 3

Robinson 45 43 24.3 25.3 24 24 38 7

Totals 158 156 52.5 9.6

Patients (N) Mean Age (yrs) Mean F/U (mos) Recurrence (%)

Modified from Brophy, Arthroscopy, 2009

KNOTLESS BANKART REPAIR

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RESULTS OF ARTHROSCOPIC STABILIZATION

Some Failures Remained…

Morgan (transglenoid sutures) 33%

Staples 23%

Caspari (transglenoid sutures 22%

Sutures + Anchors/HSS Series 18%

Voos et al AJSM 2010

REASONS FOR FAILURE: BONE DEFECTS

GLENOID BONE LOSS

Burkhart, Debeer et al. Arthroscopy 2007

• 194 patients without bone

loss: 4% recurrence

• 21 patients with significant

bone loss: 67% recurrence

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GLENOID BONE LOSS

Burkhart, Debeer et al. Arthroscopy 2007

Begun using Latarjet for >25%

bone loss

– 104 patient

4.7% recurrent instability

PREVENTING RECURRENCE:

PROPER PREOPERATIVE PLANNING

XR/CT/MRI findings; Patient Factors

0-10% Bone Loss > 20-25% Bone loss10-20%; Good

Tissue Quality

Arthroscopic (+)

- Double Row

- Remplissage

GOOD PREOPERATIVE IMAGING

CT Scan

• En Face Sagittal View

• 3D Reconstructions

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320 Matrix, 3T CT

*Different Patients

CT

THE FUTURE? ZTE PROTOCOL

320 Matrix, 3T

24M

ZTE PROTOCOL

LATARJET PROCEDURE

‘Bone Block effect + Sling effect + Bumper Effect’

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-5.0

-4.0

-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

Max IR 30 IR 0 ER 30 ER Max ER

Po

ste

rio

r

[mm

] A

nte

rio

r

Change in Humerus Position Following Capsulotomy and LatarjetAnterior-Posterior

Capsulotomy

Latarjet

Conjoint

Unloaded

With conjoint loaded in ER, head moved posteriorly; with tendon

unloaded, shifted anterior

Significant effect of conjoint tendon!

BIOMECHANICAL ANALYSIS OF THE MODIFIED LATARJET

PROCEDURE IN A CADAVERIC ANTERIOR SHOULDER

INSTABILITY MODEL DINES JSES 2013

LATARJET RESULTS

Gilles Walch

- > 2500 Latarjets

- Recurrence rate <2%

LATARJET IS GREAT BUT….

• Non-Anatomic

• Short- Term Complications

– 25% incidence

– Infection

– Recurrent Instability

– Nerve InjuryShah, Warner JP. JBJS 2012

• Long- Term Complications

Pain / screws, OA…

Osteolysis, Nonunion

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PREVENTING RECURRENCE:

PROPER PREOPERATIVE PLANNING

XR/CT/MRI findings; Patient Factors

0-10% Bone Loss > 20-25% Bone loss10-20%; Good

Tissue Quality

Arthroscopic (+)

- Double Row

- Remplissage

PREVENTING RECURRENCE:

PROPER PREOPERATIVE PLANNING

XR/CT/MRI findings; Patient Factors

0-10% Bone Loss > 20-25% Bone loss10-20%; Good

Tissue Quality

Arthroscopic (+)

- Double Row

- Remplissage

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INDICATIONS FOR

ARTHROSCOPY +

• Bone loss <20%

• Poor quality ligaments

• Revision surgery

• Extreme sports participation

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BANKART + REMPLISSAGE

THIS APPLIES TO CAPSULE/LABRUMDOUBLE ROW LABRAL REPAIRS:

AIGHL-LC ATTACHMENT ANATOMY

Itoigawa Y, Itoi E, et al. Attachment of AI Glenohumeral Ligament-Labrum

Complex to the Glenoid: Anatomic Study. Arthroscopy 2012.

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RECREATION OF ANATOMY

Kim D. et al. SR vs DR Capsulolabral Repair: Comparative Evaluation of

Contact Pressures. AJSM 2012.

39.4% 78.4%

AIGHL-LC ATTACHMENT ANATOMY

Dines J, Thompson M, Altchek D, McGarry M, Lee TQ.

1st part of study:

Labral tear Measure IR/ER, translation

Dissecting capsule off IR/ER, translation

2nd part of study:

3-anchor single row repair, simple knots

double row with 3 anchors laterally; 2 medially

AIGHL-LC ATTACHMENT ANATOMY

Dines J, Lee TQ et al. Accepted for Publication Arthroscopy

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

10N A 10N P 15N A 15N P

An

t-In

f o

r P

ost-

Inf

[mm

]

Glenohumeral Translation at 60 ER

Intact

Bankart

Double Row Repair

P < 0.05* vs. Intact+ vs. Bankart

+

+

*

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AIGHL-LC ATTACHMENT ANATOMY

Dines J, Lee TQ et al. Accepted for Publication Arthroscopy

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0

450.0

500.0

Yield Load Ultimate Load

Lo

ad

(N

)

Yield Load and Ultimate Load

Single Row

Double Row

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RESULTS

• Lafosse et al. Cassiopeia

– 12 patients

– No short term complications

• Ahmad et al. TSES 2012

– 6 Patients

– No Short Term complications

CONCLUSIONS

• Good preoperative imaging critical

• Ideal treatment based on bone loss +

expectations

• Arthroscopic Stabilization can provide

good to excellent results in majority of

cases

• Need to be aware of patients at high risk

for redislocation• Candidates for advanced arthroscopic or

open stabilization