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Shoulder Instability
Shoulder instability 2016
Nick Jansen
Facts instability
Most frequent dislocated ( 1/2)
2 peaks 21-30 61-80
Ant : 84% Post : 1,5%
Recurrency : - 25y: 60% +34y: 25%
Golfball on tee : 3 to 4 times size
Functional Anatomy
Bony Landmarks :
Glenoid fossa ( Saha )
7° retroversion
5° superior tilt
Humerus 30° retro
( Walch – Boileau : 17,9° )
Functional Anatomy
STATIC RESTRAINTS
- intra-articular pressure
( -42cm. H2O in cadaver )
- ligaments-capsule
- labrum
- adhesion-cohesion
( 1 mm.joint fluid adhesiveness )
Functional Anatomy
Ligaments
SGHL
MGHL
IGHL
Functional Anatomy
SUPERIOR GH LIGAMENT
= most constant ,
but variable thickness
resists inf. subluxation and contributes tostability in POST and INF. directions
Functional Anatomy
MIDDLE GH LIGAMENT
limits anterior translation with 60 to 90°abduction and external rotation
limits inf. translation with
the arm adducted
Functional Anatomy
INFERIOR GH LIGAMENTthis HAMMOCK acts as a sling
limits ant, post and inf. translationdepending on arm position
= most important stabiliseronly restraint at full abd-ext rot
Functional Anatomy
Labrum
deepens the glenoid by 50%
contributes 20% to stability
3 purposes :
increase surface contact area
buttress
anchor point
Functional Anatomy
DYNAMIC RESTRAINTS > Static restraints
cuff
deltoid / biceps
scapulo-thoracic muscles
concavity compression
Functional Anatomy
Dynamic structures
Superficial layer
scapulothoracic muscles
positioning scapula towards thorax
( trapezius , levator , serratus )
reinforce GH mobility
( deltoid , pectorales , latissimus )
Deep layer : Cuff
Functional Anatomy
DYNAMIC RESTRAINTS
CUFF
- synergetic coordinated cuff activity
- ligament dynamisation
( direct connection cuff andcapsulo-ligamentous structures )
Functional Anatomy
CUFF
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
Functional Anatomy
Supraspinatus elevation
Infraspinatus external rotationSubscapularis internal rotation
Teres Minor external rotation
Functional Anatomy
Function : dynamic activity
depression function
( InfraS , subscap , Tm )
SupraS , deltoid
= centering the head
FORCE COUPLE
Arthroscopy
Anatomy
Pathology
LABRUM CUFF
Arthroscopy
Ligaments
Arthroscopy
Labral tear
Pathology
LAXITY : asymptomatic translation of the humeral head on the glenoid
INSTABILITY : when laxity becomes pathologic
= symptomatic pain and apprehensionassociated with excessive translation of the humeral head during active motion
Pathology
LAXITY
FYSIOLOGIC
HYPERLAXITY
Clinical Exam
- Muscular atrophy
( cuff , scapula )
- Tenderness AC-SC
- ROM ( active / passive )
- Muscle strength
( Ss , Is , Subscap )
Clinical Exam
- Signs of hyperlaxity
- Sulcus sign 1+ : less than 1 cm
2+ : 1-2 cm
3+ : +2 cm ( MDI )
neutral versus exorotation ( RCI )
Hyperlaxity
hhh
Clinical Exam
- Anterior translation testing
- Load and shift test
- Anterior apprehension
- Jobe relocation test
Clinical Exam
Imaging
- Xray True AP / Scapular Y
Axillary / Westpoint
- CT / Arthro CT
- ( Arthro-MRI )
Acute Shoulder Dislocation
Anteriorly directed force applied to the posterior aspect of the externally rotatedabducted arm
< 30y : recurrent dislocation ( < 16 : 99% )
> 50y : rotator cuff tears
Acute Shoulder Dislocation
Why lower re-dislocation rate at the ageabove 30-40 y ??
= DIFFERENT PATHOLOGY
Hertz Young : labrum disruption
older : NO lesions labrum but rupture joint capsule
Reeves : decreased capsular tensile strengthas individuals age
Acute Shoulder Dislocation
Physical exam
- adducted and internally
rotated arm
- humeral head may
be palpated
check cuff and axillary nerve
10,8 % incidence > 40y
Acute Shoulder Dislocation
Xray : confirm diagnosis
exclude fractures
confirm reduction
Reduction :
Acute Shoulder Dislocation
Reduction by Kocher
arm adducted and elbow flexed
max exoR till resistance
lift arm forward as far as possible
finally intR is performed
Acute Shoulder Dislocation
Post trauma treatment
2-3 weeks adduction sling
( gentle motion , avoid
abD and extR )
( Itoi abduction sling )
CAVE : young : redislocation
old : cuff tear
Start physio as soon as pain allows
Recurrent Anterior Instability
Therapy = Physiotherapy
Recurrent Anterior Instability
Failure conservative treatment
Choose the one and only operation
Decision making
ISIS Scoring system ( Boileau )
Recurrent Anterior Instability
Prototype patient in the office
more than one dislocation
feels unstable / about to come out
avoids abD-extR
failed conservative R/
wants definite solution !
Recurrent Anterior Instability
Choose the right operation
for the right patient
Age of the patient ?
Does patient perform high level contactsports ?
What is the type of instability ?
What is the radiologic lesion ?
Recurrent Anterior Instability
Intrinsic lesionanterior dislocation causesthe posterolateral aspect of the superior humerus toimpinge on the antero-inferiorrim of the glenoid
Glenoid : Bankart lesionHumerus : Hill-Sachs lesion
Recurrent Anterior Instability
Bankart lesion
Fracture of the glenoid rim = Bony Bankart
Non osseous Bankart lesion involves the cartilaginous glenoid labrum
Diagnostic tool : arthro-ct scan
Recurrent Anterior Instability
Hill Sachs lesion
osteochondral compression fracture of the postero-lateral humeral head
Recurrent Anterior Instability
HAGL lesion humeralavulsionGH ligaments
Incidence : 2 to 9%after dislocation the gleno-humeralligaments can tear away from theirbase on the humerus
Glenoid track concept
Measure bipolar bone loss
Biomechanically quantify the effects of a combined glenoid and humeral head bonedefect on instability
engaging Hill Sachs
Glenoid track concept
Yamamoto : cadaver model 60° abductionand max ext rot : the distance from the contact area to the medial margin of the footprint : 84% of the glenoid width :
glenoid track
Glenoid track concept
- measure the actual glenoid width , 84% of this width is the glenoid track , GT
- measure the Hill Sachs lesion
if HS > GT : possible engaging
Recurrent anterior instability
Decision making
Recurrent Anterior Instability
ISIS scoring system
prognostic factors of failure afterarthroscopic Bankart procedure
=
instability severity index score
Recurrent Anterior Instability
Questionnaire- Age at surgery < 20y : 2
> 20y : 0- Degree of sport practice
competition : 2recreational or none : 0
- Type of sport : contact or forced abD-extR : 1others : 0
Recurrent Anterior Instability
Exam : Hyperlaxity Yes : 1
No : 0
Xray AP
Hill Sachs on XR in extR : 2
not 0
Glenoid loss of contour : 2
no loss : 0
Recurrent Anterior Instability
ISIS
<3 recurrent risk : 5% after AS Bankart
4-6 risk : 10%
>6 risk : 70%
Literature AS stabilisations
Am J Sports Med Nov 2011 – Jaap Willems
Longterm results AS stabilisation anchors
65 patients , 8-10 y FU : 35% redislocation
The presence of a Hill-Sachs defect and the use of less than 3 suture anchors mightincrease the chance of a redislocation
Literature AS stabilisations
Arthroscopy 2012 Mar , Castagna
AS stabilisation in adolescent athletes in overhead or contact sports
67 patients ( age 13 to 18 ) , mean FU : 63m
81% returned pre-injury level
21% failure rate , recurrence rate was relatedto the type of sport performed
Literature AS stabilisations
Chinese group 2011 July
AS Bankart repair with suture anchors
188 patients ( 50 athletes , 138 nonathletes )
mean age : 25,3 , mean FU 38,6
Recurrence rate : 28% in athletes ( 7,2 %)
Age under 20 and athletes are the most important risk factors for recurrence
Decision making
ISIS score <3 : arthroscopic Bankart procedure
Ideal patient AS repair
non contact sportanterior instability secondaryto traumathick mobile labral Bankart lesionand little or no capsular laxity
Arthroscopic Repair
Aim
Refix the torn labrum to the glenoid andperform a capsular shift from south tonorth
Arthroscopic Repair
Dual balanced traction
Arthroscopic Repair
Circumferential access
Arthroscopic Repair
3 portal surgery
Arthroscopic repair
antero-inferior portal
Arthroscopic repair
antero-superior portal
Arthroscopic repair
Arthroscopic repair
Arthroscopic repair
prepare labrum
Arthroscopic repair
Arthroscopic repair
spectrum hook
Arthroscopic repair
position anchor
Arthroscopic repair
Arthroscopic Repair
Define the lesion
Debride labrum and release inferiorly till yousee the muscle fibers of the subscap
Arthroscopic Repair
Refix the labrum anatomically / shift
Arthroscopic Repair
Refix the hammock
( anterior and posterior band of the
IGH ligament )
Arthroscopic Repair : refix hammock
Arthroscopic repair case
Case : age 11 , ACL rupture
2016 : Soccer : fall on elbow as goalkeeper
dislocation , reposition hospital
Clinical : MDI , apprehension ant.inf
CT scan :
Arthroscopic repair case
CT scan :
Arthroscopic repair case
10/11/2016 : scopic repair
Arthroscopic repair case
surgery :
Arthroscopic Repair
Post op treatment
4 weeks adduction sling
after 4 weeks aim regaining mobility
( sparing extR 6 weeks )
after 8 weeks start regaining power
Decision making
ISIS > 3
no or minimal bone loss
no Hill Sachs
with / without HAGL
AS / Open Bankart repair – capsular shift
( Hagl repair open)
Open Bankart repair with shift
Repair anatomic lesion ~ AS repair
Open Bankart repair with shift
HAGL repair
Absorbable anchor in humerus with refixationof the GH ligaments to the humerus
HAGL repair
zzzzz
Decision making
ISIS > 3
no or minor glenoid bone loss
large Hill Sachs lesion
Latarjet procedure
Hill Sachs remplissage
Hill Sachs remplissage
Arthroscopic procedure with
posterior capsulodesis and
infraspinatus tenodesis
using sutures and suture
anchors to fill up the humeral
Hill Sachs defect
Hill Sachs Remplissage
Boileau :
Remplissage and bankart repair :
98% patients stable shoulder joint
with 10° of restriction in ext rot .
( no affect on sports return )
However : 33% some posterosuperior pain
Decision making
ISIS > 3
bony bankart lesion
no hill sachs
Sugaya : AS reinsertion bony fragment
Latarjet
Re-insertion bony fragment
Sugaya :
Decision making
ISIS > 3
glenoid bone loss
How much ?
Itoi : 20% glenoid length
25% glenoid width
= Latarjet
Bony Bankart 60 year old
CT scan :
Case
16 year old breakdancer
Bilateral shoulder instability , ever since he fell over during a handstand move
throwing a ball dislocated the left shoulder
he stopped all sport activity
Case
16 year old breakdancer CT scan
Latarjet procedure
Coracoid transfer procedure ( 1958 )
= transfer of coracoid process withattached muscles to the deficient area over the front of the glenoid
Latarjet procedure
= replacing missing bone and the transferredmuscles act as a sling preventing furtherdislocation ( Clavert and Itoi )
Latarjet procedure
Does it work ?
Latarjet procedure
Results
Latarjet procedure
Does it work ?
18 year old professional skater
subluxation in the past , one real dislocation
exam : MDI , ant-inf instability
Latarjet procedure
skater , 8 weeks post op
Latarjet procedure
Does it work ?
Latarjet procedure
George Athwal : 8 cadaver study
intact glenoid , 30% defect glenoid
Latarjet loaded , Latarjet unloaded
loaded : 8/8 no dislocation
unloaded : 6/8 no dislocation
Latarjet procedure
Athwal theory :
- improves tension antinf
structures by wrapping around the anteroinferior aspect of the humeral head
- improves tension of the subscap muscle
HERTEL : sling effect is important but notessentiel
Compare bone blocks and bankart
Arthroscopy september 2014
Group Nicola Malfulli : Latarjet , Bristow , Eden-Hybinette procedures for anteriorshoulder dislocation : Systematic review andquantitative synthesis of the literature
Recurrence rate
46 studies included , 3211 shouldersevaluated
open Bristow-Latarjet : 7,5% (0-19,1%)
comparing open BB-Bankart : (5,9%-23,2%)
scopic Latarjet : 3,4%
Eden Hybinette : 9,8%
Complications
15% Latarjet-Bristow
17,2% AS Latarjet
17,6% Eden Hybinette
( postop infections , neurologic injuries ( ulnaror radial nerve ) , hematoma , asepticnecrosis transplant , partial dislocationtransplant , graft lysis , no bony union , screwbending or breakage , …
Older Bristow procedure
Lysis
Latarjet procedure
Union ?
Latarjet procedure
Malunion !
Postop arthritis
comparing Bankart and bone block procedures
NO
SIGNIFICANT
DIFFERENCE
Future
English : try to improve AS techniques
French : Latarjet procedure
BUT !
Do you dare to perform a Latarjet procedure in a 16 year old contact sporter without severe bone loss
Can we improve our AS results
Orthop Traumatol Surg Res. 2010 dec Boileau and French Society
125 patients 2007-2008 ISIS < or = 4 , all had capsuloligamentous reinsertion with at least3 anchors and 4 sutures
mean FU 18 months : 3,2 % recurrence
Can we improve our AS results
Oper Orthop Traumatol 2007 june – Imhoff
Use of a deep antero-inferior portal extra toreach the 5.30 position
first 147 patients : 6,1 % redislocationsat 3y FU
Can we improve our AS results
RECONSTRUCT ANATOMY BETTER
Use more anchors
Reach better the 5.30 position
Recreate the hammock ( posterior band )
Solution : all suture anchors ?!
All suture anchors
Y-knot
Jugger knot
- 1,4 mm. deployable anchor , is a completely suture based system
- #5 polyester suture and loaded withmaxbraid suture
Linvatec Y knot
1,3 mm. all suture anchor
SOFT : entirely made of high strengthUHMWPE suture
SMALL : 1,3 mm drill bit
SECURE : the anchor contracts vertically andexpands laterally , producing a 360° formfitfixation within the bone
All suture anchors
Advantages :
- volume of bone removal with 3.0 mm. anchor ~ to 4 ASA knot drill holes
- smaller cannula makes it less invasive forsurrounding tissue
Multiple anchors in various anatomicallocations
All suture anchor solutions
Position more anchors and have more freedom to postion the anchors
All suture anchor solutions
All suture anchor solutions
All suture anchor solutions
5 ANCHORS !!!
Summary
Individualise patient
AGE
Type and level of sport
Bony component
Individualise your treatment
Thank you
rrr