shoulder instability 2016 · facts instability most frequent dislocated ( 1/2) 2 peaks 21-30 61-80...

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


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


Physical exam

- adducted and internally

rotated arm

- humeral head may

be palpated

check cuff and axillary nerve

10,8 % incidence > 40y


Xray : confirm diagnosis

exclude fractures

confirm reduction

Reduction :


Reduction by Kocher

arm adducted and elbow flexed

max exoR till resistance

lift arm forward as far as possible

finally intR is performed


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


Failure conservative treatment

Choose the one and only operation

Decision making

ISIS Scoring system ( Boileau )


Prototype patient in the office

more than one dislocation

feels unstable / about to come out

avoids abD-extR

failed conservative R/

wants definite solution !


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 ?


Intrinsic lesionanterior dislocation causesthe posterolateral aspect of the superior humerus toimpinge on the antero-inferiorrim of the glenoid

Glenoid : Bankart lesionHumerus : Hill-Sachs lesion


Bankart lesion

Fracture of the glenoid rim = Bony Bankart

Non osseous Bankart lesion involves the cartilaginous glenoid labrum

Diagnostic tool : arthro-ct scan


Hill Sachs lesion

osteochondral compression fracture of the postero-lateral humeral head


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


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


- 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


ISIS scoring system

prognostic factors of failure afterarthroscopic Bankart procedure

=

instability severity index score


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


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


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


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


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

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 :


CT scan :


10/11/2016 : scopic repair


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


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


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


5 ANCHORS !!!

Summary

Individualise patient

AGE

Type and level of sport

Bony component

Individualise your treatment

Thank you

rrr

shoulder instability 2016 · facts instability most frequent dislocated ( 1/2) 2 peaks 21-30 61-80...

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