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Surgical treatment of shoulder sports injuries

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.

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Surgical treatment of shoulder sports injuries

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  1. Surgical treatment of shoulder sports injuries Mr Lee Van Rensburg United Kingdom

  2. Objectives • Surgical options for shoulder instability • Glenohumeral • Acute traumatic • Recurrent traumatic

  3. 30 YO male,Professional Rugby payer,

  4. Surgical options

  5. Shoulder Instability Hippocrates 400 BC • method of reduction • cauterisation of inferior capsule

  6. 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

  7. 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

  8. Modified Open Bankart Repair • Numerous modifications - capsular imbrication - suture anchors • Multiple series published • Accepted recurrence rate Open Bankart Repair 8 –12% • Loss of ER

  9. 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

  10. 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 follow-up.Lane JG et al. Arthroscopy 1993

  11. 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

  12. 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

  13. 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

  14. 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

  15. Arthroscopic Stabilisation • Suture Anchor Stabilisation - problems staple & transglenoid fixation - difficulty in capsule plication with tacks - improvements in suture anchor design - improvements in instrumentation

  16. Arthroscopic washout Arthroscopic Stabilisation v Arthroscopic Lavage • 2 yr f/u (1 lavage & 3 stabilisation – lost) - Re-dislocation - stab 3/42 ( 7%) - lavage 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

  17. 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 meta-analysis of 62 studies including 3044 arthroscopic operations.Hobby et al. JBJS Br .2007

  18. Surgical options summary • Hot Poker in axilla • Open Bankart • Arthroscopic • Staple • Transglenoid suture • Suture tacks • Arthroscopic washout • Suture anchors

  19. Again? • Age 30 continues to play what are chances it will happen again

  20. Non-Operative Treatment Prognosis: age at time of dislocation 12-22 yrs 23-29 yrs 30-40 yrs Re dislocated73% 56% 25% x1 disloc 20% 18% 10% Recurrence ( > x2) no surgery 12% 10% 5% surgery 40% 28% 10% Non-operative treatment of primary anterior shoulder dislocation in patients forty years and younger. A prospective twenty-five-year follow-up. Hovelius et al JBJS Am 2008

  21. Open Access Journal of Sports Medicine 2011:2 19–24

  22. 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

  23. Alcohol and chlorhexidine, superior to povidone iodine J Bone Joint Surg Am. 2009;91:1949-53

  24. Diagnostic arthroscopy • Equipment • Arthroscopy stack • 30 degree scope • Fluid management system • High flow arthroscopy trocars • Radiofrequency probe • Arthroscopic shaver • Suture passers • Anchors

  25. Diagnostic arthroscopy • Portals • Posterior – viewing portal • Anterior- working portal (inside out, spinal needle) • Procedure • Biceps anchor • Anterior labrum • MGHL • Subscapularis • SGHL (Pulley) • Biceps (tunnel) • Supraspinatus • Infraspinatus • Inferior recess • Articular surfaces • Glenoid • Humeral head • Closure • Subcuticularprolene

  26. Portal Placement • Anterior Portal – 2nd ‘working’ gleno-humeral portal 2 1

  27. Arthroscopic Bankart

  28. Diagnostic Arthroscopy

  29. Suture Anchor Insertion

  30. Knott Tying

  31. Second Anchor

  32. Arthroscopic stabilisation

  33. Arthroscopic stabilisation

  34. SLAP tears 3 2 + bucket handle 4 Bucket into biceps 5 Assoc dislocation 1 Frayed 2 Superior A and P 7 Tear into MGHL 8 2 + P labrum 6 2 with A or P labral flap 9 2 + Circumferential labrum 10 2 + P + Inf labrum

  35. SLAP tears • Options • Debridement • Type 1 • Re attachment (SLAP repair) • Biceps tenotomy/ tenodesis

  36. J Shoulder Elbow Surg (2011) 20, 326-332

  37. Again?

  38. Recurrence rates • Arthroscopic (suture anchor) 8-11% • Open (Bankart) 0-11% • Arthroscopic slightly better ROM Sports Health. 2011 Jul;3(4):396-404.

  39. Glenoid Bone Loss • Re-Dislocation - 194 arthroscopic stabilisations - 21 significant bone loss - no bone loss 4% recurrence - inverted pear 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

  40. 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

  41. 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

  42. Latarjet

  43. Humeral defects • Massive Hill-Sachs lesion • >25% volume of the humeral head • Management - rotational osteotomy - hemiarthroplasty - infraspinatus transfer - osteo-articular allograft - arthroscopic remplissage

  44. 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

  45. Arthroscopic Remplissage • arthroscopic Bankart • capsulodesis and infraspinatus tenodesis

  46. SummaryYoung sports dislocation 1 week

  47. Bone loss - Plain x-ray - CT - CT recon

  48. Practically • Arthroscopic Bankart with anchors • 1st time dislocator • Recurrent with no bony defect • Open Latarjet • Failed arthroscopic Bankart • Bony defects (glenoid) • Chronic dislocation

  49. J Bone Joint Surg Am. 2009;91:966-78

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