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What are the limits of arthroscopic shoulder instability repair

What are the limits of arthroscopic shoulder instability repair. Emmanuel Antonogiannakis Director Of “Center for Shoulder Arthroscopy” ΙΑΣΩ General Hospital, Athens. WWW.SHOULDER.GR. The Shoulder. Greatest Range of Motion in the Body Motion in all 3 planes of movement

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What are the limits of arthroscopic shoulder instability repair

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  1. What are the limits of arthroscopic shoulder instability repair Emmanuel Antonogiannakis DirectorOf “Center for Shoulder Arthroscopy” ΙΑΣΩ General Hospital, Athens WWW.SHOULDER.GR

  2. The Shoulder • Greatest Range of Motion in the Body • Motion in all 3 planes of movement • Prone to injuries • 8-20% of all sports injuries WWW.SHOULDER.GR

  3. Instability • Biomechanical Dysfunction • Failure of static and dynamic stabilizers • Ranges from mild subluxation to traumatic dislocation WWW.SHOULDER.GR

  4. Instability Profiles T.U.B.S.Traumatic Unidirectional Bankart lesion Surgery A.M.B.R.I.Atraumatic Multidirectional Bilateral Rehabilitation Inferior capsular shift A.I.O.S.Acquired Instability Overstress Surgery WWW.SHOULDER.GR

  5. Types of instability Not a black or white issue WWW.SHOULDER.GR

  6. Arthroscopic Shoulder Stabilization Patient Selection • Patients of all ages and all activity levels with recurrent anterior instability who are impaired functionally and in whom nonoperative treatment has failed • Revision stabilization • First-time, acute shoulder dislocations WWW.SHOULDER.GR

  7. Arthroscopic Reconstruction Success rate 50-100% WWW.SHOULDER.GR

  8. High Initial Failure Rate of Arthroscopic Techniques • Technical factors (medial repair) • Failure to treat other lesions (RI, capsular laxity) • Failure to recognize the importance of the dynamic stabilizers and the rehabilitation program WWW.SHOULDER.GR

  9. The Ideal Patient • Unidirectional, traumatic instability • Bankart lesion • First dislocation • Robust labroligamentous tissue • Low activity levelno athletes • Experienced surgeon WWW.SHOULDER.GR

  10. As Dr Rockwood proposed following all the above limitations probably no-one should be treated arthroscopic

  11. What have we learned ?

  12. Bankart Lesion the essential lesion • Avulsion of the IGHL from the glenoid rim from 2 o’clock to 6 o’clock • Primary restraint to anterior translation at 90o of abduction • 85% in traumatic anterior dislocations • Not enough to induce symptomatic instability WWW.SHOULDER.GR

  13. Bankart Lesion WWW.SHOULDER.GR

  14. Bankart Lesion Equivalent • Recurrent dislocations also can cause stretching of the glenohumeral capsule and ligaments • This plastic deformation occurs from repetitive loading WWW.SHOULDER.GR

  15. Associated Lesions • BONY LESIONS • Humeral Head • Glenoid rim LABRAL - LIGAMENTOUS INJURY • Bankart lesion • A.L.P.S.A. • H.A.G.L. • Capsular Tear • INCREASED CAPSULAR VOLUME • Atraumatic elongation • Traumatic stretch • BICEPS LESIONS • ROTATOR CUFF TEARS • Partial thickness • Full thickness • ROTATOR INTERVAL PATHOLOGY • Widening • Synovitis • Rupture WWW.SHOULDER.GR

  16. Hill-Sachs humerus glenoid • Indentation fracture • Present in 85% of recurrent dislocations

  17. SLAP II SLAP IV

  18. Arthroscopic Shoulder Reconstruction • Goal of the Operation: • Restoration of the Labrum to its anatomic attachment • Reestablishment of the appropriate tension in the GH ligaments and capsule WWW.SHOULDER.GR

  19. Goal of arthroscopic shoulder reconstruction Proximal Shift of the Capsule WWW.SHOULDER.GR

  20. Arthroscopic Reconstruction: Technique Define Pathology Debride damaged tissue Release capsule to/past 6 o’clock 4. Abrade glenoid 5. Repair capsulolabral complex 6. Associated Injuries (Posterior capsule, Rotator Interval, SLAP) WWW.SHOULDER.GR

  21. 1. Identify and Define Pathology WWW.SHOULDER.GR

  22. Scope in Anterior-SuperiorPortal Change portals WWW.SHOULDER.GR

  23. Mobilization of Anterior Labrum WWW.SHOULDER.GR

  24. Anchor Placement WWW.SHOULDER.GR

  25. 1st suture passage WWW.SHOULDER.GR

  26. Knot Tying WWW.SHOULDER.GR

  27. Evaluation of Repair WWW.SHOULDER.GR

  28. Postoperative Rehabilitation supervised and individualized • Sling for 4/52 • Isometrics and pendulum exercises immediately • Active forward elevation may begin after 3/52 • External rotation to 30° to 40° at 4/52 • Progressive strengthening at 8/52 • Return to sport at 18 to 36 weeks WWW.SHOULDER.GR

  29. Arthroscopic Stabilization of the Shoulder: A ProspectiveRandomized Study of Absorbable VersusNonabsorbableSuture Anchors Frostick, et all Arthroscopy, July, 2006 130 patients mean follow-up: 2.6 years Lost to follow-up 5%. Redislocation rate 6%. WWW.SHOULDER.GR

  30. The “Purse-String” Technique: An ArthroscopicTechnique forStabilization of the anteroinferior instability of the Shoulder. Early and Medium-Term Results Ofer Levy et all ArthroscopyJanuary, 2007 36 pt (37 shoulders). Follow up : 36 months (range, 27 to 87 months) . 2 recurences (5.4%) 97% returned to the same sport that they had played before injury. 66% ofpatients returned to their preinjury level of sports WWW.SHOULDER.GR

  31. Arthroscopic anterior stabilization and posterior capsular plication for anterior glenohumeral Instability: A Report of 71 Cases J. Snyder, M.D. et all Arthroscopy, May 2006 • 71 patients (follow-upm.a. 33.3 months) • 5 redislocations 7% • 97% of patients reported theywere able to return to their normal activity level, • 90% of patients reported that they were ableto return to their previous level of athletics WWW.SHOULDER.GR

  32. Limitations of theArthroscopic Techniques Glenoid Bone Loss > 30% WWW.SHOULDER.GR

  33. Traumatic Glenohumeral Bone Defects and Their RelationshiptoFailure of Arthroscopic Bankart Repairs: Significanceof the Inverted-Pear Glenoid and the HumeralEngaging Hill-Sachs Lesion S.S. Burkhart and J. F. De Beer, M.D. Arthroscopy,October2000 WWW.SHOULDER.GR

  34. Total group: 194 patients • 173 pt without significant bone defects : 7ptsustained a recurrence (4%) • 21 ptwith significant bone defects: 14 ptdeveloped recurrent instability(67%)

  35. Arthroscopic Management of Traumatic Anterior ShoulderInstability in Collision Athletes: Analysis of 204 CasesWith a 4- to 9-Year Follow-Up and Results With the SutureAnchor Technique Larrain et all ArthroscopyDecember2006 WWW.SHOULDER.GR

  36. 204 rugby players with acute or recurrent traumatic anterior instability • mean follow-up 5.9 years • 39 cases of acute instability : arthroscopic stabilization : 2 redislocations (5.1%) • 158 cases of recurrent instability : 121 arthroscopic stabilization: 10 recurences(8.3%)

  37. The level of athletic activity after arthroscopic stabilization probably is not a factor of recurence ,the presence of bone defects is!! WWW.SHOULDER.GR

  38. Compression Bankart Normal Glenoid Bony Bankart loss of anterior rim inverted pear pear

  39. Engaging Hill-Sachs Lesion anterior capsule humeral head glenoid Articular Arc Deficit

  40. Limitations of theArthroscopic Techniques • Glenoid Bone Loss > 30% Open Latarjet procedure

  41. Limitations of theArthroscopic Techniques • Glenoid Bone Loss > 30% Arthroscopic Latarjet procedure L. Lafosse Arthroscopic shoulder stabilization with a bone block E. Taverna et all Nice shoulder course 2006 WWW.SHOULDER.GR

  42. Limitations of theArthroscopic Techniques Engaging Hill-Sachs WWW.SHOULDER.GR

  43. Limitations of theArthroscopic Techniques • Engaging Hill-Sachs-glenoid bone loss Hill- Sachs Remplisage: An arthroscopic surgical solution for the engaging Hill-Sachs E.M. Wolf Nice shoulder course 2006 WWW.SHOULDER.GR

  44. Hill- Sachs Remplisage

  45. Hill- Sachs Remplisage

  46. Limitations of theArthroscopic Techniques HAGL lesions WWW.SHOULDER.GR

  47. Limitations of theArthroscopic Techniques • HAGL lesions Arthroscopic repair of HAGL and reverse HAGL lesions A Cowboy’s guide to advanced shoulder arthroscopy Burkhart’s view of the shoulder WWW.SHOULDER.GR

  48. Limitations of theArthroscopic Techniques • Absent destroyed capsule i.e.Thermal shrinkage Allograft reconstruction

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