Arthroscopic Stablization Cherry Blossom Test 2009
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Transcript of Arthroscopic Stablization Cherry Blossom Test 2009
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Benjamin Shaffer MD
Arthroscopic Stabilization in Anterior Instability
Indications, Pearls and Pitfalls
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Arthroscopic stabilization has become
the “de facto” standard
In 2009…
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Indications Contributory pathology Technology, instrumentation Technical skill
Improved outcomes likely due to:
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“Ideal” Arthroscopic Indication
Post-traumatic Unidirectional Discrete Bankart Good tissue quality Overhead throwing
athlete
2009
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Contraindications
1. HAGL
2009
Avulsion off humeral side
Index of suspicion Exposed subscap Best seen w/ 70° lens Easy to repair open
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Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue
2009
Tissue Insufficient Revision Cases Soft tissue
augmentation
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Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue3. Intra-capsular IGHL rupture
2009
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Contraindications
1. HAGL2. Poor Quality Capsulolabral Tissue3. Intra-capsular IGHL rupture4. Revision Surgery
2009
Previous failed arthroscopic
Patient disappointed and/or hostile –need to do the surgery with the highest success rate
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Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue3. Intra-capsular IGHL rupture4. Revision Surgery5. Significant Glenoid or Bony
Bankart Pathology
2009
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Significant Glenoid Or Bony Bankart Lesion
~ 22% initial traumatic dislocations
up to 73% of recurrent cases
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Good screening x-ray - Bernageau ViewArthroscopy Sept. 2003
Significant Glenoid Bone Loss
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CT Scan 3-D Reconstructions
Significant Glenoid Bone Loss
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Bone Loss With Inverted Pear
Failure rate ~ 60% with arthroscopic repair
(Lo, Burkhart Arthroscopy 2000)
↓ stability to ant transl w/ defect >21% glenoid width
Inferior
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How to assess arthroscopically?
Glenoid Bare spot provides consistent reference point to quantify % bone loss of inferior
glenoid
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Measure Radius (12.5mm)
Estimate Normal Diameter (25mm)
Measure Actual Diameter (20mm)
Bone Loss:
AB
CD
Bone loss
12.5mm25mm20mm
(25-20)/25 x100 = 20%
Calculate Bone Loss
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>20 – 25% Loss: Bony (Open) Procedure
Significant Glenoid Bone Loss Treatment Options
AnatomicGlenoid Reconstruction
SalvageBristow-Laterjet
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Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue3. Intra-capsular IGHL rupture4. Revision Surgery5. Significant Glenoid or Bony
Bankart Pathology6. Engaging Hill-Sachs Lesion
2009
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Humeral Bone LossSignificant Hill-Sachs Lesion
25% w/ ant sublux 80% w/ 1º ant Disl Up to 100% w/
recurrent ant instability
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Humeral Bone LossSignificant Hill-Sachs Lesion
Arthroscopic (Soft tissue) procedures cannot prevent Hill-Sachs lesion from engaging rim (articular arc deficiency)
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Stryker Notch Apical Oblique View.
How to Asses Pre-Op
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CT scan Measure length, width and depth > 25% of articular surface or depth > 15%
HHD may need tx
How to Asses Pre-Op
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Treatment Options
“Engaging” Hill-Sachs Lesion
Anatomic Fill defect with
bone/substitute Repair defect
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Treatment Options
“Engaging” Hill-Sachs Lesion
Non-anatomic Fill defect with soft
tissue Bristow
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Miniaci ASES 2004 18 patients, defect > 25% of
humeral head Irradiated humeral head
allografts, anterior approach 50 month f/u No recurrences
Humeral Bone LossEngaging Hill-Sachs Lesion
OATS ALLOGRAFT
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OATS AUTOGRAFT
Humeral Bone LossEngaging Hill-Sachs Lesion
Clinical Results Pending
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BONE SUBSTITUTE plugs
Humeral Bone LossEngaging Hill-Sachs Lesion
12 pts arthroscopic grafting of the
engaging humeral head lesions.
No significant intra-operative complications
Clinical results pending
John Kelly MDArthroscopy abstract ’07
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Multiple sizes Limited data OA, ON, focal
chondral defects
Humeral Bone LossEngaging Hill-Sachs Lesion
Prosthetic (HEMI-CAP)
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Humeral Bone LossEngaging Hill-Sachs Lesion
Auto Body Technique w/ “transhumeral elevation and
allograft augmentation of the impacted head
fragment”
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Humeral Bone LossEngaging Hill-Sachs Lesion
Arthroscopic technique limits engagement of defect
Remplissage (French: “To Fill”)
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Humeral Bone LossEngaging Hill-Sachs Lesion
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Remplissage
• In an unpublished review, only 2 of 24 patients (7%) had recurrent instability
• Both recurrences occurred after sig trauma.
• No sig complications or loss of ROM
Results
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SalvageBristow-Latarjet
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Contraindications
1. HAGL2. Poor Quality Capsulolabral
Tissue3. Intra-capsular IGHL rupture4. Revision Surgery5. Significant Glenoid or Bony
Bankart Pathology6. Engaging Hill-Sachs Lesion7. Contact/Collision Sport Athlete
2009
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Collision sports (football, hockey) Stability more important than full motion Cosmesis not a concern Can you afford failure in your high level athlete?
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Higher failure rates in these athletes may be due to bone deficiency rather than
sport.
Another explanation…
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Restore Stability Anatomic Repair Minimal Morbidity
Goals of Reconstruction
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Instrumentation
Standard Scope, 30° and 70° Lenses
Periosteal elevator Suture Anchors Suture Passing Instruments Knot pusher/cutter Cannulae (and introducers)
which accommodate instrumentation
70°
30°
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1. Position Patient2. Establish Portals3. Evaluate and Treat Pathology4. Prepare (and mobilize) opposing tissues5. Insert Anchors6. Pass Sutures7. Secure Fixation8. Address Capsular Patholaxity
Surgical Steps
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1. Position Patient/EUA
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In the beginning…
“Twin” anterior portals
High ASP Low AIP
2. Establish Portals
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2. Establish Portals
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3. Evaluate/Tx Pathology
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4. Prepare Tissues
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5. Insert Anchors
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6. Pass Sutures
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7. Secure Fixation
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Complete the Repair
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• Difficult to recognize• Occurs even w/
“isolated” Bankart pathology
• Addressed w/ apical stitch/plication
• RIGlenoid
IGHL
6
8. Address Capsular Patholaxity/Rotator Interval
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3 wks immobilization Progressive ROM,
strength RTA 4-6 months
Post-op Rehabilitation
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Year Author(s)#
ShouldersMean F/U (months)
Recurrence Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
2007 Thal 72 Min 2yr 6.9%13.5% <22yrs, 7.5% in
contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA
Arthroscopic Bankart Results
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Year Author(s)#
ShouldersMean F/U (months)
Recurrence Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
2007 Thal 72 Min 2yr 6.9%13.5% <22yrs, 7.5% in
contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA
Arthroscopic Bankart Results
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Year Author(s)#
ShouldersMean F/U (months)
Recurrence Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
2007 Thal 72 Min 2yr 6.9%13.5% <22yrs, 7.5% in
contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA
Arthroscopic Bankart Results
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Year Author(s)#
ShouldersMean F/U (months)
Recurrence Rate Comments
2005 Mazzocca 18 37 11% Contact/collision
2005 Sugaya 42 34 5% All w/ bony lesions
2005 Bottoni 32 32 3% Prospective
2006 Carierra 72 46 10% Prospective
2006 Marquardt 54 3.7 yrs 7.5% Prospective
2006 Larrain 121 5.9 yrs 8.3% Rugby players
2006 Rhee 16 >2 yrs 25% Collision
2006 Cho 14 >2 yrs 29% Collision
2007 Thal 72 Min 2yr 6.9%13.5% <22yrs, 7.5% in
contact/collision sports
2008 Ozbaydar 93 47 10.7% 7% Bankart vs 19% ALPSA
Arthroscopic Bankart Results
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Caution
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Recurrent instability Uncommon
Loss of Motion Implant-related problems Nerve Injury
Complications
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Most instability surgery can be performed w/ scope.
Don’t do arthroscopic procedure in pts with deficient capsule and sig bone defects
Consider arthroscopic repair for revision cases, HAGL lesions and contact/collision sports athletes.
Practice makes perfect Good to excellent results in most cases.
Summary
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Thank You