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GLENOID FRACTURES : ARTHROSCOPIC TREATMENT. GIORGOS - GRIGORIS KARACHALIOS Orthopaedic Surgeon Director of Arthroscopic Surgery Dpt Iatriko Kentro Athinon P.Falirou P. Faliro , Athinai , Hellas. Confusing literature. Complex anatomy and function .
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GLENOID FRACTURES : ARTHROSCOPIC TREATMENT GIORGOS - GRIGORIS KARACHALIOS Orthopaedic Surgeon Director of Arthroscopic Surgery Dpt Iatriko Kentro Athinon P.Falirou P. Faliro , Athinai , Hellas .
Confusing literature • Complex anatomy and function . • There is no generally accepted classification ( Euler & Ruedi , Goss , Ideberg , Thompson , Zdravkovic & Damholt ) . • The decision on treatment is mainly based on personal experience , since these are rare . • Very often indicators of major trauma – the # is often neglected
Epidemiology 5% of all fractures to the shoulder girdle 3% of all injuries to the shoulder girdle 0.4 – 1% of all fractures Mean age 35 -45 years
One per 3000 operated fractures ~ 10% of glenoid fractures internal fixation
Intra-articular - extra-articular Body and spine 50% glenoid neck 25% glenoid cavity 10%acromion 7% coracoid 7% Scapular fractures classification
Types II through V : closed reduction under anaesthesia ALWAYS unsuccessful . Late improvement . 75% good results by early mobilization . European literature more aggressive
Type I to be distinguished from 1. Bony Bankart lesion 2. Type II joint surface <glenoid neck
Mechanism of dislocation sometimes redislocation after reduction
risk : Instability ( late dislocation or subluxation ) Joint degeneration
TREATMENT ? TARGETretain congruity of the articular surface stability of the joint
indications for internal fixation displacement > 10 mm.& fragment > ¼ of the glenoid internal fixation( De Palma ) fragment > ¼ of the glenoid &instability internal fixation ( Rockwood )
indications for internal fixation Type I fracture ( Ideberg ) > 21% of the length of the glenoid ( av. 26,2 % in his pts ) One fragment Step > 2 mm No neurological deficit Fragment ‘s size 27 % Sugaya 2005 Tauber 2008
fragment > 21% of the length of the glenoid ( av. width 6.8 mm ) resecting a fragment > 6,8 mm and refixing the capsular-ligamentous complex to the glenoid defect ,creates instability and reduces the ext. rotation Itoi 2000 indications for internal fixation ( A x 96,5% - B ) / A x 100 21%
openreduction and internal fixation failure 10 % complications 10% Schandelmaier 2002 good- excellent functional outcome 82 % anatomic reduction 89 % Mayo 1998 implant impingement - loosening neural injury infection stiffness
potential advantages of arthroscopic fixation Initial diagnostic arthroscopy to exclude / assess associated injuries Reduced soft tissue damage ( particulary of the subscapularis tendon) Overall lower postop morbidity
the arthroscopic assessment , offers : << no need >> of C - arm Confirmation of the reduction … … and the stability of the joint
Attempts of arthroscopic fixation using : Suture anchors Percutaneous wire fixation Screw fixation
assesment Assesement of the injury and mobility of the fragment 2 1 3
debridement mobilization 4 6 5 7
Temporary fixation by k-wire 8 10 reduction 9 11
average glenoid length : 35 mm average glenoid width : 25 mm ACUTRAK – ACUMED tapered cannulated HEADLESS self-taping usually length of 25 – 30 mm is adequate length – instrumentation ??? Arthroscopic use
12 drilling Screw placement 13
insertion of two screws – at the proximal and distal edges of the fractures -
Suture passing around the bony element of the fragment and reduction - temporary fixation by a guide K-wire , before the knot tying
Self – tapping Threaded head Longer pitch of the distal threads Smooth proximal section 10/10 k-wire Barouk screw DePuy
Check of reduction Check of screw impingement posterior portal anterior portal
bioabsorbable “ anchor “ transosseous suture
screw ( Barouk – DePuy ) check