1. GLENOID FRACTURES : ARTHROSCOPIC TREATMENT GIORGOS - GRIGORIS KARACHALIOS Orthopaedic Surgeon Director of Arthroscopic Surgery Dpt Iatriko Kentro Athinon P.Falirou P. Faliro , Athinai , Hellas .

2. 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

3. 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

4. One per 3000 operated fractures ~ 10% of glenoid fractures  internal fixation

5. Intra-articular - extra-articular Body and spine 50% glenoid neck 25% glenoid cavity 10%acromion 7% coracoid 7% Scapular fractures classification

6. intra-articular Ideberg

7. Glenoid fossa Goss

8. Types II through V : closed reduction under anaesthesia ALWAYS unsuccessful . Late improvement . 75% good results by early mobilization . European literature more aggressive

9. Type I to be distinguished from 1. Bony Bankart lesion 2. Type II joint surface <glenoid neck

10. Mechanism of dislocation sometimes redislocation after reduction

11. risk : Instability ( late dislocation or subluxation ) Joint degeneration

12. TREATMENT ? TARGETretain congruity of the articular surface stability of the joint

13. 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 )

14. 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

15. 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%

16. 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

17. 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

18. the arthroscopic assessment , offers : << no need >> of C - arm Confirmation of the reduction … … and the stability of the joint

19. Attempts of arthroscopic fixation using : Suture anchors Percutaneous wire fixation Screw fixation

20. Sugaya 2005

21. Bauer 2006

25. assesment Assesement of the injury and mobility of the fragment 2 1 3

26. debridement mobilization 4 6 5 7

27. Temporary fixation by k-wire 8 10 reduction 9 11

28. 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

29. 12 drilling Screw placement 13

33. Assesement of the injury and mobility of the fragment

34. reduction

35. insertion of two screws – at the proximal and distal edges of the fractures -

36. Suture passing around the bony element of the fragment and reduction - temporary fixation by a guide K-wire , before the knot tying

37. Knot tying

38. Self – tapping Threaded head Longer pitch of the distal threads Smooth proximal section 10/10 k-wire Barouk screw DePuy

39. Drilling screw placement

40. Check of reduction Check of screw impingement posterior portal anterior portal

44. displacement

45. meticulus mobilization

46. bioabsorbable “ anchor “ transosseous suture

47. screw ( Barouk – DePuy ) check

48. Male , 47 , r shoulder