1 / 31

Approach to Failed Shoulder Stabilization

Approach to Failed Shoulder Stabilization. M Prud’homme-Foster AHD April 5 th , 2012. Glenohumeral joint is most common large joint to dislocate 11.2 per 100,000 person-years 90% traumatic dislocation: anterior This review will focus primarily on anterior instability. Pathoanatomy

tadita
Télécharger la présentation

Approach to Failed Shoulder Stabilization

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Approach to Failed Shoulder Stabilization M Prud’homme-Foster AHD April 5th, 2012

  2. Glenohumeral joint is most common large joint to dislocate • 11.2 per 100,000 person-years • 90% traumatic dislocation: anterior This review will focus primarily on anterior instability Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  3. Pathoanatomy • Clinical Evaluation • History and Evaluation • Imaging • Recurrent Instability • Surgical Treatment • Arthroscopic Bankart Revision • Open Bankart Revision • OsteoarticularPathalogy Boone et al. OrthClin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  4. Pathoanatomy • GH relies on Dynamic and Static stabilizers • Critical static components • Glenolabral complex • Capsuloligamentous structures • Labrum increases surface area and depth: 50% Boone et al. OrthClin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  5. Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  6. Pathoanatomy • Bankart lesion most common pathology with anterior instability • Anteroinferior labrum with attached IGHLC • Recurrent episodes—>elongation anteroinferior capsule • ‘Osseous Bankart’ Suguya 2003 • 50% of traumatic de novo and 86% in recurrent Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  7. Cadaveric study with Bankart repair • Showed shoulder stable up to 21% defect • Instability with IR and restrictive ER

  8. Bone loss affects contact pressures • Geiss et al. JSES 2002 • 30% glenoid defect increases contacts pressure 100% • Buscayret et al. Am J SpMed 2004 • Osseous defect and number of dislocation risk factor for OA Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  9. Hill-Sachs lesion • Posterolateral aspect of head • Found in • 90% primary dislocators • 100% recurrent dislocators • 40% recurrent subluxators • Clinically significant threshold • 20-30% • Lesions parallel parallel to ant. glenoid surface in at risk position (Abd + ER) Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  10. Clinical Evaluation Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  11. History • Determine if instability and severity • Traumatic v. atraumatic • What was possibly overlooked? • 89% of failures have glenoid bone loss • Capsular laxity, HAGL, MDI, SLAP, Hill-Sachs, neuropraxia, SubS weakness, failed Bankart repair Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  12. Physical Examination • Comparison to contralateral • Sulcus sign and Gagey signs: inferior laxity • A/PROM • ROM: chondrolysis, hardware impingement, overtightening of capsulolabral complex • RC evaluation • Higher incidence of RCT >40yoa • Open repair: 23% incompetent SubS (positive belly press) and 27% of contralateral • Apprehension and relocation testing Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  13. Imaging • Radiographs: • AP, true AP, axillary • Westpoint • Anteroinferior bone loss • Styker Notch and AP in IR • Hill-Sachs Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  14. CT Scan: Axial and sagittal views Itoi et al.: 21% represents 50% glenoid bone loss Saito et al.: 3 o’clock Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  15. CT scan: humeral head subtracted • When length of lesion is half the diameter of the glenoid: 30% decrease in dislocation force

  16. Bare spot? Not reliable

  17. MR arthrography RCT, HAGL, capsular tears or laxity, posterior extension of Bankart MR not a substitute for CT

  18. Recurrent Instability Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  19. Prospective, 131 consecutive • Mean fu 31 months • Overall recurrence: • 15.3% • Recurrence with bone lesion or hyperlaxity • 75% • Open repair with more than 6 points • Similar studies support findings

  20. How many anchors? Four

  21. Recurrent Instability: Closed v Open • Brophy 2009: roughly equal, 6.4% v 8.2% • Tauber 2004 at revision: 56% bony Bankart, 22% large capsule, 5% laterally torn capsule • Burkhart 2000: closed, 4% without bony, 67% with signicant • Yiannakopoulous 2007: 15.4% with inverted pear (28.8% loss) Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  22. Recurrence: soft tissue • 83-91% reported to have poor capsulolabral tissue or redundancy • Asymmetric or overtightening: Erlenmeyer flask phenomena (tight anteriorly and superiorly and inferior instability)—22% • Improper position of anchors: @ margin of articular surface—46-100% Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  23. Hawkins and Hawkins 1985: 38.7% due to misdiagnosis Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  24. Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  25. Surgery for revision Open Arthroscopic • Levine 2000: 17% failure or 44% if multiple revisions • Scar tissue affects abitility to maintain • Notable decrease in outcome and patient satisfaction • Careful selection: minimal bone loss <15% • Can identify ST pathologies and minimize iatrogenic (Subscap) • Limited evidence, 10-27% recurrence with 78% good-excellent results Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  26. Osteoarticular: Laterjet or Bristow Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  27. Subscapularis: to split or not? Positioning • L-shaped incision: 2/3 split • Decrease muscle power • L-shaped:42% • Split:8% • Lateralization: early OA • Mediliazation: instability • Capsular repair can make the corocoid intra or extra articular • Laterjet: 95% success (Burkart) Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  28. Humeral Head defects • Important for 30% of articular surface • Structural allograft: sized matched humeral heads or femoral head • Artrhoplasty in older patients Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  29. Capsular plication Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

  30. Boone et al. Orth Clin of NA 2010 ; Shah et al. Artrhroscopy 2011 ; OKU 3 Shoulder & Elbow

More Related