double row repairs: for the labrum? › wp-content › uploads › 2016 › 02 › ... · 2/8/2016...
TRANSCRIPT
2/8/2016
1
MANAGEMENT OF ANTERIOR INSTABILITY
WITH AND WITHOUT BONE LOSS
Josh Dines, MDSports Medicine and Shoulder Service
FORE Current Solutions in Shoulder & Elbow Surgery
Tampa FL; Feb 5-7, 2016
HISTORY
How it occurred?
How was it put back in?
How many times?
Goals of the patient?
Age at first dislocation?
PHYSICAL EXAM
1. Generalized Laxity
2. Unstable at Midrange motions• Apprehension (+) at lower degrees of Abduction
and decreased ER
2/8/2016
2
• X-rays– Hill - Sachs
– Bony Bankart
– Head Centered
• MRI – If > 40 to r/o rotator cuff
tear
– If surgery considered
• CT – If concerned with bone loss
IMAGING
OPERATIVE VS NON-OPERATIVE
Systematic Review
Study Con Surg Con Surg Con Surg Con Surg
Arciero 15 21 19.5 20.5 23 32 80 20
Bottoni 12 9 23 21.6 37 36 75 11
Kirkley 15 16 22.7 23.3 79 79 60 20
Kirkley 21 19 22.8 22.1 36 32 47 16
Jakobsen 39 37 20 23 120 120 62 8
Yannmis 32 30 22 21 40 33 38 3
Robinson 45 43 24.3 25.3 24 24 38 7
Totals 158 156 52.5 9.6
Patients (N) Mean Age (yrs) Mean F/U (mos) Recurrence (%)
Modified from Brophy, Arthroscopy, 2009
KNOTLESS BANKART REPAIR
2/8/2016
3
RESULTS OF ARTHROSCOPIC STABILIZATION
Some Failures Remained…
Morgan (transglenoid sutures) 33%
Staples 23%
Caspari (transglenoid sutures 22%
Sutures + Anchors/HSS Series 18%
Voos et al AJSM 2010
REASONS FOR FAILURE: BONE DEFECTS
GLENOID BONE LOSS
Burkhart, Debeer et al. Arthroscopy 2007
• 194 patients without bone
loss: 4% recurrence
• 21 patients with significant
bone loss: 67% recurrence
2/8/2016
4
GLENOID BONE LOSS
Burkhart, Debeer et al. Arthroscopy 2007
Begun using Latarjet for >25%
bone loss
– 104 patient
4.7% recurrent instability
PREVENTING RECURRENCE:
PROPER PREOPERATIVE PLANNING
XR/CT/MRI findings; Patient Factors
0-10% Bone Loss > 20-25% Bone loss10-20%; Good
Tissue Quality
Arthroscopic (+)
- Double Row
- Remplissage
GOOD PREOPERATIVE IMAGING
CT Scan
• En Face Sagittal View
• 3D Reconstructions
2/8/2016
5
320 Matrix, 3T CT
*Different Patients
CT
THE FUTURE? ZTE PROTOCOL
320 Matrix, 3T
24M
ZTE PROTOCOL
LATARJET PROCEDURE
‘Bone Block effect + Sling effect + Bumper Effect’
2/8/2016
6
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
1.0
2.0
3.0
4.0
5.0
Max IR 30 IR 0 ER 30 ER Max ER
Po
ste
rio
r
[mm
] A
nte
rio
r
Change in Humerus Position Following Capsulotomy and LatarjetAnterior-Posterior
Capsulotomy
Latarjet
Conjoint
Unloaded
With conjoint loaded in ER, head moved posteriorly; with tendon
unloaded, shifted anterior
Significant effect of conjoint tendon!
BIOMECHANICAL ANALYSIS OF THE MODIFIED LATARJET
PROCEDURE IN A CADAVERIC ANTERIOR SHOULDER
INSTABILITY MODEL DINES JSES 2013
LATARJET RESULTS
Gilles Walch
- > 2500 Latarjets
- Recurrence rate <2%
LATARJET IS GREAT BUT….
• Non-Anatomic
• Short- Term Complications
– 25% incidence
– Infection
– Recurrent Instability
– Nerve InjuryShah, Warner JP. JBJS 2012
• Long- Term Complications
Pain / screws, OA…
Osteolysis, Nonunion
2/8/2016
7
PREVENTING RECURRENCE:
PROPER PREOPERATIVE PLANNING
XR/CT/MRI findings; Patient Factors
0-10% Bone Loss > 20-25% Bone loss10-20%; Good
Tissue Quality
Arthroscopic (+)
- Double Row
- Remplissage
PREVENTING RECURRENCE:
PROPER PREOPERATIVE PLANNING
XR/CT/MRI findings; Patient Factors
0-10% Bone Loss > 20-25% Bone loss10-20%; Good
Tissue Quality
Arthroscopic (+)
- Double Row
- Remplissage
21
INDICATIONS FOR
ARTHROSCOPY +
• Bone loss <20%
• Poor quality ligaments
• Revision surgery
• Extreme sports participation
2/8/2016
8
BANKART + REMPLISSAGE
THIS APPLIES TO CAPSULE/LABRUMDOUBLE ROW LABRAL REPAIRS:
AIGHL-LC ATTACHMENT ANATOMY
Itoigawa Y, Itoi E, et al. Attachment of AI Glenohumeral Ligament-Labrum
Complex to the Glenoid: Anatomic Study. Arthroscopy 2012.
2/8/2016
9
RECREATION OF ANATOMY
Kim D. et al. SR vs DR Capsulolabral Repair: Comparative Evaluation of
Contact Pressures. AJSM 2012.
39.4% 78.4%
AIGHL-LC ATTACHMENT ANATOMY
Dines J, Thompson M, Altchek D, McGarry M, Lee TQ.
1st part of study:
Labral tear Measure IR/ER, translation
Dissecting capsule off IR/ER, translation
2nd part of study:
3-anchor single row repair, simple knots
double row with 3 anchors laterally; 2 medially
AIGHL-LC ATTACHMENT ANATOMY
Dines J, Lee TQ et al. Accepted for Publication Arthroscopy
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
10N A 10N P 15N A 15N P
An
t-In
f o
r P
ost-
Inf
[mm
]
Glenohumeral Translation at 60 ER
Intact
Bankart
Double Row Repair
P < 0.05* vs. Intact+ vs. Bankart
+
+
*
2/8/2016
10
AIGHL-LC ATTACHMENT ANATOMY
Dines J, Lee TQ et al. Accepted for Publication Arthroscopy
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
400.0
450.0
500.0
Yield Load Ultimate Load
Lo
ad
(N
)
Yield Load and Ultimate Load
Single Row
Double Row
2/8/2016
11
2/8/2016
12
RESULTS
• Lafosse et al. Cassiopeia
– 12 patients
– No short term complications
• Ahmad et al. TSES 2012
– 6 Patients
– No Short Term complications
CONCLUSIONS
• Good preoperative imaging critical
• Ideal treatment based on bone loss +
expectations
• Arthroscopic Stabilization can provide
good to excellent results in majority of
cases
• Need to be aware of patients at high risk
for redislocation• Candidates for advanced arthroscopic or
open stabilization