Gonzalo Samitier Hospital General de Villalba (Madrid)

MANEJO DE LOS DEFECTOS ÓSEOS EN LA INESTABILIDAD

Am J Sports Med. 2009 Apr;37(4):669-73 Long-term follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocations in young athletes. Owens BD1, DeBerardino TM, Nelson BJ, Thurman J, Cameron KL, Taylor DC, Uhorchak JM, Arciero RA.

Arthroscopy. 2013 May;29(5):920-33 Long-term outcomes after Bankart shoulder stabilization. Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM, Cole BJ, Bach BR Jr, Romeo AA, Verma NN.

Balg F, Boileau P. The instability Severity Index Score (ISIS score). A rationale approach for patient selection in arthro- scopic Bankart repair. J Bone Joint Surg (Br) 2007;89:1470—7.

NO TIENE EN CUENTA:

- Pobre calidad de los tejidos- Laxitud de los tejidos- Número de recurrencias- No cuantifica el grado de

pérdida ósea

FRENCH

NON FRENCH

BOILEAU LAFOSSE WALCH

0 104 653 7

0 104 653 7

Itoi et al. JBJS Am 2000 Burkhart et al. Arthroscopy 2002 Yamamoto, Itoi et al. JBJS 2010

25%17%

Di Giacomo G, Itoi E, Burkhart SS. Arthroscopy. 2014 Jan;30(1):90-8.

- Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from "engaging/non-engaging"

lesion to "on-track/off-track" lesion -

Algorithm treatment

TREATMENT OPTIONS

• GLENOID BONE LOSS – Latarjet Open – Iliac crest vs – Fresh allograft Arthroscopic

• HUMERAL BONE LOSS – Remplissage – Fresh allografts

Arthroscopy. 2014 Sep;30(9):1184-211 Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature. Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V.

Journal of Arthroscopy 2009 Vol 25, No 4 (April), 2009: pp 446-452 Anatomic Osteochondral Glenoid Reconstruction for Recurrent Glenohumeral Instability With Glenoid Deficiency Using a Distal Tibia Allograft LCDR Matthew T. Provencher, M.D., MC, USN, Neil Ghodadra, M.D., Lance LeClere, M.D., MC, USN, CDR Daniel J. Solomon, M.D., MC, USN, and Anthony A. Romeo, M.D.

LATARJET

BONE BLOCK EFFECT (BUTÉE)

SLING EFFECT

What are the Indications …?

LAURENT LAFOSSE

ANNECY

WHY ARTHROSCOPIC ??!!!

What a man can do another man can do ...

VIDEOTECHNIQUE

Operative difficulties

1. Subscapularis Split level 2. Passing through the subscapularis 3. Conditions of visualization 4. Positioning of the wires

RESULTS

High satisfaction index (>95%) Extremely low recurrence rate (1.5%)

__

- Problems & Complications (25%)

- Revision rate is low (3.7%)

- ER limitation - OA ?

COMPLICATIONS

• Breakage • Neuro-vascular damage • Malpositioning • Coracoid graft osteolysis • Non Union • Mobilization of the screws • Limited external rotation • Infection • Glenohumeral arthrosis

Complications 337 cases

–8 malunion –3 stiffness –4 Recurrent Instability –32 screw removals –3 revision by Iliac crest

SFA 2015Complications on 1555 cases

since each surgeon first @Latarjet

1st @ Latarjet

NB NEURO INF HEMAT FRACT GRAFT

RECUR DISLOC

REVISION

LL 2003 500 2 2 4 4 5 17JL 2007 145 0 2 1 2 6 20RB 2009 246 0 0 2 0 2 4PC 2009 240 1 1 0 2 3 3GN 2010 202 0 0 0 4 4 4PM 2010 222 1 5 0 2 10 10

Total 1555

4 0,2%

10 0,6%

7 0,4%

14 1%

30 2%

58 3,7%

George S. Athwal, M.D., F.R.C.S.C., Robert Meislin, M.D., Charles Getz, M.D., David Weinstein, M.D., and Paul Favorito, M.D.

Short-term Complications of the Arthroscopic Latarjet Procedure: A North American Experience

“The rate of adverse events reported in this arthroscopic series is not insignificant and is

similar to that reported with the traditional open Latarjet”

Superior osteolysis

Massive osteolysis

TOO HIGH TOO PROUD

TOO MEDIAL

TOO LOW

TOO SUPERFICIAL

TOO MUCH !!

NON-UNION

SCREW MOBILIZATION

BREAKAGE SCREWS

SUMMARY - Bone loss is probably single most important factor for recurrence of instability

- Preoperative bone loss quantification is critical

- Bone loss <10% Bankart

- Bone loss >20% Latarjet

- 10-20% look for other significant risk factors: age, activity-overhead, off track, # dislocations, revision, intraoperative factors (soft tissue quality/laxity)

- With significative bone loss or moderate + risk factors, Latarjet is probably the most reliable operation to avoid recurrence

- Personal preference Arthroscopic/Open: Complication/Recurrence rate is not insignificant both

SUMMARY• Arthroscopic Latarjet is only since 2007 and is here to stay … Improvement of the

Procedure and Devices is still needed

• - In shoulder instability there is no procedure without risk or complications … INACTION IS AN ACTION ITSELF

• Most patient do Well with minimal recurrencies

• Complication rate is high but not higher than open surgery

• Complication = Revision (3.7%)

• Unanswered Questions Remain … Indications, graft placement, Osteolysis

• Doable/Learning Curve

• “When in doubt … Chicken out” … conversion to Open surgery is possible at any stage

… Gracias