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Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic Sports Medicine Fellowship Emory Healthcare Sports Medicine

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Page 1: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Spero G. Karas, MDHead Team Physician- Atlanta

FalconsTeam Physician- Georgia Tech Baseball

Associate Professor of OrthopaedicsDirector, Orthopaedic Sports Medicine Fellowship

Emory Healthcare Sports Medicine

Page 2: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Labral complex

“Bumper”- deepens glenoid

Attachment of glenohumeral ligaments

Page 3: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Glenohumeral ligaments

SGHL- Rotator intervalMGHL IGHLAnt and post bandsAxillary pouch

Page 4: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Rotator Interval

SGHLCHLBiceps

Page 5: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

FOOSH

AbER injury

Direct Trauma

Page 6: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Subluxation vs Dislocation

ER reduction“Popped it in myself”

“Went in and out”

Page 7: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

“Load and Shift”

Grade 1- up faceGrade 2- on rimGrade 3- over rim

Page 8: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

AbER reproduces symptoms

Posterior force relieves symptoms

Page 9: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Inferior translation

Interval lesion

Resolves in external rotation?

Page 10: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Bankart Lesion

Caps-labral complex off glenoid

Classic lesionTraumatic Dislocators

Page 11: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Bony Bankart Lesion

Bankart lesion with anterior glenoid rim fracture

Page 12: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

ALPSA lesion

Healed BankartTension off GH ligaments

Release and repair anatomically

Page 13: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Tear/deficiency of interval capsule

Restraint to inferior translation

Sulcus sign

Page 14: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Humeral Avulsion of Glenohumeral Ligaments

≈10% of patients

Pre-op MRI

Usually open Repair

Recently Arthroscopic

Karas, Spang Arthroscopy 2005

Page 15: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Glenolabral Articular Disruption

Superficial anterior-inferior labral tear

Associated with anterior-inferior articular cartilage injury

Page 16: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Posterior Humeral Head Defect

Increased Dislocation Rate

“Remplissage”

Fills defect with infraspinatus

Page 17: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Plain Film

Orthogonal viewsBony BankartHill Sachs lesion

Page 18: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

MRI

Capsular anatomy Bankart v HAGL

Glenoid insufficiency (CT better)

Interval lesion SLAP Arthrogram improves

technique

Page 19: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Recurrence Rates

Skeletally immature: near 100%

<22: 50-85%23-40: 25-50%>40: low

Sling Management

External rotation?S

trengthening program

Bracing?

Page 20: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Indications

Age? Sport? Hill Sachs? In season / pre-season

athlete Full ROM and Strength Brace (If not a thrower) Recurrence:

1.4/athlete/seasonBuss, AJSM, 2004

Page 21: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

External Rotation Immobilization

F/U 15 mos Recurrence IR- 30% ER- 0 Recent information not a

favorable… Probably does work better

than internal rotation (Hovelius 1996; Kiviluoto, 1980)

Page 22: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic
Page 23: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

ResultsResults

StudyStudyNN

%f/u%f/uRecurrenceRecurrence

Surgery GroupSurgery GroupRecurrence Recurrence

Nonop.Nonop.GroupGroup

P-valueP-value ClinClinSignifSignif

KirkleyJARS, 1999

4095%

16%(3/19)

47%(9/19)

0.03 31%31%

YESYES

BottoniAJSM, 2002

2488%

10%(1/10)

64%(9/14)

NR 54%54%

YESYES

WintzellJSES, 1999

30100%

20%(3/15)

56%(9/15)

0.03 36%36%

YESYES

Page 24: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Nonoperative Treatment Has a Higher Recurrence

Rate than Arthroscopic Repair

Page 25: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Can arthroscopic instability procedures reproduce open results?

Yes:Caspari, Savoie,

Romeo, Gartsmann No:

Guanche, Walch

Page 26: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

DiagnosisHill Sachs, HAGL,

Glenoid Insufficiency Address labral injury Treat capsular

redundancyPlication/ShiftETAC

Interval Closure? Rehabilitation

Page 27: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Open ShiftLubowitz, CORR,

’96○54-60%

Karas, et al, JSES, ‘04○51%

Miller, ASES, ’01○Lateral- 49%○ Vertical- 40%○Medial- 37%

Page 28: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Arthroscopic ShiftSuture Plication- 19%

ETAC- 33%Plication + ETAC- 41%

Used only four tucks and no interval closure

Page 29: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic
Page 30: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic
Page 31: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic
Page 32: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Glenoid deficiency

Bone GraftLaterjet

Multiple dislocations

Large HSL

Laxity ↑↑

Page 33: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Common Injury

Contact Athletes

High Recurrence Rates

Non-operative Management:

Older patients Sport dependent In-season athletes

Arthroscopy Decreases Recurrence Rates

Open Surgery

Multiple Recurrences Large Hill Sachs Glenoid Bone

Deficiency

Page 34: Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball Associate Professor of Orthopaedics Director, Orthopaedic

Thank You ! Spero G. Karas, [email protected]

www.sperokaras.com


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