Surgical treatment of shoulder sports injuries
Mr Lee Van Rensburg
United Kingdom
Objectives
• Surgical options for shoulder instability
– Glenohumeral• Acute traumatic• Recurrent traumatic
30 YO male,Professional Rugby payer,
Surgical options
Hippocrates 400 BC
• method of reduction
• cauterisation of inferior capsule
Shoulder Instability
Bankart Lesion• Perthes 1906• Bankart 1938
– “essential lesion” of the capsulolabral complex
Uber operation bei habitueller schulterluxation. Perthes G. Dtsch Z Chir 1906
The pathology and treatment of recurrent dislocation of the shoulder joint. Bankart B Br J Surg 1938
Bankart Repair
• Bankart 1938• 1st procedure 1923 on his
former House Surgeon• re-attaching capsule to the
glenoid with transosseous sutures
• repairing subscapularis with NO overlap or shortening
The pathology and treatment of recurrent dislocation of the shoulder joint. Bankart A. Br J Surg 1938
Modified Open Bankart Repair
• Numerous modifications- capsular imbrication- suture anchors
• Multiple series published
• Accepted recurrence rate Open Bankart Repair 8 –12%
• Loss of ER
Arthroscopic Stabilisation
• Johnson 1982
- Arthroscopic Staple Capsulorrhaphy
- Metal Staple
- 106 patients
- > 18 mth F/U
- 21% recurrence
Early complications of acute anterior dislocation of the shoulder in middle-aged and elderly patients. Johnson JR et al. Injury 1982
Staple Capsulorrhaphy
Lane et al 1993
- 54 patients Staple Capsulorrhaphy
- >39 month F/U
- 18 (33%) re-dislocated
- 36 stable – 15 % loose staple + articular injury
- < 50 loss of ER
- Caution in considering Staple Capsulorrhaphy
- ROM & functional level well maintained
Arthroscopic staple capsulorrhaphy: A long term follow-up. Lane JG et al. Arthroscopy 1993
Transglenoid Stabilisation
• Caspari 1988
- Transglenoid arthroscopic stabilisation
- multiple sutures passed through
AI capsule
- transglenoid drill hole
- passed A to P through glenoid
- sutures tied onto infraspinatus
fascia
Arthroscopic reconstruction for anterior shoulder Arthroscopic reconstruction for anterior shoulder instability.instability. Caspari.Caspari. Tech OrthopTech Orthop 1988 1988
Transglenoid Stabilisation
• Torchia 1997
- 150 transglenoid stabilisation
- F/U > 2 yrs
- av age 29yrs (14 – 67)
- 11 dislocations (7.3%)
- areas of risk - P fixation
- < 25 yrs
Arthroscopic transglenoid multiple suture repair: 2- 8 year results in 150 patients. Torchia et al. Arthroscopy 1997
Transglenoid Stabilisation
• Soderlund 2008
- 455 army recruits (1992 – 2000) Questionaire
- 312 (68.5%) responded av 20yr (18-28)
- Av time from surg 6.4yrs (1-14)
- 177 (56%) re-dislocations
Long-term outcome of a transglenoid suture technique for anterior shoulder instability in young adults. Soderlund et al JBJS Br 2008
Bioabsorbable Tack Stabilisation
• Bioabsorbable Tack Stabilisation
Speer 1996
- 52 recurrent dislocators
- Suretac stabilisation
- > 2yr F/U (24 – 60 mth)
- 11 dislocations (21%)
- 7 of 8 open revision Bankart
healed with ‘patulous capsule’
An arthroscopic technique for anterior shoulder stabilisation of the shoulder using a bio-absorbable tack. Speer et al. J BJS Am. 1996
Arthroscopic Stabilisation
• Suture Anchor Stabilisation
- problems staple & transglenoid
fixation
- difficulty in capsule plication
with tacks
- improvements in suture anchor
design
- improvements in instrumentation
Arthroscopic washout
Arthroscopic Stabilisation v Arthroscopic Lavage
•2 yr f/u (1 lavage & 3 stabilisation – lost)
- Re-dislocation
- stab 3/42 ( 7%)
- lavage 16/42 (38%)
- Reduction in risk
- 76% re-disc & 82% instab
Primary arthroscopic stabilisation for a first-time anterior dislocation of the shoulder. Robinson JBJS Am 2008
Suture Anchor Stabilisation
• Metanalysis
Hobby 2007
- 20 suture anchor stabilisation studies
- 1030 patients
- recurrence as end point
- failure rates ranged from 0 – 30%
- most < 10%
Is arthroscopic surgery for chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations. Hobby et al. JBJS Br .2007
Surgical options summary
• Hot Poker in axilla• Open Bankart• Arthroscopic
– Staple– Transglenoid suture– Suture tacks– Arthroscopic washout– Suture anchors
Again?
• Age 30 continues to play what are chances it will happen again
Non-Operative Treatment
Prognosis: age at time of dislocation
12-22 yrs 23-29 yrs 30-40 yrs
Re dislocated 73% 56% 25%
x1 disloc 20% 18% 10%
Recurrence ( > x2)
no surgery 12% 10% 5%
surgery 40% 28% 10%
Non-operative treatment of primary anterior shoulder dislocation in patients forty years and younger. A prospective twenty-five-year follow-up. Hovelius et al JBJS Am 2008
Open Access Journal of Sports Medicine 2011:2 19–24
Diagnostic arthroscopy• Anaesthetic
– GA– Regional block – www.nerveblocks.co.uk
• Interscalene block• Supraclavicular +- Axillary nerve block
• Setup– Beach position– Lateral position
• Skin preparation– Alcohol/ chlorhexidine preparation
• Propriono bacterium acnes
• Prophylactic antibiotics– Implant surgery– P acnes
• Flucloxacillin _+- Gentamycin
• Alcohol and chlorhexidine, superior to povidone iodine
J Bone Joint Surg Am. 2009;91:1949-53
Diagnostic arthroscopy
• Equipment– Arthroscopy stack
• 30 degree scope– Fluid management system– High flow arthroscopy trocars– Radiofrequency probe– Arthroscopic shaver– Suture passers– Anchors
Diagnostic arthroscopy• Portals
– Posterior – viewing portal– Anterior- working portal (inside out, spinal needle)
• Procedure– Biceps anchor– Anterior labrum– MGHL– Subscapularis– SGHL (Pulley)– Biceps (tunnel)– Supraspinatus– Infraspinatus– Inferior recess– Articular surfaces
• Glenoid• Humeral head
• Closure– Subcuticular prolene
Portal Placement
• Anterior Portal – 2nd ‘working’ gleno-humeral portal
21
Arthroscopic Bankart
Diagnostic Arthroscopy
Suture Anchor Insertion
Knott Tying
Second Anchor
Arthroscopic stabilisation
Arthroscopic stabilisation
SLAP tears
1 Frayed
2 Superior A and P
32 + bucket handle
4Bucket into biceps
5 Assoc dislocation
62 with A or P labral flap
7Tear into MGHL
82 + P labrum
92 + Circumferential labrum
102 + P + Inf labrum
SLAP tears
• Options– Debridement
• Type 1
– Re attachment (SLAP repair)– Biceps tenotomy/ tenodesis
J Shoulder Elbow Surg (2011) 20, 326-332
Again?
• Recurrence rates– Arthroscopic (suture anchor) 8-11%– Open (Bankart) 0-11%
• Arthroscopic slightly better ROM
Sports Health. 2011 Jul;3(4):396-404.
Glenoid Bone Loss
• Re-Dislocation
- 194 arthroscopic stabilisations- 21 significant bone loss
- no bone loss 4% recurrence- inverted pear 61% recurrence
- “Inverted Pear” 25% of glenoid surface area
Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the glenoid’s “inverted pear” and the humeral “engaging Hills-Sachs lesion”. Burkhart & De Beer Arthroscopy 2000
• Glenoid• Concavity depression• De Beer – Inverted pear• Deficiency antero inferior diameter >25%
– Augment glenoid
• Humeral• Hills sachs lesion• Engaging Hill Sachs lesion
– Dx Arthroscopy– Address humerus
J Shoulder Elbow Surg (2009) 18, 317-328
Glenoid defects
• Eden Hybbinette ( 1918/ 1932)• Initially Tibia• Now iliac crest
• Bristow (Helfett 1958)• 1-2 cm Coracoid transfer distal to pectoralis minor• Single screw
• Latarjet (1954)• Larger 2-3 cm• Length ways 2 screws• Arthroscopic
Latarjet
• Massive Hill-Sachs lesion• >25% volume of the humeral
head• Management
- rotational osteotomy
- hemiarthroplasty
- infraspinatus transfer
- osteo-articular allograft
- arthroscopic remplissage
Humeral defects
Humeral Bone Loss
• Osteoarticular humeral head allograft
- 18 patients failed surgery
with >25% Hill-Sachs
- osteoarticular allograft
- 0 recurrence at 2 yrs
- early x-ray evidence of
allograft collapse
Recurrent anterior instability following failed surgical repair: Allograft reconstruction of large humeral defects. Miniaci, Tytherleigh-Strong. JBJS 2001
Arthroscopic Remplissage
• arthroscopic Bankart
• capsulodesis and infraspinatus tenodesis
SummaryYoung sports dislocation
1 week
- Plain x-ray
- CT
- CT recon
Bone loss
Practically
• Arthroscopic Bankart with anchors– 1st time dislocator– Recurrent with no bony defect
• Open Latarjet– Failed arthroscopic Bankart– Bony defects (glenoid)– Chronic dislocation
J Bone Joint Surg Am. 2009;91:966-78
The End