Pre-Op Athletic Participation 132 patients Recreational – 101 High School – 8 College – 21 Professional – 2 Recreational – 101 High School – 8 College – 21 Professional – 2

Operative Time – 63 minutes Number of sutures – 6 (3-9) Operative Time – 63 minutes Number of sutures – 6 (3-9)

Repeat Surgery for Instability 13 patients 8.6% 13 patients 8.6%

Subjective Symptoms 12 patients 8% 12 patients 8%

Bankart Scoring System Excellent 90 – 100 Good 75 – 89 Fair 51 – 74 Poor 0 – 50 Excellent 90 – 100 Good 75 – 89 Fair 51 – 74 Poor 0 – 50

Suture Technique Avg. Pre-op Bankart Score : 27 Avg. Post-op Bankart Score : 90 Avg. Pre-op Bankart Score : 27 Avg. Post-op Bankart Score : 90

Suture Technique Multiple attachments Superior and medical capsular advancement Avoid screw / staples about the shoulder Multiple attachments Superior and medical capsular advancement Avoid screw / staples about the shoulder

Previous Surgery Not a contradiction to arthroscopic reconstruction

Arthroscopic Reconstruction of the Shoulder

Suture Technique Suture Punch Five to Eight Sutures in Labrum Suture Punch Five to Eight Sutures in Labrum

Suture Technique Debridement

Suture Technique Abrade Anterior Glenoid Neck

Suture Technique Sutures placed through Beath Pin Sutures pulled posteriorly Sutures placed through Beath Pin Sutures pulled posteriorly

Arthroscopic Mulitsuture Repair for Anterior Instability 2 – 8 year follow up 150 Shoulders

Savoie – Caspari 1988 – 2 year follow up 50 shoulders 4% redislocation 4% resubluxation 1988 – 2 year follow up 50 shoulders 4% redislocation 4% resubluxation

Arthroscopic Bankart Results Torchia Caspari

M/M Follow Up 2 – 8.2 years Mean – 4.1 years Minimum – 2 years 2 – 8.2 years Mean – 4.1 years Minimum – 2 years

150 Patients 3.6 year follow up

Chief Complaint Instability – 125 cases Overhead pain – 25 cases Instability – 125 cases Overhead pain – 25 cases

Etiology Trauma – 121 cases Repetative Microtrauma – 29 cases Trauma – 121 cases Repetative Microtrauma – 29 cases

Symptomatology Documented dislocation – 61 cases Duration of symptoms – 49 mos. (3 – 360) Documented dislocation – 61 cases Duration of symptoms – 49 mos. (3 – 360)

Symptomatology Sleep – 42 cases ADL’s – 85 cases Sports – 29 cases Sleep – 42 cases ADL’s – 85 cases Sports – 29 cases

Pre-op Surgical Procedures 34 Cases Open Stabilizations – 6 cases –Bankart – 1 –Bristow – 1 –Dutoit – 1 –Putti – Platts – 3 Open Stabilizations – 6 cases –Bankart – 1 –Bristow – 1 –Dutoit – 1 –Putti – Platts – 3

Pre-Op Surgical Procedures 34 Cases Arthroscopic Stabilizations – 4 Bankart – 1 Allografts – 2 Staple – 1 Arthroscopic Stabilizations – 4 Bankart – 1 Allografts – 2 Staple – 1

Pre-Op Surgical Procedures 34 Cases Other procedures –Arthroscopic Acromioplasties – 9 –Arthroscopic Labral Excisions – 8 –Diagnostic Arthroscopy – 1 –Arthroscopic Staple Removal – 1 Other procedures –Arthroscopic Acromioplasties – 9 –Arthroscopic Labral Excisions – 8 –Diagnostic Arthroscopy – 1 –Arthroscopic Staple Removal – 1

Pre-Op Surgical Procedures 34 Cases Other procedures – 24 cases –Open Acromioplasties – 2 –Suprascapular nerve decompression – 1 –Arthroscopic Synovectomy – 1 –Rotator Cuff Debridement – 1 Other procedures – 24 cases –Open Acromioplasties – 2 –Suprascapular nerve decompression – 1 –Arthroscopic Synovectomy – 1 –Rotator Cuff Debridement – 1

Photo of Athlete – swimmer gymnast or thrower.

Exam under anesthesia Dislocation – 86 75% Translocation – 45 50% Translocation – 5 Not Recorded – 14 Dislocation – 86 75% Translocation – 45 50% Translocation – 5 Not Recorded – 14

Photo doing exam in OR

Operative Findings Hill Sachs Lesions – 112 (51 superficial – 61 Deep) Bankart Lesions – 97 Capsular Laxity – 84 Hill Sachs Lesions – 112 (51 superficial – 61 Deep) Bankart Lesions – 97 Capsular Laxity – 84

Operative Findings Rotator Cuff tears – 20 (16 partial – 4 full thickness) Glenoid deficiency – 19 SLAP Lesions – 2 (Types I & III) Rotator Cuff tears – 20 (16 partial – 4 full thickness) Glenoid deficiency – 19 SLAP Lesions – 2 (Types I & III)

Photo of OR team doing shoulder surgery

M.E. Torchia, M.D. R.B. Caspari, M.D. M.A. Asselmeier, M.D. W. R. Beach, M.D. M. Garyari, M.S. M.E. Torchia, M.D. R.B. Caspari, M.D. M.A. Asselmeier, M.D. W. R. Beach, M.D. M. Garyari, M.S.

Arthroscopic Picture of Bankart Lesion

Reproduce slide by Maki***

Slide of ancients reducing a shoulder

M/M 1984 – Shoulders 150 Follow-up (96%) 1984 – Shoulders 150 Follow-up (96%)

M/M Chronic documented instability Single surgeon (RBC) Consecutive Procedures No Preselection Chronic documented instability Single surgeon (RBC) Consecutive Procedures No Preselection

Consecutive Procedures All patients with anterior instability were treated with arthroscopic repair

No Preselection Activity level Degree of laxity Prior surgery Pathological findings Activity level Degree of laxity Prior surgery Pathological findings

Chart Review Telephone Contact Recurrent dislocation Recurrent subluxation Bankart scores Revision surgery Recurrent dislocation Recurrent subluxation Bankart scores Revision surgery

M/M Follow-up Examination 31 Patients Physical Examination X-Rays Physical Examination X-Rays

Other Factors Operative time Number of sutures Duration of immobilization Post-op Complications Operative time Number of sutures Duration of immobilization Post-op Complications

Other Factors Pattern of Instability Degree of Instability Age Sex Extremity Dominance Pattern of Instability Degree of Instability Age Sex Extremity Dominance

Other Factors Athletic Activity Pre-op Physical Exam Previous Procedures Exam under anesthesia Athletic Activity Pre-op Physical Exam Previous Procedures Exam under anesthesia

Survival Analysis and Statistical Methods Kaplan – Meyer Method Predicts cumulative probability of failure as a function of time

Survival Analysis and Statistical Methods Peto – Peto Univariate analysis to setermine effect of patient and operative variables on probability of failure

Patient Characteristics 147 patients – 150 shoulders Mean Age – 29 years (14 – 67) 147 patients – 150 shoulders Mean Age – 29 years (14 – 67)

Patient Characteristics 104 men 43 women 97 dominant extremities 104 men 43 women 97 dominant extremities

Overview of Meniscal Lesions : Indications for repair John F. Meyers, M.D.

Introduction Meniscal injuries common Twisting mechanism Meniscal injuries common Twisting mechanism

Incidence Stable knees medial > lateral ACL Tears –Acutelateral > medial –Chronicmedial > lateral Stable knees medial > lateral ACL Tears –Acutelateral > medial –Chronicmedial > lateral

Treatment Options Excise Leave alone Repair Excise Leave alone Repair

Treatment History Total meniscectomy –Joint deterioration Partial Meniscectomy –Mixed results Total meniscectomy –Joint deterioration Partial Meniscectomy –Mixed results

Treatment History 1883 – Annadale 1936 – King 1948 – Fairbank 1969 – Ikeuchi 1970 – Dehaven 1980 – Henning 1883 – Annadale 1936 – King 1948 – Fairbank 1969 – Ikeuchi 1970 – Dehaven 1980 – Henning

Basic Science Anatomy –Fibrocartilagenous –Semilunar –Concave superior –Flat / concave inferior –Medial “C” shape –Lateral “O” shape Anatomy –Fibrocartilagenous –Semilunar –Concave superior –Flat / concave inferior –Medial “C” shape –Lateral “O” shape

Basic Science Vascular anatomy –Age dependent –Skeletal maturity –Peripheral penetration Medial 10 – 30% Lateral 10 – 25% Vascular anatomy –Age dependent –Skeletal maturity –Peripheral penetration Medial 10 – 30% Lateral 10 – 25%

Basic Science Histology –75% collagen –90% type I collagen –Fibers Circumferential Radial “ties” “hoops” Histology –75% collagen –90% type I collagen –Fibers Circumferential Radial “ties” “hoops”

Basic Science Function –Load bearing –Shock absorption –Joint stability –Joint lubrication Arnoczky et al, 1987 AAOS Function –Load bearing –Shock absorption –Joint stability –Joint lubrication Arnoczky et al, 1987 AAOS

Basic Science Healing sequence –Fibrin clot –Capillary budding –Fibrovascular scar –Fibrocartilage Healing sequence –Fibrin clot –Capillary budding –Fibrovascular scar –Fibrocartilage

Tear Classification Vascular Zone Position Pattern Vascular Zone Position Pattern

Vascular Zones Red-red Red-white White-white Red-red Red-white White-white

Indications No treatment –Partial thickness –<5mm length –<2mm displacement No treatment –Partial thickness –<5mm length –<2mm displacement

Indications Partial meniscectomy –Tear not amenable to repair Partial meniscectomy –Tear not amenable to repair

Indications Repair –Peripheral tear –Longitudinal tear –Young patient Repair –Peripheral tear –Longitudinal tear –Young patient

Indications Ideal repair situation –Traumatic tear –Acute injury –Vascular zone –Tear length > 7mm –Stable knee Ideal repair situation –Traumatic tear –Acute injury –Vascular zone –Tear length > 7mm –Stable knee

Contraindications Unstable knees > 5mm rim width Multiple longitudinal tears Non-surgical tears Unstable knees > 5mm rim width Multiple longitudinal tears Non-surgical tears

Special Tear Situations ACL Posterior horn LM Radial Avascular Zone ACL Posterior horn LM Radial Avascular Zone

Repair Techniques Open Outside – In Inside – Out All Inside Open Outside – In Inside – Out All Inside

Augmentation Techniques Fibrin clot Trephination Synovial abrasion Collagen scaffold Fibrin clot Trephination Synovial abrasion Collagen scaffold

Fibrin Clot Technique 50 – 70 cc venous blood Clot forms Clot tubularized or aspirated Cannula insertion or injected 50 – 70 cc venous blood Clot forms Clot tubularized or aspirated Cannula insertion or injected

Meniscal Repair Conclusion Alternative Treatment Restores Function Protective Effect Alternative Treatment Restores Function Protective Effect

Suture Technique Sutures tied over infraspinatus Fascia

Suture Technique Shoulder Immobilizer X 3 Weeks Out for Pendulum Exercises Daily Shoulder Immobilizer X 3 Weeks Out for Pendulum Exercises Daily

Post Repair Instability : Conventional Reconstruction Torg 8.5% : Modified Bristow Reconstruction Rowe 3.5% : Modified Bankart Reconstruction O’Driscoll 21% : Dutoit Staple Capsulorraphy Torg 8.5% : Modified Bristow Reconstruction Rowe 3.5% : Modified Bankart Reconstruction O’Driscoll 21% : Dutoit Staple Capsulorraphy

Post Repair Instability : Arthroscopic Reconstruction Johnson 15% : Staple Capsulorraphy Matthews 33% : Staple Capsulorraphy Johnson 15% : Staple Capsulorraphy Matthews 33% : Staple Capsulorraphy

49 Suture Repairs

Re-Evaluation 2 – 6 Year post reconstruction Bankart Score Rowe : JBJS – 6 Year post reconstruction Bankart Score Rowe : JBJS 1978

Arthroscopic Bankart Repair 92% Satisfactory Results Decreased Morbidity Simple Technique, Avoid Staples or Screws Acceptable Method of Primary Reconstruction of the Unstable Shoulder 92% Satisfactory Results Decreased Morbidity Simple Technique, Avoid Staples or Screws Acceptable Method of Primary Reconstruction of the Unstable Shoulder

Post Repair Instability : Suture Repair Two Dislocations Two Subluxations Two Dislocations Two Subluxations

Open Surgicval Procedures for Anterior Shoulder Instability Repair of Capsule & Labrum Muscle and Capsule Plication Procedures Capsulorraphies Muscle & Tendon Sling Procedures Bone Block Procedures Osteotomies Repair of Capsule & Labrum Muscle and Capsule Plication Procedures Capsulorraphies Muscle & Tendon Sling Procedures Bone Block Procedures Osteotomies

Arthroscopic Procedures for Anterior Shoulder Instability Staple Capsulorraphy Rivet Capsulorraphy Cannulated Screw Fixation Allograft Reconstruction Bioabsorbable Tack Suture Repair Technique Staple Capsulorraphy Rivet Capsulorraphy Cannulated Screw Fixation Allograft Reconstruction Bioabsorbable Tack Suture Repair Technique

AIGHL must be sectioned to create anterior instability.

Shoulder Instability Classification & Differential Diagnosis Dislocation : “The complete displacement or disarrangement of the normal relation of the bones entering into the formation of a joint.”

Shoulder Instability Classification & Differential Diagnosis Subluxation : “An incomplete dislocation : though a relationship is altered contact between joint surfaces remains.”

Recurrent Anterior Instability Cofiekd : 82% < 20 years old Hovelius : 50% < 22 years old Cofiekd : 82% < 20 years old Hovelius : 50% < 22 years old

Recurrent Anterior Instability Rowe : 92% < 20 years old Henry : 90% recurrence rate Rowe : 92% < 20 years old Henry : 90% recurrence rate

Arthroscopic Findings in the Subluxating Shoulder F. J. McGlynn & R. B. Caspari C.O.R.R. 1984

Labral Detachment Hill-Sach Lesion Incompetent AIGHL Labral Detachment Hill-Sach Lesion Incompetent AIGHL