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 st 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 Arthroscopic Staple Capsulorrhaphy - Metal Staple 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 patients Staple Capsulorrhaphy - >39 month F/U - 18 (33%) re-dislocated - 36 stable – 15 % loose staple + articular injury - < 5 0 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 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 instability. Caspari.Tech Orthop 1988 Arthroscopic reconstruction for anterior shoulder instability. Caspari. Tech Orthop 1988

Transglenoid Stabilisation Torchia 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 army recruits (1992 – 2000) Questionaire (68.5%) responded av 20yr (18-28) - Av time from surg 6.4yrs (1-14) (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 Speer 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%) - lavage16/42 (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 suture anchor stabilisation studies 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 yrs yrs 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 – 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:

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 – 2 nd ‘working’ gleno-humeral portal 2 1

Arthroscopic Bankart

Diagnostic Arthroscopy

Suture Anchor Insertion

Knott Tying

Second Anchor

Arthroscopic stabilisation

SLAP tears 1 Frayed 2 Superior A and P bucket handle 4 Bucket into biceps 5 Assoc dislocation 6 2 with A or P labral flap 7 Tear into MGHL P labrum Circumferential labrum P + Inf labrum

SLAP tears Options – Debridement Type 1 – Re attachment (SLAP repair) – Biceps tenotomy/ tenodesis

J Shoulder Elbow Surg (2011) 20,

Again?

Recurrence rates – Arthroscopic (suture anchor) 8-11% – Open (Bankart) 0-11% Arthroscopic slightly better ROM Sports Health Jul;3(4):

Glenoid Bone Loss Re-Dislocation 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,

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

Summary Young sports dislocation 1 week

- Plain x-ray - CT - CT recon Bone loss

Practically Arthroscopic Bankart with anchors – 1 st 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