1. Surgical treatment of shoulder sports injuries Mr Lee Van Rensburg United Kingdom

2. Objectives Surgical options for shoulder instability – Glenohumeral Acute traumatic Recurrent traumatic

3. 30 YO male,Professional Rugby payer,

4. Surgical options

5. Hippocrates 400 BC method of reduction cauterisation of inferior capsule Shoulder Instability

6. 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

7. Bankart Repair Bankart 1938 1 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

8. Modified Open Bankart Repair Numerous modifications - capsular imbrication - suture anchors Multiple series published Accepted recurrence rate Open Bankart Repair 8 – 12% Loss of ER

9. 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

10. 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 - < 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

11. 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 instability. Caspari.Tech Orthop 1988 Arthroscopic reconstruction for anterior shoulder instability. Caspari. Tech Orthop 1988

12. 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

13. 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

14. 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

15. Arthroscopic Stabilisation Suture Anchor Stabilisation - problems staple & transglenoid fixation - difficulty in capsule plication with tacks - improvements in suture anchor design - improvements in instrumentation

16. 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

17. 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

18. Surgical options summary Hot Poker in axilla Open Bankart Arthroscopic – Staple – Transglenoid suture – Suture tacks – Arthroscopic washout – Suture anchors

19. Again? Age 30 continues to play what are chances it will happen again

20. 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

21. Open Access Journal of Sports Medicine 2011:2 19–24

22. 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

23. Alcohol and chlorhexidine, superior to povidone iodine J Bone Joint Surg Am. 2009;91:1949-53

24. Diagnostic arthroscopy Equipment – Arthroscopy stack 30 degree scope – Fluid management system – High flow arthroscopy trocars – Radiofrequency probe – Arthroscopic shaver – Suture passers – Anchors

25. 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

26. Portal Placement Anterior Portal – 2 nd ‘working’ gleno-humeral portal 2 1

27. Arthroscopic Bankart

28. Diagnostic Arthroscopy

29. Suture Anchor Insertion

30. Knott Tying

31. Second Anchor

32. Arthroscopic stabilisation

34. SLAP tears 1 Frayed 2 Superior A and P 3 2 + bucket handle 4 Bucket into biceps 5 Assoc dislocation 6 2 with A or P labral flap 7 Tear into MGHL 8 2 + P labrum 9 2 + Circumferential labrum 10 2 + P + Inf labrum

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

36. J Shoulder Elbow Surg (2011) 20, 326-332

37. Again?

38. Recurrence rates – Arthroscopic (suture anchor) 8-11% – Open (Bankart) 0-11% Arthroscopic slightly better ROM Sports Health. 2011 Jul;3(4):396-404.

39. 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

40. 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

41. 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

42. Latarjet

43. Massive Hill-Sachs lesion >25% volume of the humeral head Management - rotational osteotomy - hemiarthroplasty - infraspinatus transfer - osteo-articular allograft - arthroscopic remplissage Humeral defects

44. 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

45. Arthroscopic Remplissage arthroscopic Bankart capsulodesis and infraspinatus tenodesis

46. Summary Young sports dislocation 1 week

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

49. Practically Arthroscopic Bankart with anchors – 1 st time dislocator – Recurrent with no bony defect Open Latarjet – Failed arthroscopic Bankart – Bony defects (glenoid) – Chronic dislocation

50. J Bone Joint Surg Am. 2009;91:966-78

51. The End