1. Matt Nugent, MD Steadman Hawkins Clinic of the Carolinas Feb 25, 2013 Matt Nugent, MD June 7, 2013

3. Normal Anatomy: Labrum increases depth of glenoid IGHL 1 0 static check to A/P and inf @ 45-90 0 SGHL and MGHL play stabilizing roles in lower ranges of abduction MGHL @ <45 abduction, MGHL: resists ER when arm is FF Inferior Glenohumeral Ligament Complex Hunt et al. JAAOS 2007

4. Normal Anatomy: IGHL complex forms “Hammock” Anterior band resists anterior translation in Abd/ER Glenoid “bare spot” is central

5. History: Arm in Abducted/ER positon Was an ER reduction required? Age? Contact athlete/Military? Position? Ultimate goals? End/Beginning of Season?

6. Physical Exam: Apprehension- Relocation (Instability) AbER reproduces symptoms Posterior force relieves Load & Shift (Laxity) Grade I – Up face Grade II – To Rim w/ immediate reduction Grade III – Over Rim Bahk et al. AJSM 2007

7. Laxity or Excessive Translation Does Not Equal Instability

8. EUA is Critical: Compare translation of BOTH shoulders for any increase in anterior translation

9. How should we treat the primary event? Risks for recurrent instability Position of immobiliztion Length of immobilization Meeting patients goals and expectations

10. Risks for Recurrent Instability Rowe 1980 1 <20yo = 94% recurrent instability 21-30yo = 79% 31-40yo = 50% >40yo = 14% Arciero 1989 2 Ave age 18yo (17-22) 3wks of immobilization (position not specified) 92% recurrence if treated nonoperatively 1.Rowe CR. Acute and recurrent anterior dislocations of the shoulder. Ortho Clin North Am 1980;11:253-70. 2.Wheeler JH, et al. Arthroscopic vs. Nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy 1989;5:213-217.

11. Younger Patients Recurrence Rates AgeRecurrence Rowe<2094% McLaughlin<2095% Henry, Genung17-2390% Simonet, CofieldAthletes<3082% WestPoint17-2485% Marans 1992Open Physes100% Postacchini 2000Adolescents92%

12. Risks for Recurrent Instability Arciero et al. Arthroscopic bankart vs nonoperative treatment for acute, initial anterior shoulder dislocations. AJSM 1994;22:589-594.

13. Contact Athletes Recurrence Rates AgeRecurrence Larrain, 200117-2794% West Point Wheeler et al 1989 Arciero et al 1994 17-2386% Hovelius 1978<20, hockey90% Henry, Genung 198217-2390% Simonet, Cofield 1984<3082%

14. Risks for Recurrent Instability Group 1 = immobilized IR for 3-4 weeks Group 2 = immobilized IR until patient felt comfortable Group 3 = immobilization less than 3 weeks Hovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.

15. Risks for Recurrent Instability Hovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.

16. Risks for Recurrent Instability Hovelius L, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. JBJS Am 2008;90:-45-952.

17. Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

18. Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477.

23. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta- analysis of the literature. JBJS AM 2010;92:2924-2933.

24. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta- analysis of the literature. JBJS AM 2010;92:2924-2933.

25. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta- analysis of the literature. JBJS AM 2010;92:2924-2933.

26. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta- analysis of the literature. JBJS AM 2010;92:2924-2933.

27. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta- analysis of the literature. JBJS AM 2010;92:2924-2933.

28. Position/Length of Immobilization Paterson WH, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta- analysis of the literature. JBJS AM 2010;92:2924-2933.

29. Itoi, JBJS 2007 RCT, Level II, 2yr f/u 198pts sling vs 10 0 ER x 3wks (ER group more compliant (68% vs 80%) ER group w/ reduced recurrence (38% Rel. Risk)

30. Itoi, JBJS, 2007 Immobilize 10 0 ER Must initiate tx early Most effective if <30yo

31. Conservative Treatment: Strengthen GH rotators and scapular stabilizers Injury Prevention Graduated Return GOAL –To keep head centered

32. Scapular Exercises: Push-up plus Bear hug Seated rows Shrugs Upright rows Moseley et al., AJSM 1992. Decker MJ, Hawkins RJ, AJSM 1999.

33. Arthroscopic Repair after Primary Event?

34. Results of Arthroscopic Repair: Contact Athletes SampleFollow UpRecurrence O’Neill JBJS 1999 4152 months5% Mazzocca AJSM 2005 1837 months11% Robinson AOSSM 2006 2851 months7%

35. Brophy RH and Marx RG. A systematic review. Arthroscopy 2009

36. Risks after Primary Repair Porcellini G, et al. JBJS AM 2009;91:2537-2542.

37. Risks after Primary Repair

38. Risk Factors for Failure 194 consecutive arthroscopic Bankart repairs; 101 contact athletes Recurrence in Contact Athletes: Without significant bony defects: 6.5% With significant bony defects: 89% Engaging Hill-Sachs Glenoid bone loss 25% Burkhart SS, DeBeer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic bankart repairs: significance of the inverted-pear glenoid and the humeral engaging hill-sachs lesion. Arthroscopy 2000;16:677-694.

39. Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

40. Glenoid Bone Loss: Biomechanical Evidence Osseous defect at least 21% of glenoid length may cause instability Itoi E et al. JBJS(A) 2000 Jan Anteroinferior glenoid defect diminished stability by almost 50% Bone grafting increased stability by 150% to 230% Montgomery WH et al. JBJS (A) 2005 Sept.

41. Burkhart SS, DeBeer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic bankart repairs: significance of the inverted-pear glenoid and the humeral engaging hill-sachs lesion. Arthroscopy 2000;16:677-694.

42. Bushnell BD, et al. Bony instability of the Shoulder. Arthroscopy 2008;24:1061-1073.

43. Quantifying the Risk Factor Cadaveric study : Quantify glenoid bone loss by arthroscopic means “The bare spot of the glenoid…consistent reference point from which to determine glenoid bone loss…” Burkhart SS, De Beer JF et al. Arthroscopy, 2002 May

44. Itoi E, et al. The effect of glenoid defect on anterior inferior stability of the shoulder after bankart repair: a cadaveric study. JBJS Am 2000;82:35-46.

49. Risks for Recurrent Instability

51. Remplissage Procedure

53. Remplissage Decreased recurrent dislocations/instability from 67% to 10% in pts with large HS lesion - Wolf, et al, Arthoscopy, 2007 For larger lesions may need to consider humeral head allograft

54. Does surgery cause OA? Buscayret et al, AJSM 2004 (Mixed procedures) Arthroscopic, Latajet and Capsulolabral repair/shift 20% of surgical patients developed OA Franceschi et al, AJSM 2011 (case series)(Arthroscopic) Arthroscopic Bankart 22% developed progressed in OA stage Associations: age, increased time from 1 st episode to surgery, increased number of dislocations, increased number of anchors, degenerative labrum. Kavaja et al, JSES 2012 (case series) 13 year f/u 64% arthrosis; 80% of those were mild Mean WOOS and WOSI scores was good 75% of patients were satisfied Loss of motion cited as reason for dissatisfaction

55. 3B Effect 1.Labral repair (Bumper effect) 2.Increased bony contact via coracoid transfer (Bony effect) 3.Sling effect of conjoined tendon and lowered subscap (Belt or sling effect) Boileau et al. Orthop Clin N Am 2010;41:381-392.

56. Results of Latarjet At 15yrs, 98% excellent or good At 15yrs, only 4/118 redislocated (3%) Hovelius L, et al. JSES 2004;13:509-516.

57. Other Options ICBG Distal clavicle Tibial plafond allograft ??????

58. Tibial Plafond Allograft

60. Things aren’t always as they first appear…

61. Thank You