Management of Humeral Bone Loss in Anterior Shoulder Instability. Scott D. Mair, MD University of Kentucky Sports Medicine
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1 Management of Humeral Bone Loss in Anterior Shoulder Instability Scott D. Mair, MD University of Kentucky Sports Medicine
2 Disclosure Smith and Nephew Endoscopy fellowship support
3 Importance Bone loss (glenoid or humerus) frequent cause of recurrence Kuhn (evidence-based anterior instability): question isn t whether arthroscopic Bankart is as good in contact athletes, it is whether it should be done with bone loss
4 Burkhart (Arthroscopy, 2000) 194 arthroscopic Bankart repairs 7/173 failures without bone defects 14/21 failures with bone loss Contact athletes recurrence 6.5% vs. 89%
5 Glenoid Bone Loss Bone loss and bony Bankart are very different
6 When to Address Glenoid Bone Loss Best measured on 3D CT scan Glenoid defect of around 20% Lower threshold Revision surgery Contact athlete
7 Surgical Options Glenoid Bone Loss Open Bankart repair Glenoid bone graft Laterjet (coracoid transfer) Distal clavicle Iliac crest Distal tibial allograft
8 Hill-Sachs Lesion Impaction injury to posterolateral humeral head Described by Hill and Sachs in 1940 Pathognomonic of anterior shoulder dislocation
9 Incidence of Hill-Sachs First-time dislocation 47-80% Recurrent dislocator approaches 100% Larger with dislocations of Greater duration Multiple recurrences Higher energy
10 Bankart, 1948 Regarding Hill-Sachs lesions Nothing can be done about them if they are found
11 Surgical Treatment Options Ignore Restrict external rotation (over-tighten capsule) Fill defect (allograft) Humeral head-plasty Remplissage (infraspinatus tenodesis) Rotational osteotomy Glenoid augmentation (Laterjet) Metal hemi-cap or hemiarthroplasty
12 When to Address Hill-Sachs Surgically Size 20-30% of articular surface Engaging Hill-Sachs Burkhart Engagement point is >70 degrees abduction, without extension Failure of prior surgery
13 Restrict External Rotation Open Bankart repair o ER loss common One cm capsule = 20 degrees Generally done with open Bankart repair / anterior capsulorraphy
14 Humeral Head-Plasty Percutaneous technique 14 cadavers None had recurrent dislocation Kazel, et al., Arthroscopy, 2005
15 Humeral Head-Plasty Open technique, acorn drill, ACL guide 4 patients No instability at 1 year follow-up Re, et al., Arthroscopy, 2006
16 Fill Defect with Bone Anterior or posterior approach Options Osteochondral allograft Fill completely or plugs
17 Open Osteochondral Allograft Open anterior deltopectoral approach 18 patients >25% articular surface involved Open Bankart repair / capsulorraphy Miniaci, et al., Tech Shoulder Elbow Surg, 2004
18 Open Osteochondral Allograft Osteochondral allograft fashioned to fill defect Fixation with headless screws Results no recurrences, 2 required screw removal Miniaci, et al., Tech Shoulder Elbow Surg, 2004
19 Posterior Allograft Plug Staged procedure Arthroscopic Bankart repair 6 weeks later Posterior approach Allograft plug Case report Kropf and Sekiya, Arthroscopy, 2007
20 Remplissage Eugene Wolf French to fill Infraspinatus tenodesis / posterior capsulodesis
21 Remplissage - Technique Arthroscopic, includes Bankart repair Suture anchors placed within defect Sutures passed through infraspinatus tendon Knots tied in subacromial space Tip 2 separate lateral portals
22 Remplissage Results (Wolf) 20 patients with follow-up (of 22) Follow-up months 2 suffered traumatic re-dislocations 2 other second-looks tendon healed No loss of ROM
23 Remplissage Do We Get Our Fill? 11 patients, post-op 9-27 months Average 1.4 anchors 3T MRI scan All defects filled % No infraspinatus muscle atrophy Park, et al., AOSSM Specialty Day 2012
24 Case Report 19 yo college wide receiver Had open Bankart repair in high school Dislocated 3 times freshman year Also had ER loss and apprehension
25 Case Report Revised Bankart arthroscopically Performed remplissage
26 Case Report Returned to play 3 years without dislocation
27 Video - Remplissage
28 Conclusions Most need not be treated surgically My preference, young patients Large lesions remplissage Enormous lesions open allograft
29
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2nd Chairmen: Samuel Antuña Emilio Calvo Fernando Marco www..com 2nd 2 2nd INDEX General Information 04 Faculty 05 Program at a Glance 06 Scientific Program Thursday October 18th 08 Friday October 19th