Jon JP Warner, MD Chief, MGH Shoulder Service Chair, Q&S Committee, MGOA Professor of Orthopedic Surgery
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1 Jon JP Warner, MD Chief, MGH Shoulder Service Chair, Q&S Committee, MGOA Professor of Orthopedic Surgery
2 Disclosures Wright Medical: Royalty on Rotator cuff implant; Consultant IMASCAP: Stock Smith and Nephew: Fellowship Funding Arthrex: Fellowship funding Breg: Fellowship Funding San Diego Shoulder Institute: BOD
3 The shoulder is Connected to a Person Teeth/Tatoo < 1 = bad outcome Depression Chronic narcotics Smoking Worker s Comp
4 An Operation can fail before the patient Goes to the operating room (C.Gerber)
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6 - 88% of Patients subjectively rated as Good/Excellent - Dissatisfaction was associated with pain - Preoperative pain = 20x Higher liklihood of postoperative pain
7 40yo man fell off a deck one year ago
8 1. Correct Diagnosis 2. Correct Patient 3. Correct Procedure 4. Technically well done Surgery 5. Postoperative Compliance
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10 Unrecognized SEIZURE DISORDER AND POSTERIOR INSTABILITY (Can also be anterior)
11 Capsular Laxity and it s role in recurrence Mom Patient Anterior Posterior
12 Voluntary Instability
13 Unrecognized RCT
14 Unrecognized posterior instability with winging
15 Scapular winging may present with both Posterior and anterior instability which fails Treatment.
16 6 instability surgeries Instability & winging resolved After Pectoralis Major transfer
17 The number of surgeons indicating their preferred stabilization procedure was arthroscopic more than quadrupled from only 16% in 2002 to 71% in Decision Bias The numbers who now potentially offer stabilization surgery to first-time dislocators virtually doubled from 35% to 68%. There was increase in the use of magnetic resonance imaging (MRI) arthrograms (up 550%). Malhotra A, Freudmann M, Hay S. Management of traumatic anterior shoulder dislocation in year age group: a dramatic evolution of practive. J Shoulder Elbow Surg (2012) 21,
18 Poor anchor Placement Without chondral injury
19 24 yo man.injury in 2011 Original Injury was in Hockey told he had a posterior glenoid fracture Thinks he had a posterior Bankart repair 2011
20 2011: Another surgeon. Posterior glenoid reconstruction With ICBG + Capsular shift
21 2012: Pain
22 2012: Pain and limited ROM
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24 Surgery #2 (Same surgeon): 1 year later he comes to see me. - Worse than before surgery - Pain level = 8-10/10 - SSV = 10% - AFF/PFF = 30 O ;AER = -30 O ; Very weak ER. 2014: Had removal of screws 2 years ago
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30 Hemiarthroplasty TSA Reverse Shoulder Other Glenohumeral fusion
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32 6 mo Postoperative after Surgery #3: -Pain 0-4/10 - SSV = 75% - AFF = 100 O (HAND TO TOP OF HEAD) - IR = Hand to hip pocket - Hand almost to abdomen - Returned to work!
33 28 yo Physician with instability AND Subscapularis insufficiency 10 yrs. After rugby injury and open Bankart
34 Issues after Open Bankart Repair Correlation of Results with Postoperative Subscapularis Function Sachs RA, et al 2005 American Journal of Sports Medicine 30 Patients, 4 year follow-up 23% with Subscapularis Deficiency (MRI) 27% strength of opposite side 57% Good/Excellent 77% with normal subscapularis >80% strength 91% Good/Excellent (Courtesy M. Provencher)
35 Group 1: 7/11 Instability patients improved with Pect. Major Transfer
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37 Untreated Capsular Laxity Medial anchor placement
38 STIFFNESS: IS IT BENIGN? TREAT BEFORE DEVELOPMENT OF CAPSULORRHAPHY ARTHROPATHY
39 Ax nerve palsy after Latarjet 76% Nerve Alterts Usually Temporary. Actual risk < 1%
40 Problems = 18% (No effect on outcome) Complications = 10% - Intraoperative coracoid P. Fx = 7% - Axillary N. Palsy (transient) = 1/76 patients - 7/76 (9%) = reoperation rate
41
42 22% Recurrence Rate
43 28% Failure
44 Recurrence Rate 19% Major Risk Factors for Failure = Number of prior surgeries and Hyperlaxity
45 Latarjet is more Cost Effective for Revision surgery than Arthroscopic Bankart
46 Courtesy L. Lafosse
47 AJSM, /263(4%) Instability cases over 3 years Severe bone loss Failed Latarjet Severe bone loss
48 AJSM, /263(4%) Instability cases over 3 years Severe bone loss Failed Latarjet Severe bone loss
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52 Degree Time Sustainability
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