MR Imaging for Glenohumeral Instability & Bone Loss

Transcription

1 MR Imaging for Glenohumeral Instability & Bone Loss Russell C. Fritz, M.D. San Francisco, CA I have no conflicts of interest to disclose Russell C. Fritz, M.D. MR imaging is a powerful diagnostic tool in orthopedics and sports medicine 1

2 MR imaging is useful to establish an anatomic diagnosis Visualize anatomy as well as verify and characterize pathology in all three planes We use the same basic method to evaluate for internal derangement of joints throughout the body 2

3 Standard Routine Proton density FSE 3000/35 Fat-sat T2-weighted FSE 4000/50 High resolution axial, sagittal, coronal Standard Routine Proton density FSE 3000/35 Fat-sat T2-weighted FSE 4000/50 High resolution axial, sagittal, coronal Imaging of the shoulder: Do I need contrast?

4 Imaging of the shoulder: Do I need contrast? No! MR Imaging of the Shoulder early spin echo imaging MR arthrography with T1 fatsat fast spin-echo sequences, ABER FSE high resolution imaging FSE high resolution imaging!!! A C 4

5 Coronal section normal normal 5

6 normal normal normal 6

7 normal normal normal 7

8 normal normal normal 8

9 normal Shoulder instability a situation in which symptoms result from excessive translation of the humeral head on the glenoid fossa Frederick A. Matsen III, M.D Anterior dislocation 9

10 Anterior dislocation 1 week ago Anterior dislocation 1 week ago Anterior dislocation 1 week ago 10

11 Anterior dislocation 1 week ago Anterior dislocation 1 week ago Anterior dislocation 1 week ago 11

12 Anterior dislocation 1 week ago Anterior dislocation 1 week ago Anterior dislocation 1 week ago 12

13 Anterior dislocation 1 week ago Anterior dislocation 1 week ago Anterior dislocation 1 week ago 13

14 Anterior dislocation 1 week ago Anterior dislocation 1 week ago Anterior dislocation 1 week ago 14

15 Normal Labrum Bankart Lesion ruptured periosteum Bankart Lesion 15

16 ALPSA lesion Anterior Labroligamentous Periosteal Sleeve Avulsion ALPSA Lesion ALPSA Lesion medial labral displacement 16

17 ALPSA lesion ALPSA lesion ALPSA lesion Arthroscopic view of the anterior glenoid rim 17

18 18

19 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. - Patients with significant bone deficits are not candidates for arthroscopic Bankart repair. Burkhart SS, De Beer JF. Arthroscopy 16:677-94, 2000 Steve Burkhart, MD 19

20 Steve Burkhart, MD recurrent dislocation, missed glenoid rim fracture recurrent dislocation, missed glenoid rim fracture 20

21 recurrent dislocation, missed glenoid rim fracture recurrent dislocation, missed glenoid rim fracture recurrent dislocation, missed glenoid rim fracture 21

22 recurrent dislocation, missed glenoid rim fracture recurrent dislocation, missed glenoid rim fracture recurrent dislocation, missed glenoid rim fracture 22

23 anterior glenoid rim fracture: the inverted pear anterior glenoid rim fracture: the inverted pear anterior glenoid rim fracture: the inverted pear 23

24 anterior glenoid rim fracture: the inverted pear 25% glenoid deficiency: rim defect glenoid width 6 mm 24 mm 7 mm 28 mm 8 mm 32 mm MRI: primary imaging technique to detect bone loss, labral tears, chondral defects, biceps & cuff pathology 24

25 CT: primary imaging technique to measure bone loss & characterize fracture fragments - Include 3D reformations with & without subtraction of the humerus 22-year-old football player Previous glenoid fx and labral repair 25% deficient 25

26 22-year-old football player Previous glenoid fx and labral repair 25% deficient 22-year-old football player Previous glenoid fx and labral repair 25% deficient 22-year-old football player Previous glenoid fx and labral repair 25% deficient 26

27 22-year-old football player Previous glenoid fx and labral repair 25% deficient 22-year-old football player Previous glenoid fx and labral repair 25% deficient 22-year-old football player Previous glenoid fx and labral repair 25% deficient 27

28 22-year-old football player Previous glenoid fx and labral repair 25% deficient 22-year-old football player Previous glenoid fx and labral repair 25% deficient 22-year-old football player Previous glenoid fx and labral repair 25% deficient 28

29 22-year-old football player Previous glenoid fx and labral repair 25% deficient 22-year-old football player Previous glenoid fx and labral repair 25% deficient Small glenoid fx fragment Recurrent dislocation 12 years post labral repair 29

30 Small glenoid fx fragment Recurrent dislocation 12 years post labral repair Small glenoid fx fragment Recurrent dislocation 12 years post labral repair Small glenoid fx fragment Recurrent dislocation 12 years post labral repair 30

31 Small glenoid fx fragment Recurrent dislocation 12 years post labral repair Small glenoid fx fragment Recurrent dislocation 12 years post labral repair Small glenoid fx fragment Recurrent dislocation 12 years post labral repair 31

32 Small glenoid fx fragment Recurrent dislocation 12 years post labral repair Jiang C. Am J Sports Med 41: , 2013 Jiang C. Am J Sports Med 41: ,

33 Deficient glenoid rim Frederick A. Matsen III, M.D Deficient glenoid rim, small Hill Sachs Deficient glenoid rim, small Hill Sachs 33

34 Deficient glenoid rim, small Hill Sachs Deficient glenoid rim, small Hill Sachs Deficient glenoid rim, small Hill Sachs 34

35 Deficient glenoid rim, small Hill Sachs Laterjet procedure for glenoid rim deficiency Steve Burkhart, MD Open capsular shift for engaging Hill-Sachs lesions Steve Burkhart, MD 35

36 Steve Burkhart, MD deep shallow Hill-Sachs lesions Nonengaging Hill-Sachs lesion 36

37 Nonengaging Hill-Sachs lesion Steve Burkhart, MD engaging Hill-Sachs lesion Steve Burkhart, MD Am J Sports Med 39: ,

38 Am J Sports Med 39: ,

39 On-Track Hill-Sachs Lesion Giacomo GD, Itoi E, Burkhart SS. Arthroscopy 30:90-98,

40 Off-Track Hill-Sachs Lesion Giacomo GD, Itoi E, Burkhart SS. Arthroscopy 30:90-98, Giacomo GD, Itoi E, Burkhart SS. Arthroscopy 30:90-98,

41 SLAP, Bankart & Hill-Sachs lesions SLAP, Bankart & Hill-Sachs lesions 41

42 SLAP, Bankart & Hill-Sachs lesions SLAP, Bankart & Hill-Sachs lesions SLAP, Bankart & Hill-Sachs lesions 42

43 SLAP, Bankart & Hill-Sachs lesions Intact SLAP & Bankart repairs Intact remplissage Intact SLAP & Bankart repairs Intact remplissage 43

44 Intact SLAP & Bankart repairs Intact remplissage Intact SLAP & Bankart repairs Intact remplissage Intact SLAP & Bankart repairs Intact remplissage 44

45 Intact SLAP & Bankart repairs Intact remplissage Intact SLAP & Bankart repairs Intact remplissage Intact SLAP & Bankart repairs Intact remplissage 45

46 Intact SLAP & Bankart repairs Intact remplissage Intact SLAP & Bankart repairs Intact remplissage Intact SLAP & Bankart repairs Intact remplissage 46

47 Intact SLAP & Bankart repairs Intact remplissage Intact SLAP & Bankart repairs Intact remplissage Intact SLAP & Bankart repairs Intact remplissage 47

48 Intact SLAP & Bankart repairs Intact remplissage MRI: primary imaging technique to detect bone loss, labral tears, chondral defects, biceps & cuff pathology CT: primary imaging technique to measure bone loss & characterize fracture fragments - Include 3D reformations with & without subtraction of the humerus 48

49 25% glenoid deficiency: rim defect glenoid width 6 mm 24 mm 7 mm 28 mm 8 mm 32 mm anterior glenoid rim fracture: the inverted pear Thank You Russell C. Fritz, M.D. San Francisco, CA 49

50 7/15/2014 Bipolar Bone Loss: A Quantitative Way to Assess the Need for Latarjet versus Remplissage Stephen S. Burkhart, MD San Antonio, Texas Disclosure Stephen S. Burkhart is a consultant for, and receives inventor s royalties from Arthrex, Inc. (Naples, FL). He also receives book royalties from Wolters-Kluwer (Philadephia, PA). Bipolar Lesions With glenoid bone loss, H-S engages more easily 1

51 7/15/2014 Treating the Engaging H-S by Treating the Glenoid Side Lengthen the glenoid articular arc so much that H-S cannot engage The Sling Effect of the Conjoined Tendon Causes posteriorly-directed forces in abd-er Prevents engagement of H-S Prevents H-S from overriding glenoid track Addresses glenoid and humeral defects with glenoid-based graft only Treating the Hill-Sachs by Remplissage Making the H-S extra-articular 2

52 7/15/2014 Remplissage Indications Minimal glenoid bone loss Large H-S Evaluating Bipolar Bone Loss: The Glenoid Track The Glenoid Track - Yamamoto, Itoi, et al, JSES

53 7/15/2014 Engagement of H-S: Overriding of Glenoid Track On-Track Off-Track Evolving Concept of the Hill-Sachs Lesion: From Engaging/Non-Engaging Lesion to On-Track/Off-Track Lesion - DiGiacomo, Itoi, Burkhart; Arthroscopy 2014 Glenoid Track: Cadaver Study (Yamamoto et al) Glenoid pushes cuff 16% of glenoid width Glenoid track is 84% of glenoid width (as measured from rotator cuff attachments on posterior humeral head) 4

54 7/15/2014 The Glenoid Track Narrows with Glenoid Bone Loss Glenoid Track = 84% normal glenoid width minus width of glenoid defect Assessing Bipolar Bone Loss In Live Subjects, the Glenoid Track is 83% of the Glenoid Width (In cadavers = 84%) - Itoi et al 2013 Can measure this from en face projection of normal shoulder on 3D CT scan 5

55 7/15/2014 Measuring the Glenoid Track on 3D CT Scan On-Track Hill-Sachs Lesion If H-S lesion is within the margins of glenoid track, there is no engagement (on-track) Off-Track Hill-Sachs Lesion If medial margin of H-S defect extends beyond glenoid track, the H-S engages the glenoid rim (off-track) 6

56 7/15/2014 Is Arthroscopic Observation of Engagement Adequate to Diagnose On-Track/Off-Track? Dynamic Arthroscopy May over-estimate engagement due to damaged capsule/labrum Testing for engagement after repair could damage the repair Templating the Glenoid Track onto the Humerus: Does the Hill-Sachs Engage? Plot the glenoid track width onto the humerus, beginning at medial margin of rotator cuff footprint This H-S lesion is Off-Track 7

57 7/15/2014 Developing a Treatment Paradigm for Bipolar Bone Loss Group 1 = glenoid defect < 25% plus on-track H-S Arthroscopic Bankart repair (ABR) Group 2 = glenoid defect < 25% plus off-track H-S ABR + Remplissage Group 3 = glenoid defect 25% plus on-track H-S Latarjet Group 4 = glenoid defect 25% plus off-track H-S Latarjet Treatment Paradigm Group 1 = glenoid defect < 25% plus on-track H-S Treatment = Arthroscopic Bankart repair Treatment Paradigm Group 2 = glenoid defect < 25% plus offtrack H-S Treatment = Arthroscopic Bankart repair plus remplissage 8

58 7/15/2014 Treatment Paradigm Group 3 = Glenoid defect 25% plus ontrack H-S Treatment = Latarjet Treatment Paradigm Group 4 = glenoid defect 25% plus off-track H-S Treatment = Latarjet ± humeral-sided procedure (humeral bone graft or remplissage); if H-S is not engageable after Latarjet, do Latarjet only From a practical standpoint, Latarjet alone is almost always adequate Can Also Do Arthroscopic Assessment of On-Track/Off-Track Status of a Hill-Sachs Lesion 9

59 7/15/2014 Arthroscopic Evaluation of Off-Track Lesion Calculate Diameter of Normal Inferior Glenoid Diameter = 2x radius (Radius = distance from bare spot to posterior glenoid rim) 10

60 7/15/2014 Calculate Width of Glenoid Bone Defect (d) d = posterior radius minus anterior radius Calculate Width of Glenoid Track Glenoid track width = 83% D - d = 0.83 x 30 5 (in our case) Glenoid track = = 19.9 mm Measure Width of H-S 11

61 7/15/2014 Measure Width of Bone Bridge Between Cuff & H-S Calculate Width of Hill-Sachs Interval (HSI): Distance of Medial Rim of Hill-Sachs from Rotator Cuff Attachment HSI = Width of H-S plus width of intact bone bridge (BB) 12

62 7/15/2014 Compare Width of Glenoid Track to Width of Hill-Sachs Interval (HSI) HSI = 12 mm (Hill-Sachs width) + 12 mm (Cuff - HS bone bridge) = 24 mm (H-S interval) Glenoid track = 19.9 mm (in our case) HSI > Glenoid Track Hill-Sachs extends medial to glenoid track Hill-Sachs is off-track/engaging Treatment Glenoid defect < 25% Off-track Hill-Sachs Treatment = Arthroscopic Bankart repair plus remplissage 13

63 7/15/2014 Developing a Treatment Paradigm for Bipolar Bone Loss Group 1 = glenoid defect < 25% plus on-track H-S Arthroscopic Bankart repair (ABR) Group 2 = glenoid defect < 25% plus off-track H-S ABR + Remplissage Group 3 = glenoid defect 25% plus on-track H-S Latarjet Group 4 = glenoid defect 25% plus off-track H-S Latarjet 14

64 7/15/2014 Thank You! 15

65 Algorithm for Open Techniques for Bone Loss CDR Matthew T. Provencher, MD MC USN Associate Professor of Surgery & Orthopaedics Chief, Sports Medicine and Surgery Head Team Physician, New England Patriots Massachusetts General Hospital Harvard University A Free sample background from Disclosures Royalties - None Stock None Consultant - JRF; Arthrex Research Support -AOSSM Grant (2005); AANA Research Grant (2008; 2006); OREF Grants (2002;2004); BUMED (2009;2012) Editorial Boards - Elsevier (Arthroscopy-Deputy Editor; JSES), JBJS, JAAOS, SLACK (Orthopaedics, JKS), Sage (AJSM) Board Memberships - AOSSM (Board of Directors, Research) SOMOS (Past Pres.); AAOS (Pubs); BOS (Research); ISAKOS (UE); AANA (Program/Education); ASES (Program; Membership) Membership;Technology) A Free sample background from How To Stay Out of Trouble... The Glenoid Does Not Take a Joke... Between 4-6 mm anterior bone loss Can amount to 20-25% of glenoid 1.5 mm = 5% approx Piasecki, A Free sample Romeo, background Provencher from

66 The Importance of Bony Defects VAST majority of instability failures Bone Loss Not recognizing preoperatively Understanding patient expectations My opinion: You should go into an instability workup not worried about their soft tissues, but Do They Have Bone Loss? A Free sample background from You Can Predict Bone Loss From Exam and History Instability in Mid-Abduction A Free sample background from JAAOS 2009; JBJS 2010 KEY: Glenoid bone loss Occurs Parallel to Long Axis of Glenoid A Free sample background from AJSM

67 Glenoid Bone Loss Measure with Circle Bottom 2/3rds of Glenoid Simple Diameter at bare spot A Free sample background from Types of Glenoid Bone Loss Not all bone loss is the same type Acute Fracture 5% Bony Loss Partial Resorption Partial Attritional 78% pts Bony Loss Complete Resorption Fully Attritional 11% pts These patients are different in history, presentation, and likely outcomes depending upon procedure chosen A Free sample background from Provencher, Bernhardson, Golijanin AOSSM 2014 The ALPSA Tear Neviaser 1991 A Free sample background from 3

68 AP x-ray Ex. Questionnaire 7/18/2014 ALPSA Tears Have Worse Outcomes Arthroscopy 2008 Bankart (72%) 67 shoulders Lower number (4.9) dislocations before surgery 7% Failure ALPSA (28%) 26 shoulders Higher number (12.3) dislocations before surgery 20% Failure ALPSA Associated with Glenoid Bone Loss?? A Free sample background from Glenoid bone loss in shoulder instability: The significance of the ALPSA lesion Bernhardson A, Dewing CB, Leonardelli D, Barlow B, Provencher MT JSES consecutive patients CT scans ALPSA and bone loss compared ALPSA 2x the amount of glenoid bone loss A Free sample background from Instability Severity Index Score (ISIS) points Age (at Surgery) Sport Activity Type of sport < 20 y > 20 y Competition Leisure or No sport Contact or forced overhead Other = 2 = 0 = 2 = 0 = 1 = 0 Hyperlaxity Ant. ou inf. Hyperlaxity No Hyperlaxity = 1 = 0 Hill-Sachs lesion PDS osseuse glenoidienne Visible in ER Non visible in ER Bone Loss No Bone Lloss = 2 = 0 = 2 = 0 Boileau 2010 Total = 10 4

69 AP x-ray Ex. Questionnaire 7/18/2014 Instability Severity Index Score (ISIS) points Age (at Surgery) Sport Activity Type of sport < 20 y > 20 y Competition Leisure or No sport Contact or forced overhead Other = 2 = 0 = 2 = 0 = 1 = 0 Hyperlaxity Ant. ou inf. Hyperlaxity No Hyperlaxity = 1 = 0 Hill-Sachs lesion PDS osseuse glenoidienne Visible in ER Non visible in ER Bone Loss No Bone Lloss = 2 = 0 = 2 = 0 Can get to 3 points very easily... ISIS Score Revisited Weber ASES 2013 ISIS score not helpful in predicting outcomes Need to critically assess the variables - are these correct? What level? However, ISIS does get us thinking clearer about the problem..... Engagement Made easier with glenoid bone loss - BIPOLAR A Free sample background from 5

70 How Important is a Small to Medium Sized Hill-Sachs with Some Glenoid Bone Loss? What to Do? Data to Guide us? Clinically relevant scenario Biomechanics of Bipolar Bone Loss Real Patients > 3D Printer 144 CT Scans of Hill-Sachs - Median Lesion Cadaver 3D Printer Model Hill-Sachs (Averaged median 144 pts) 4 mm Glenoid Bone Loss 6

71 A Middle of the Road Hill-Sachs with just 4 mm Bone Loss was a problem How To Stay Out of Trouble Proper Preoperative Planning XR, CT, MRI Arthroscopy? 0 to 15% 15% to 25% > 20-25% -Arthroscopic Repair -Incorporate Bony Fragment -Liberal use of anchors -Consider posterior repair (contact athletes) A Free sample background from -Arthroscopic Repair CAUTION! (>20%) -Best with bony fragment that is incorporated -Open procedures ± bone augmentation OPEN bone Augmentation procedures JAAOS 2009; JBJS 2010 A Free sample background from 7

72 Open Repair Studies Very Good Pagnani et al AJSM patients open shoulder instability repair 84% Hill-Sachs (27% engaging) Mean 14% anterior glenoid deficiency Recurrence 2% Higher if had engaging Hill- Sachs. 12 degrees loss RO A Free sample background from Other (very good) Open Repair Clinical Studies Porcellini et al AJSM arthroscopic repairs over 6 years 31.5% had bony Bankart Chronic = WORSE Outcomes (61 vs 92 scores Rhee et al Int Orthop Open Bankart repair those with glenoid bone loss (20 pts) and those without (20 pts) Less favorable scores with larger glenoid bone loss Porcellini et al A Free sample background from Latarjet Procedure Graft is placed so that it becomes an extra-articular platform that acts as an extension of the articular arc of the glenoid Many ways in which to do a Latarjet A Free sample background from Burkhart

73 A Free sample background from Latarjet Example Failed Anterior Stabilization A Free sample background from Latarjet is NOT Benign Procedure Pulled-off conjoint Miserable scar for revision Resorption of Latarjet - IT Exists! Arthrosis concerns BUT, Test of time is hard to argue.... Click to edit Master text styles A Free sample background f rom snet.co.uk 9

74 Caution Re: Small Caliber (<3.5 mm)cannulated Screws! A Free sample background from Courtesy of LCol D. White Is there an Optimal Placement of the Latarjet Bone Block? A Free sample background from JBJS 2010 Lateral edge Is the glenoid surface Piasecki, Romeo, Provencher JAAOS 2009 A Free sample background from 10

75 Traditional Latarjet - Lateral Edge Latarjet Coracoid transfer Latarjet Lyon Chir 1954 Lateral edge of coracoid Glenoid Face Lateral Edge A Free sample background from Newer Latarjet Inferior Aspect Inferior surface of the coracoid Glenoid face Burkhart Arthrosc 2000 J. De Beer 2000 Burkhart and De Beer It fit better More bone to work with Inferior Edge A Free sample background from Coracoid Anatomy Mean width = 16 mm Mean height 11.5 to 13.5 mm Coracoid tip to CA Ligament = 28.5 mm Click to edit Master text styles Click to edit Master text styles Dolan 2011 JSES A Free sample background from 11

76 Results 91% FOLLOW UP of Bristow-Latarjet 52 Shoulders in 49 Patients Mean Follow-up 26.4 yrs (range, yrs) Overall recurrence = 14% SANE= 90, WOSI = 180 (92.5% of normal) A Free sample background from Other long-term studies Hovelius Gilles Walch with >2500 Latarjet Cases JSES 2004; Recurrence < 2 % 1/118 redislocations 15 years 11/118 subluxation 4 once; 7 several times Satisfaction 76% very 22% satisfied Moderate/severe arthropathy 24% A Free sample background from Can We Provide A More Congruent Joint? A Free sample background from 12

77 Distal Tibia Fits Humeral Head - Distal Tibia Readily Available - Tough to obtain a glenoid - Other options (Fem Head -Chen, Prox Tibia, Clavicle - Tokish) A Free sample background from Results - Tekscan Type to enter text Intact 30% Defect ICBG Latarjet-INF A Free sample background from Inferior surface Latarjet provided best normalization of joint Latarjet-LAT Imaging - Continued A Free sample background from 13

78 A Free sample background from Anterior A Free sample background from Postop Imaging 24 months A Free sample background f rom snet.co.uk 14

79 Iliac Crest Autografts for Glenoid Defects Literature is sparse Klammer HL, Haaker GA, Eickoff U 24 patients Autogenous ICBG 6-24 month f/u No recurrence Military Medicine 1993 Warner et al. 11 cases, no recurrent instability AJSM 2006 A Free sample background from Warner et al ICBG To Anterior Glenoid A Free sample background from 1 Year Postop A Free sample background from 15

80 Open Humeral Side Example Not Frequently Seen No glenoid bone loss Only Humeral Deficiency A Free sample background from A Free sample background from A Free sample background from 16

81 A Free sample background from A Free sample background from How should I treat Bone Loss Injuries in 2014? Glenoid Based Both Humeral Based A Free sample background from 17

82 Think Bipolar Check Glenoid - Outcomes Humbling Acute Fracture 5% Bony Loss Partial Resorption Partial Attritional 78% pts Bony Loss Complete Resorption Fully Attritional 11% pts 7% Failure Scope 24% Failure Scope 5% Failure Bone 4% Failure Bone Augment Augment A Free sample background from Provencher, Romeo Tech Orthop 2008; AAOS 2014 In Presence of Moderate Hill-Sachs Amount of Glenoid Bone Loss 0 to 10% 10 to 15?% > 20% -Arthroscopic Repair -Incorporate Bony Fragment -Liberal use of anchors -Consider posterior repair (contact athletes) A Free sample background from -Arthroscopic Repair CAUTION! (>20%) -Best with bony fragment that is incorporated -Open procedures - OPEN REPAIR! - ± Bone augmentation? Remplissage OPEN bone Augmentation procedures Rare case: HS grafting Bernhardson, Provencher, 2013 (transition pic) A Free sample background f rom from snet.co.uk 18

83 Thank You! A Free sample background f rom snet.co.uk 19

84 Postoperative MRI after failed shoulder instability surgery Michael B Zlatkin MD President NationalRad Weston, Fl Voluntary Professor of Radiology University of Miami School of Medicine No disclosures for this presentation Steps to Success Artifact-limiting protocol Determine type of procedure Know basic surgical principles Review MR images Ask: was correct surgery done? Ask: has surgical repair broken down? Ask: does the patient have new pathology? 1

85 Treatment of instability Anterior instability Direct repair of labral and capsular lesions (Bankart) Open or arthroscopic Indirect. Tighten capsule via manipulation of subscapularis (Putti Platt) Movement of the coracoid process (Bristow/Laterjet) Bankart repair Scarring and artifact can impair visualization Labral repair Circumferential repair Multiple suture anchors 2

86 Repair of Bone defect Recurrent Instability Inadequate/incorrect repair Missed ant/post instability with isolated treatment of one Overtight repair (indirect repairs, capsular manip) Hardware failure (displaced tacks/tackheads, anchors) Untreated Bone Defects (engaging HS, inverted pear glenoid) Nonunion bone block (Bristow/Laterjet) Untreated/unrecognized may result in recurrent sublux/disloc/djd Failed Bankart Repair Recurrent displaced anterior labroligamentous structures MR agm assists in assessment of soft tissue lesions, cartilage/bone loss 3

87 Recurrent Bankart lesion Failed Bankart Repair, Bone defects Recurrent Bankart lesion, moderate Hill Sachs, large glenoid bone defect Failed Bankart Repair Posterior and superior labral tear. Absent anterior labrum. Redundant capsule 4

88 Post Op Ant and Post tear HAGL post Bankart repair Hardware failure Displaced tack Displaced anchor 5

89 Post op Bankart DJD loose body Conclusion MRI useful in post op shoulder assessment Must understand surgical procedures and post op anatomy MRI arthrography direct/indirect helpful tools 6