Shoulder Instability and Reconstruction of Bone Defects

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Calvin Ramsey
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1 Shoulder Instability and Reconstruction of Bone Defects Anthony Miniaci MD FRCSC Professor of Surgery Cleveland Clinic Foundation Cleveland, Ohio USA Shoulder Instability Surgery Many Questions Open vs.arthroscopic repairs andffailure rates Long term function? What factors are involved in successful surgery? ( Bone defects) When do we do which operations for a successful result Humeral Head Impression Fractures Hill Sachs defects associated with anterior instability Unusual cause for instability Usually a consequence rather than cause Repairs directed at soft tissue pathology The Use of Humeral Head Reconstruction for Defects Not a lot of indication in primary instability surgery results of soft tissue repairs are excellent! Revision instability Multiple dislocations Epilepsy patients Contact athletes with bone loss? Fixed chronic, missed dislocations Bone Defects and Recurrent Instability Burkhart and De Beer described failure of arthroscopic repairs(2000) suggest Latarjet Miniaci described failures related to Humeral Head defects (1999) suggest humeral head allograft unrecognized failures related to glenoid and humeral bone loss Diagnosis of Bone Loss History and physical Apprehension <30 degrees Radiographs, CT scan arthroscopy Do we really have a clinical problem? What is critical size of bone defect of Glenoid, Humerus- Are combined defects more significant? When and what do we fix? 1 P a g e

best on 3D and Pico methods which are not universally used Biomechanics Small Combined lesions act like bigger

2 Radiographic Summary Current radiographic methods underestimate lesion size by 10-20% and may not be as reliable as we thought Humeral defects measurements are more accurate in depth and not width Glenoid measurements are best on 3D and Pico methods which are not universally used Biomechanics Small Combined lesions act like bigger Humeral or glenoid defects alone. Humeral lesions are ROTATIONAL issues! Glenoid defects are translational 2 P a g e

3 Anatomical reconstruction is the key to a succesful result! For humeral head defects the best option is to fix the pathology Clinical results are excellent 20 pts Minimum 2 year follow up All had Hill Sachs with Hemicap 9 combined with Latarjet/allograft glenoid 0 repeat dislocations/instabiity Improved QOL (Fritsch et al AAOS 2012) 20 pts allograft 0 dislocations Complications related to hardware Miniaci A, Gish Michael: Management of Anterior Glohumeral Instability Associated with Large Hill-Sachs Defects. Techniques in Shoulder and Elbow Surgery. 5(3): If Glenoid is deficient fix the glenoid If humeral head is broken why fix the glenoid? Latarjet Results Good stability but 30 percent complication rate Remplissage No clinical comparative trials Loss of motion Does not attend to pathology Summary Anatomical Restoration is the key to the best results 3 P a g e

4 References 1. Arthroscopic double-pulley remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs. Koo SS, Burkhart SS, Ochoa E. Arthroscopy Nov;25(11): [Osteoathritis after SLAP Lesion? Clinical and arthro- MRI evaluation after arthroscopic SLAP refixation] Lehmann LJ, Dinter D, Monateseri S, Scharf HP, Weckbach S. Sportverletz Sportschaden Sep;23(3): Epub 2009 Sep 11. German. 3. Partial humeral head resurfacing and Latarjet coracoid transfer for treatment of recurrent anterior Moros C, Ahmad CS. Orthopedics Aug;32(8). pii: orthosupersite.com/view.asp?rid= doi: / Open reconstruction of large bony glenoid erosion with allogeneic bone graft for recurrent anterior shoulder dislocation. Weng PW, Shen HC, Lee HH, Wu SS, Lee CH. Am J Sports Med Sep;37(9): Epub 2009 May Decreased range of motion following arthroscopic remplissage. Deutsch AA, Kroll DG. Orthopedics May;31(5): Arthroscopic autologous bone graft with arthroscopic Bankart repair for a large bony defect lesion caused by recurrent shoulder dislocation. Mochizuki Y, Hachisuka H, Kashiwagi K, Oomae H, Yokoya S, Ochi M. Arthroscopy Jun;23(6):677.e1-4. Epub 2006 Nov Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid. Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Am J Sports Med Aug;35(8): Osteochondral allograft transplantation for treatment of Chapovsky F, Kelly JD 4th. Arthroscopy Aug;21(8): Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography. Itoi E, Lee SB, Amrami KK, Wenger DE, An KN. Am J Sports Med Jan-Feb;31(1): [Double-contrast arthro-ct in diagnosis of shoulder instability] Hartwig CH, Braunschweig R, Böhm P, Cormann PL. Sportverletz Sportschaden Mar;9(1):9-13. German. 13. Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. Diklic ID, Ganic ZD, Blagojevic ZD, Nho SJ, Romeo AA. J Bone Joint Surg Br Jan;92(1): Reconstruction of humeral head defect for locked posterior shoulder dislocation. Modi CS, Wicks L, Srinivasan K. Orthopedics Sep;32(9). pii: orthosupersite.com/view.asp?rid= doi: / Modified MacLaughlin procedure in the treatment of neglected posterior dislocation of the shoulder. Castagna A, Delle Rose G, Borroni M, Markopoulos N, Conti M, Maradei L, Garofalo R. Chir Organi Mov Apr;93 Suppl 1:S1-5. Review. 16. Partial humeral head resurfacing and Latarjet coracoid transfer for treatment of recurrent anterior Moros C, Ahmad CS. Orthopedics Aug;32(8). pii: orthosupersite.com/view.asp?rid= doi: / Decreased range of motion following arthroscopic remplissage. Deutsch AA, Kroll DG. Orthopedics May;31(5): [Treatment strategies for chronic glenoid defects following anterior and posterior shoulder dislocation] Seebauer L, Goebel M. Oper Orthop Traumatol Dec;20(6): German. 19. Reconstruction of the articular surface of the humeral head after locked posterior shoulder dislocation: a case report. Khayal T, Wild M, Windolf J. Arch Orthop Trauma Surg Apr;129(4): Epub 2008 Sep [Filling a humeral head defect with a chondrocostal autograft combined with subscapularis transfer for chronic posterior glenohumeral dislocations] Lepage D, Obert L, Rochet S, Gallinet D, Garbuio P, Tropet Y. Rev Chir Orthop Reparatrice Appar Mot Sep;94(5): Epub 2008 May 6. French. 21. Allograft reconstruction of segmental defects of the humeral head associated with posterior dislocations of the shoulder. 4 P a g e

5 Martinez AA, Calvo A, Domingo J, Cuenca J, Herrera A, Malillos M. Injury Mar;39(3): Anatomical reconstruction for Reverse Hill-Sachs lesions after posterior locked shoulder dislocation fracture: a case series of six patients. Bock P, Kluger R, Hintermann B. Arch Orthop Trauma Surg Sep;127(7): Epub 2007 May Osteoarticular allograft transplantation for large humeral head defects in Kropf EJ, Sekiya JK. Arthroscopy Mar;23(3):322.e1-5. Epub 2006 Nov Arthroscopic reduction and repair of a locked posterior shoulder dislocation. Verma NN, Sellards RA, Romeo AA. Arthroscopy Nov;22(11):1252.e1-5. Epub 2006 Sep Transhumeral head plasty for large Hill-Sachs lesions. Re P, Gallo RA, Richmond JC. Arthroscopy Jul;22(7):798.e Arthroscopic fixation of the subscapularis tendon in the reverse Hill-Sachs lesion for traumatic unidirectional posterior dislocation of the shoulder. Krackhardt T, Schewe B, Albrecht D, Weise K. Arthroscopy Feb;22(2):227.e1-227.e Anteroinferior bone-grafting can restore stability in osseous glenoid defects. Montgomery WH Jr, Wahl M, Hettrich C, Itoi E, Lippitt SB, Matsen FA 3rd. J Bone Joint Surg Am Sep;87(9): Osteochondral allograft transplantation for treatment of Chapovsky F, Kelly JD 4th. Arthroscopy Aug;21(8): Articular arc length mismatch as a cause of failed bankart repair. Burkhart SS, Danaceau SM. Arthroscopy Oct;16(7): The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. J Bone Joint Surg Am Jan;82(1): Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. Gerber C, Lambert SM. J Bone Joint Surg Am Mar;78(3): Magnetic resonance imaging versus arthroscopy for the investigation of the osteochondral humeral defect in anterior shoulder instability. A double-blind prospective study. Denti M, Monteleone M, Trevisan C, De Romedis B, Barmettler F. Knee Surg Sports Traumatol Arthrosc. 1995;3(3): P a g e

Glenoid Track Concept vs Humeral Head Engagement in Recurrent Anterior Shoulder Instability with Glenoid Bone Loss Less Than 25%

Med. J. Cairo Univ., Vol. 85, No. 6, September: 2407-2412, 2017 www.medicaljournalofcairouniversity.net Glenoid Track Concept vs Humeral Head Engagement in Recurrent Anterior Shoulder Instability with