Shoulder Instability Disclosures

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Bony Deficiency and the Latarjet Procedure Detroit, MI July 13, 2017 Sh

, FAOAO Associated Orthopedists of Detroit, PC Sports Medicine, Shoulder Surgery and Hip Arthroscopy Assistant Professor, Michigan State University College of Osteopathic Medicine Assistant

Sports Section Past-President, Detroit Academy of Orthopaedic Surgery Paid Consultant DePuy Synthes Companies Zimmer Biomet Arthrex Rotation Medical Ceterix Trice Medical Surgeon Advisory

2 (Minnesota) to 23.9 Per 1,000,000 (Sweden) Kroner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Truama Surg. 1989 Sep;108(5):288-90.

1 Bony Deficiency and the Latarjet Procedure Detroit, MI July 13, 2017 Shariff K. Bishai, D.O., M.S., FAOAO Associated Orthopedists of Detroit, PC Sports Medicine, Shoulder Surgery and Hip Arthroscopy Assistant Professor, Michigan State University College of Osteopathic Medicine Assistant Professor, Oakland University William Beaumont School of Medicine Professor, Detroit Medical Center Sports Medicine Fellowship Past-President, American Osteopathic Academy of Orthopedics Sports Section Past-President, Detroit Academy of Orthopaedic Surgery Paid Consultant DePuy Synthes Companies Zimmer Biomet Arthrex Rotation Medical Ceterix Trice Medical Surgeon Advisory Boards Mitek Sports Medicine Rotation Medicial Disclosures Epidemiology Most Commonly Dislocated Joint in Body Anterior Dislocation: 95% Incidence of 17 per 1,000,000 Per Year Varies from 8.2 (Minnesota) to 23.9 Per 1,000,000 (Sweden) Kroner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Truama Surg Sep;108(5): Owens BD, Duffey MI, Nelson BJ, DeBerardino TM, Taylor DC, Mountcastle SB: The incidence and characteristics of shoulder instability at the United States Military Academy. Am J Sports Med 2007;35(7): Simonet WT, Melton LJ, Cofield RH, Ilstrup DM. Incidence of anterior shoulder dislocation in Olmstead County, Minnesota. Clin Orthop Relat Res. 1984; 186: Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg. 1995; 4:

Epidemiology Younger Age of First Dislocation Increases Chance of Future Recurrence and/or Redislocation The rate of recurrent instability declines with age at first occurrence Males are more likely

United States Military Academy. Am J Sports Med 2007;35(7):1168-1173.. McLaughlin HL, Cavallaro WU. Primary anterior dislocation of the shoulder. Am J Surg. 1950 Dec;80(6):615-21.

50-80% of patients younger than 20 years at time of initial dislocation have a recurrent dislocation Epidemiology Flynn JM, Orthopaedic Knowledge: Update 10.

2 Epidemiology Younger Age of First Dislocation Increases Chance of Future Recurrence and/or Redislocation The rate of recurrent instability declines with age at first occurrence Males are more likely to have recurrent instability than females of similar ages Owens BD, Duffey MI, Nelson BJ, DeBerardino TM, Taylor DC, Mountcastle SB: The incidence and characteristics of shoulder instability at the United States Military Academy. Am J Sports Med 2007;35(7): McLaughlin HL, Cavallaro WU. Primary anterior dislocation of the shoulder. Am J Surg Dec;80(6): Hovelius L, Nilsson JA, Nordqvist A. Prognosis of primary anterior shoulder dislocation in young adults 1990;110(1): % of patients younger than 20 years at time of initial dislocation have a recurrent dislocation Epidemiology Flynn JM, Orthopaedic Knowledge: Update 10. Chapter 24, pg Hovelius L, Olofsson A, Sandstrom B, et al: Nonoperative treatment of primary anterior shoulder dislocation in patients for years of and younger: A Prospective twenty-five year follow-up. J Bone Joint Surg Am. 2008;90(5): Kirkley S: Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1998;80(2): Bileau P, Villalba M, Hery JY, Balg F, Ahrens P, Neyton L: Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88(8): Risk of Recurrent Instability Mather et al, 2011 Validated Markov Decision Model Predicting Outcome Based on Covariates, Patient Demographics and Surgical Success Rates for First Time Dislocators Mather III R, Orlando L, Henderson R, Lawrence JTR, Taylor D. A predictive model of shoulder instability after a first-time anterior dislocation. J Shoulder Elbow Surg. 2011; 20:

Types of Instability TUBS Traumatic, Unilateral, Bankart, Surgery AMBRII Atraumatic,

Capsular Shift Multidirectional Instability Understanding the Outcomes Majority of

Lead to Arthropathy of the Joint Hovelius and Saeboe, 2009 25 Year Follow-Up 40%

3 Types of Instability TUBS Traumatic, Unilateral, Bankart, Surgery AMBRII Atraumatic, Multidirectional, Bilateral, Rehabilitation, Interval-Capsular Closure, Inferior Capsular Shift Multidirectional Instability Understanding the Outcomes Majority of Articles Use Recurrence of Instability as Outcomes Does Recurrence of Instability Lead to Arthropathy of the Joint Hovelius and Saeboe, Year Follow-Up 40% Glenohumeral Arthritis Secondary to Recurrent Instability 18% with No Recurrence Hovelius L, Saeboe M. Neer Award 2008: arthropathy after primary anterior dislocation 223 shoulder prospectively followed up for 25 years. J Shoulder Elbow Surg; 2009: 18:

Injury Type Soft Tissue Instability Bony Instability Combined Proper Diagnosis is Paramount Treating Bony or Combined Instability with Non-operative or Incorrect Operative Treatment Will Not Work

Sclerotic Glenoid Line (LSGL) Grashey Anteroposterior View 86 Shoulders with 34 shoulder instabilities 25 anterior glenoid defects 56, 64% sensitivity (2 reviewers) 100% specificity Confirmation with

4 Injury Type Soft Tissue Instability Bony Instability Combined Proper Diagnosis is Paramount Treating Bony or Combined Instability with Non-operative or Incorrect Operative Treatment Will Not Work Proper Diagnosis Osseous Defects Poor outcomes for patients with glenoid bone loss treated with soft tissue Bankart Repair Proper imaging is imperative Osseous Defects Gerber et al, 2010 Loss of Sclerotic Glenoid Line (LSGL) Grashey Anteroposterior View 86 Shoulders with 34 shoulder instabilities 25 anterior glenoid defects 56, 64% sensitivity (2 reviewers) 100% specificity Confirmation with CT Interrater Reliability of LSGL sign 0.88 for 34 unstable shoulders 0.91 for all shoulders Jankauskas L, Rudiger HA, Pfirrmann CWA, Jost B, Gerber C. Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: A diagnostic sign for an osseous defect of the anterior glenoid rim. J Shoulder and Elbow Surgery. 2010:19( ). 4

Osseous Defects Edwards et al, 2003 Chronic instability often shows evidence of bone defects on plain radiographs 160 Shoulders with

view 95% overall Cliff Sign Edwards TB, Boulahia A, Walch G. Radiographic Analysis of Bone Defects in Chronic Anterior. Arthroscopy.

Normal Glenoid Inferior 2/3rds glenoid should be a circle Huysmans JSES 2006 Absolute Indication for Latarjet Boileau et al, 2006 >

5 Osseous Defects Edwards et al, 2003 Chronic instability often shows evidence of bone defects on plain radiographs 160 Shoulders with anterior recurrent dislocation or subluxation 73% Humeral head impaction Grashey AP View 78% Glenoid defect Bernageau Glenoid Profile view 95% overall Cliff Sign Edwards TB, Boulahia A, Walch G. Radiographic Analysis of Bone Defects in Chronic Anterior. Arthroscopy. Vol 19, No 7 (Sept), 2003: Normal Glenoid Inferior 2/3rds glenoid should be a circle Huysmans JSES 2006 Absolute Indication for Latarjet Boileau et al, 2006 > 25% Anteroinferior Bone Loss (p=0.01) Inverted Pear Shape Glenoid Boileau P, Villalba M, Hery J-Y, Balg F, Ahrens P, Newton L. Risk Factors for Recurrence of After Arthroscopic Bankart Repair. J Bone J Surg A(8):

Arthroscopic Latarjet Indications for Latarjet 15º 17.

Critical Value of Anterior Glenoid Bone Loss That Leads to Recurrent

Koh Y, Bui C, Jeong WK, Akeda M, Su Cho N, McGarryMH, Lee TQ.

Bankart Repair Does Not Restore Glenohumeral Translation, Restricts

6 Arthroscopic Latarjet Indications for Latarjet 15º 17.3% Shin S-J, Kim RG, Jeon YS, Kwon TH. Critical Value of Anterior Glenoid Bone Loss That Leads to Recurrent Glenohumeral Instability After Arthroscopic Bankart Repair. Am J Sports Med Arthroscopic Latarjet Indications for Latarjet 15% Shin S-J, Won Koh Y, Bui C, Jeong WK, Akeda M, Su Cho N, McGarryMH, Lee TQ. What Is the Critical Value of Glenoid Bone Loss at Which Soft Tissue Bankart Repair Does Not Restore Glenohumeral Translation, Restricts Range of Motion, and Leads to Abnormal Humeral Head Position? Am J Sports Med (11): Arthroscopic Latarjet Indications for Latarjet 13.5% Shaha JS, Cook JB, Song DJ, Rowles DJ, Bottoni CR. Redefining Critical Bone Loss in : Functional Outcomes Worsen With Subcritical Bone Loss. Am J Sports Med, 2015, 43 (7):

European Indications for Latarjet Bone Loss Anterior Posterior Primary for Collision Athletes Revision Instability Cases Poor

Height + 15 mm Example Height = 45 mm 1/3 (45 mm) + 15 = 30 mm Actual Width = 20 mm % of Bone Lost = 10/30 33% Bone Loss LTC Owens BD,

Simple Method of Glenoid Bone Loss Calculation Using Ipsilateral Magnetic Resonance Imaging. Am J Sports Medicine 2013; 41:3, 622-624.

7 European Indications for Latarjet Bone Loss Anterior Posterior Primary for Collision Athletes Revision Instability Cases Poor Tissue/Capsule Measuring Bone Insufficiency LTC Owens et al, 2014 Height of the Glenoid Estimated Width of the Glenoid 1/3 of the Height + 15 mm Example Height = 45 mm 1/3 (45 mm) + 15 = 30 mm Actual Width = 20 mm % of Bone Lost = 10/30 33% Bone Loss LTC Owens BD, MAJ Burns TC, LTC Campbell SE, LTC Svoboda SJ, Cameron KL. Simple Method of Glenoid Bone Loss Calculation Using Ipsilateral Magnetic Resonance Imaging. Am J Sports Medicine 2013; 41:3, Articular Length Glenoid track (Omori et al.) At 90 degrees of abduction 83% of the width of the intact glenoid Must appreciate Integrity of the glenoid track location of the Hill Sachs lesion Essential in decision making 7

83 x D) d Glenoid Track Yamamoto et al, 2007 Zone of Contact between Glenoid and Humeral Head No Glenoid Defect Width of Glenoid Track is 84% of the Glenoid Width Glenoid Defect of Anterior Rim 84% -

8 Glenoid Track Calculation Measure the diameter of the anterior glenoid Arthroscopy CT Glenoid width = 1/3 height + 15 mm (Owens et al.) Determine the width (amount) of anterior glenoid bone loss Calculate AP width of glenoid track GT= (0.83 x D) d Glenoid Track Yamamoto et al, 2007 Zone of Contact between Glenoid and Humeral Head No Glenoid Defect Width of Glenoid Track is 84% of the Glenoid Width Glenoid Defect of Anterior Rim 84% - Width of Defect = Glenoid Track If Medial Margin of Hill-Sachs Lesion is Medial to the Glenoid Track, Standard Soft Tissue Stabilization is Unlikely to Restore Stability Arm in maximal external rotation, extension and abduction Yamamoto N, Itoi E, Abe H, Minagawa H, Seki N, Shimada Y, Okada K. Contact between the glenoid and the humeral head in abduction, external rottion and horizontal extension: A new concept of glenoid Track. J Shoulder Elbow ssurg. 2007; 16 (5): Arthroscopic Latarjet Glenoid Track First introduced by Itoi Evaluation of bipolar bone loss Clarified contact area of humeral head and glenoid Different amounts of ER and abduction 8

recommendations for surgical management of anterior

Humeral Defect Calculation Calculate width (medial

defect to rotator cuff attachments On or Off Track/

9 On or Off Track Lesions Further defines understanding of bipolar bone loss Make recommendations for surgical management of anterior instability With or without bipolar bone loss Humeral Defect Calculation Calculate width (medial extension) of Hill Sachs lesion Medial extension of defect to rotator cuff attachments On or Off Track/ Will it Engage? Hill Sachs Lesion < Glenoid track On track lesion Non engaging 9

10 On or Off Track/ Will it Engage? Hill Sachs lesion > Glenoid track Off track lesion Engaging On or Off Track/ Will it Engage? 4 Groups of Patients Group Glenoid Defect Hill Sachs Lesion 1 <25% On Track 2 <25% Off Track 3 >25% On Track 4 >25% Off Track 10

Group Treatment Algorithm Glenoid Defect Hill Sachs Lesion Treatment 1 <25% On Track Arthroscopic Bankart repair 2 <25% Off track Arthroscopic Bankart repair + remplissage 3 >25% On Track Latarjet

Hill-Sachs with Off-track lesion Average age: 29.8 Average follow up: 60.7 months Outcomes 11.8% redislocation rate at an average 5 years In throwers, 65.

11 Group Treatment Algorithm Glenoid Defect Hill Sachs Lesion Treatment 1 <25% On Track Arthroscopic Bankart repair 2 <25% Off track Arthroscopic Bankart repair + remplissage 3 >25% On Track Latarjet procedure 4 >25% Off Track Latarjet + humeral bone grafting Arthroscopic Latarjet Remplissage Outcomes Garcia et al, 2016 Retrospective review 50 patients (51 shoulders) who had Remplissage for large Hill-Sachs with Off-track lesion Average age: 29.8 Average follow up: 60.7 months Outcomes 11.8% redislocation rate at an average 5 years In throwers, 65.5% complained of decreased range of motion % had problems throwing Garcia GH, Wu H-H, Liu JN Huffman GR, Kelly JD. Outcomes of the Remplissage Procedure and Its Effects on Return to Sports. Am J Sports Med 2016, 44 (5): Arthroscopic Latarjet Latarjet vs. Bankart Repair Zimmerman et al, patients (364 shoulders) 93 Latarjet, 271 Bankart repairs, follow up of 6 years Instability or apprehension: 11% Latarjet 41.7% Bankart Overt Instability: 3% Latarjet 13.2% Bankart Arthroscopic Bankart was inferior to Latarjet, the difference to the quality of outcomes decreased significantly with time Zimmerman SM, Scheyerer MJ, Farshad M, Catanzaro S, Rahm S, Gerber C. Long-Term restoration of anterior shoulder stability: A retrospective analysis of arthroscopic bankart repair versus open Latarjet procedure. J Bone J Surg 2016, 98:

Group Bishai s Treatment Algorithm Glenoid Defect Hill Sachs Lesion Treatment 1 <25% On Track Arthroscopic Bankart repair 2 <25% Off track Arthroscopic Bankart

Congruent Arc Boons et al, 2013 European Inferior Coracoid Placed Against Anterior Glenoid Congruent Arc Medial Coracoid Placed Against Anterior Glenoid

inferior coracoid to be Congruent with the native glenoid Traditional Latarjet Increased contact stress/pressure Edge loading secondary to medialization of the

12 Group Bishai s Treatment Algorithm Glenoid Defect Hill Sachs Lesion Treatment 1 <25% On Track Arthroscopic Bankart repair 2 <25% Off track Arthroscopic Bankart Laterjet Procedure repair + remplissage 3 >25% On Track Latarjet procedure 4 >25% Off Track Latarjet + humeral bone grafting European vs. Congruent Arc Boons et al, 2013 European Inferior Coracoid Placed Against Anterior Glenoid Congruent Arc Medial Coracoid Placed Against Anterior Glenoid Essential in decision making Congruent Arc de Beers and Roberts, 2010 Theorized that rotating the graft 90 degrees to a traditional Latarjet would use the inferior coracoid to be Congruent with the native glenoid Traditional Latarjet Increased contact stress/pressure Edge loading secondary to medialization of the graft Congruent Arc Flush with the glenoid Decrease contact forces de Beers JF, Roberts C. Glenoid Bone Defects Open Latarjet with Congruent Arc Modification. Orthop Clin N Am :

20% Moral of the story: These patients have been

13 The Sling Effect Arthroscopic Latarjet Patient Population Bankart Repairs 20% Latarjet Procedures 20% Moral of the story: These patients have been seeing me but I have not been seeing them Radiographic Imaging 13

14 Look Closely at the Glenoid Advanced Imaging Previous Arthroscopy Pictures 14

15 Glenoid Bone Loss Calculation Glenoid Height 42 mm 42 x 1/3 = 14 mm Estimated Glenoid Width 14 mm + 15 = 29 mm Actual Width = 22 mm Percent Bone Loss 7/29 24% Bone Loss Provencher showed 4-6 mm of anterior bone loss can be 20-25% of glenoid EUA and Scope Evaluation Open Latarjet 15

Arthroscopic Latarjet Arthroscopic Posterior

Procedure with Glenoid Bone Loss First Time

Athletes Should Be Fixed Acutely Primary Latarjet

16 Arthroscopic Latarjet Arthroscopic Posterior Augmentation Correct Diagnosis Workup CT MRI Bony Procedure with Glenoid Bone Loss First Time Dislocators in Younger Patients and Collision Athletes Should Be Fixed Acutely Primary Latarjet If there is: Off-Tack Lesion Significant Bone Loss Summary 16

17 Thank You 17

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