Study of bipolar bone defects in unstable shoulder: From "engaging / non-engaging" to "on-track / off-track".

Transcription

1 Study of bipolar bone defects in unstable shoulder: From "engaging / non-engaging" to "on-track / off-track". Poster No.: C-2219 Congress: ECR 2017 Type: Educational Exhibit Authors: E. Jose Salgado Ribeiro, B. C. S. Rabelo, R. NOBRE RODRIGUES, A. Moura Abuhid Lopes, V. BARROS MACHADO, F. Oliveira Franca, A. Couto Godinho, P. Couto Godinho, G. Gomes Godinho ; Belo Horizonte/BR, Itauna/BR Keywords: Musculoskeletal bone, Musculoskeletal joint, Bones, CT, CTHigh Resolution, Image manipulation / Reconstruction, Computer Applications-3D, Education, elearning, Outcomes, Education and training, Athletic injuries DOI: /ecr2017/C-2219 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 42

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3 Learning objectives - To describe Hill-Sachs fracture evaluation concepts and techniques for the identification of "engaging" or "non-engaging" injuries. - Demonstrate techniques of quantification of glenoid bone loss. - Review surgical techniques for correction of traumatic anterior instability, with emphasis on "Remplissage" and Latarjet-Patte. - Define "glenoid track" and apply this concept in the preoperative evaluation of bipolar defects to characterize "on-track" and "off-track" injuries. Page 3 of 42

4 Background Traumatic anterior glenohumeral instability is associated with bone lesions (Hill-Sachs), glenoid lip (Bankart), and antero-inferior ligaments. One of the predisposing factors for the occurrence of dislocation is the association with large bone defects (humeral head and glenoid). The morphological study of bone defects helps to select the appropriate surgical technique to correct instability. New imaging methods consider bipolar defects (combined humeral head + glenoid) and do not rely on perioperative confirmation. Page 4 of 42

5 Findings and procedure details Hill-Sachs lesion - Impaction fracture on the posterior-superior-lateral aspect of the humeral head. - X ray is useful for initial search (internal rotation). - CT and RM are better for location and depth. - The contribution of the Hill-Sachs lesion to glenohumeral instability depends on the size, orientation and location of the defect. - "Engaging" Hill-Sachs: concept introduced by Burkhart and De Beer - reproduction of instability symptoms when the shoulder is placed in abduction with external rotation. - "Engaging" Hill-Sachs can increase the arthroscope repair failure of Bankart`s injury. - Morphological study of the lesion and characterization of possible "engaging" may be useful in preoperative planning, although the definition is per-operative (dynamic assessment during arthroscopy). "Engaging" Hill-Sachs Symptoms of instability result from the geometry of the Hill-Sachs lesion, more horizontal in relation to the humeral shaft in the neutral position, becoming PARALLEL at the anterior margin of the glenoid in the abduction position with external rotation, fitting itself. "Non-engaging" Hill-Sachs On the other hand, lesions with a greater vertical orientation in relation to the humeral shaft in the neutral position tend not to fit on the anterior border of the glenoid during abduction with external rotation. Page 5 of 42

6 Hill-Sachs - Measurement Methods - Can be made in X rays, MR or CT (3D) Hardy Index - Simple, reproducible method does not depend on magnification. - Xray anteroposterior with internal rotation. - Circle coinciding with the cortex of the humeral head ("best fit"). - Measurements of the deepest depth of the defect and the radius of the humeral head. Page 6 of 42

7 Fig. 2: Hardy index References: Hardy, P. et al. New quantitative measurement of the Hill-Sachs lesion: A prognostic factor for clinical results of arthroscopic glenohumeral stabilization. Eur. J. Orthop. Surg. Traumatol. 22, (2012). Equation = Depth (D)/Radius (R) X 100 Bankart - It may be bony or cartilaginous. Glenoid bone integrity has long been considered one of the most important factors for successful surgery. After the first traumatic event, a Page 7 of 42

8 fracture of the glenoid or friction bone injury may compromise the static stabilizers of the joint, making it even more unstable. Glenoid bone deficiency with recurrent instability is a recognized cause of surgical treatment failure. Preoperative image evaluation is essential for the detection and quantification of bone abnormalities, allowing to define the prognosis and discuss with the patient about the risks of recurrence. Bony Bankart Fig. 3: Bony Bankart Page 8 of 42

9 References: Axial Medicina Diagnostica Plain radiograph - Bony Bankart lesion may be seen as a fracture of the anteroinferior aspect of the glenoid. CT - on non-contrast CT, a fracture may be seen at the anteroinferior aspect of the glenoid. MRI - oblique sagittal plane, axial images are poorly efficient for demonstration. Sugaya method Quantification of Bone Loss Circle matching ("best fit") with the lower 2/3 of the glenoid (circumferential shape). Equation = DEFECT (b)/diameter (A) X 100 Surgical Approach- Arthroscopic Repair of Bankart - Drilling and installation of fastening anchors. - Lip suture detached at the edge of the glenoid. Surgical Approach- Remplissage - Arthroscopic technique. -Fills the bone defect with the infra-spinal tendon and the posterior capsule. Page 9 of 42

10 - Transforms an intra-articular defect into extra-articular. - Avoids the"engaging". - Significant reduction in the percentage of new dislocation in patients submitted to Bankart-remplissage in comparison with those submitted to repair only of the Bankart lesion. Fig. 6: Remplissage Page 10 of 42

11 References: Eugene wolf (2008) Surgical Approach- Latarjet-Patte - Transfer of the coracoid process to the antero-inferior border of the glenoid, correcting the bone defect. - Increases glenohumeral stability, including in impact athletes. - The distal segment of the coracoid process along with the joint tendon is attached to the edge of the glenoid using screws, passing through the subscapular muscle's belly. Page 11 of 42

12 Fig. 7: Latarjet-Patte References: Ebrahimzadeh, M. H., Moradi, A. & Zarei, A. R. Minimally invasive modified latarjet procedure in patients with traumatic anterior shoulder instability. Asian J. Sports Med. 6, e26838 (2015). Page 12 of 42

13 Fig. 8 References: Axial Medicina Diagnostica Surgical Approach- "engaging / non-engaging" - The surgical approach changes according to the dimensions of the bone defects: Page 13 of 42

14 Fig. 9 References: Axial Medicina Diagnostica Hardy limit for cited procedures: 40%. Above this value is indicated prosthesis or allograft placement (bone bank). "Glenoid Track" - Bipolar defects (combined humeral head + glenoid) may require approach with bone grafting (Latarjet). - Prior publications consider only the dimensions of the humeral head defect for engaging definition. - The position of the Hill-Sachs lesion and its relation to the glenoid are the most important factors in defining it as engaging, not its dimensions. - Criteria pre and not only per operative to characterize the engaging. - Itoi et al (2007): using CT 3D demonstrated the contact between the humeral head and the glenoid during the movement of abduction and external rotation. This contact area extends from infero-medial to super-lateral. Page 14 of 42

15 Fig. 10 References: Yamamoto N, Itoi., et al. JSES (2007) -Distance from the medial margin of the contact area of the glenoid to the medial border of the rotator cuff "footprint" with 60 degrees of abduction. - Corresponds to about 83/84% of the width of the glenoid (18.4 +/- 2.5 mm). Page 15 of 42

16 Fig. 11 References: Yamamoto N, Itoi., et al. JSES (2007) Page 16 of 42

17 Fig. 12: "Glenoid Track" References: Giacomo G et al. (2011) "On Track / Off Track" Page 17 of 42

18 Fig. 13: "On Track / Off Track" References: Giacomo G et al. (2011) Page 18 of 42

19 Fig. 14: "On Track" References: Giacomo G et al. (2011) - When the medial border of the Hill-Sachs fracture is contained within the glenoid track: ON-TRACK Page 19 of 42

20 Fig. 15: "Off Track" References: Giacomo G et al. (2011) When the medial border of the Hill-Sachs fracture exceeds medially the glenoid track limit: OFF-TRACK "On Track - non engaging" "Off Track - engaging" Page 20 of 42

21 Fig. 16: "On Track - non engaging" "Off Track - engaging" References: Giacomo G et al. (2011) Predisposing factors for off-track injury (simultaneously considering humeral head and glenoid defects): - Large glenoid bone defects: reduce "glenoid track". - Hill-Sachs lesions with marked medial extension. "On Track" - Measurement Page 21 of 42

22 Fig. 17: "On Track" - Measurement References: Giacomo G et al. (2014) Glenoid track calculation: corresponds to 83% of the width of the glenoid (G): Equation = G x Hill-Sachs interval (distance from the medial rim of the Hill-Sachs lesion to the medial border of the rotator cuff "footprint"). HILL-SACHS INTERVAL <"GLENOID TRACK" = "ON-TRACK". Surgical Approach - "on-track / off-track" Fig. 18 References: Axial Medicina Diagnostica Principles of choice of surgery: bone defect (consider glenoid combined + humeral head defects), surgeon experience and patient demand (throwing athletes, impact activity). Clinical Application - "on-track" Page 22 of 42

23 Fig. 19: Clinical Application - "on-track" References: Axial Medicina Diagnostica (glenoid width) x 0.83 = ("glenoid track") ("glenoid track")> (Hill-Sachs interval) "On-track" - Surgical approach: Bankart repair Clinical Application - "off-track" Page 23 of 42

24 Fig. 20: Clinical Application - "off-track" References: Axial Medicina Diagnostica (glenoid width) x 0.83 = (glenoid track) (bone defect) = 18.9 (corrected glenoid track) 18.9 (corrected glenoid track) <21.47 (Hill-Sachs intervened) "Off-track" - Surgical approach: Bankart repair + Remplissage. Page 24 of 42

25 Images for this section: Fig. 4: Hill Sachs Axial Medicina Diagnostica Page 25 of 42

26 Fig. 2: Hardy index Hardy, P. et al. New quantitative measurement of the Hill-Sachs lesion: A prognostic factor for clinical results of arthroscopic glenohumeral stabilization. Eur. J. Orthop. Surg. Traumatol. 22, (2012). Page 26 of 42

27 Fig. 3: Bony Bankart Axial Medicina Diagnostica Page 27 of 42

28 Fig. 5: Sugaya method Sugaya, H. (2014). Techniques to evaluate glenoid bone loss. Current Reviews in Musculoskeletal Medicine, 7(1), 1-5. Page 28 of 42

29 Fig. 6: Remplissage Eugene wolf (2008) Page 29 of 42

30 Fig. 7: Latarjet-Patte Ebrahimzadeh, M. H., Moradi, A. & Zarei, A. R. Minimally invasive modified latarjet procedure in patients with traumatic anterior shoulder instability. Asian J. Sports Med. 6, e26838 (2015). Page 30 of 42

31 Fig. 8 Axial Medicina Diagnostica Page 31 of 42

32 Fig. 10 Yamamoto N, Itoi., et al. JSES (2007) Page 32 of 42

33 Fig. 11 Yamamoto N, Itoi., et al. JSES (2007) Page 33 of 42

34 Fig. 12: "Glenoid Track" Giacomo G et al. (2011) Page 34 of 42

35 Fig. 13: "On Track / Off Track" Giacomo G et al. (2011) Page 35 of 42

36 Fig. 14: "On Track" Giacomo G et al. (2011) Page 36 of 42

37 Fig. 15: "Off Track" Giacomo G et al. (2011) Fig. 16: "On Track - non engaging" "Off Track - engaging" Page 37 of 42

38 Giacomo G et al. (2011) Fig. 17: "On Track" - Measurement Giacomo G et al. (2014) Fig. 19: Clinical Application - "on-track" Axial Medicina Diagnostica Page 38 of 42

39 Fig. 20: Clinical Application - "off-track" Axial Medicina Diagnostica Page 39 of 42

40 Conclusion - CT and MRI are important imaging methods in the preoperative planning of the previous traumatic instability, providing a morphological study of the Hill-Sachs fracture and allowing the quantification of glenoid bone loss. - "Engaging" Hill-Sachs depends more on the position of the defect and its relation to the glenoid than on its dimensions, which may be the cause of Bankart's arthroscopic repair failure. - "Glenoid track" and the definition of "on-track" and "off-track" lesions are useful in identifying patients with a higher propensity to "engaging" and recurrent dislocations. - Bipolar defects with large bone loss from the glenoid cause surgical treatment failure, due to the reduction of the glenoid track. - The choice of the appropriate surgical technique depends on the characteristics of the bone defects. - The radiologist has a crucial role in the treatment of instability, providing decisive information on the pre and post-surgical handling of patients. Page 40 of 42

41 References 1. Provencher MT, Frank RM, LeClere LE, Metzger PD, Bernhardson A, Romeo AA. The Hill-Sachs lesion: diagnosis, classification and management. J Am Acad Orthop Surg 2012; 20: Yamamoto N, Itoi E, Abe H, Kikuchi K, Seki N, Minagawa H, Tuoheti Y. Effect of an anterior glenoid defect on anterior shoulder stability. Am J Sports Med 2009; 37(5): Gyftopoulos S, Yemin A, Beltran L, Babb J, Bencardino J. Engaging Hill-Sachs lesion: is there an association between this lesion and findings on MRI? AJR Am J Roentgenol 2013;201: Park MJ, Tjoumakaris FP, Garcia G, Patel A, Kelly JD. Arthroscopic remplissage with bankart repair for the treatment of glenohumeral instability with hill-sachs defects. Arthroscopy 2011; 27(9): Skendzel JG, Sekiya JK. Diagnosis and management of humeral bone loss in shoulder instability. Am J Sports Med 2012; 40: Sekiya JK, Wickwire AC, Stehle JH, Debski RE. Hill-Sachs defects and repair using osteoarticular allograft transplantation: biomechanical analysis using a joint compression model. Am J Sports Med 2009; 37: Cho SH, Cho NS, Rhee YG. Preoperative analysis of the Hill-Sachs lesion in anterior shoulder instability: how to predict engagement of the lesion. Am J Sports Med 2011; 39: Kaar SG, Fening SD, Jones MH, Colbrunn RW, Miniaci A. Effect of humeral head defect size on glenohumeral stability: a cadaveric study of simulated hill-sachs defects. Am J Sports Med 2010; 38(3): Provencher MT, Bhatia S, Ghodadra NS, Grumet RC, Bach Jr BR, Dewing CB, LeClere L, Romeo A. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am 2010; 92(2): Page 41 of 42

42 10. Bois AJ, Fening SD, Polster J, Jones MH, Miniaci. Quantifying glenoid bone loss in anterior shoulder instability: reliability and accuracy of 2-dimensional and 3-dimensional computed tomography measurement techniques. Am J Sports Med 2012; 40: Giacomo GD, Itoi E, Burkkart SS. Evolving Concept of Bipolar Bone Loss and the HillSachs Lesion: From "Engaging/Non-Engaging" Lesion to "On-Track/Off-Track" Lesion. Arthroscopy 2014; 30 (1): Page 42 of 42