Revision Instability Repair
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1 Revision Instability Repair Anthony A. Romeo, MD Professor, Department of Orthopedics Head, Section of Shoulder and Elbow Surgery Team Physician, Chicago White Sox and Bulls Chief Medical Editor, Orthopaedics Today
2 Revision Instability Repair 1. Royalties: Arthrex, Elsevier 2. Consultant: Arthrex 3. Miscellaneous Support: Arthrex DISCLOSURES 4. Basic Science/Research Support: Arthrex, Smith and Nephew, Ossur, Miomed, DJOrtho, Conmed Linvatech, Athletico 5. Editorial Board: Orthopedics Today (Chief Medical Editor), Journal of Shoulder and Elbow Surgery, Techniques in Shoulder and Elbow, Techniques in Sports Medicine, Sports Health, Orthopedics 6. Publisher Support: Elsevier (Textbook), Orthopedics Today
3 Mechanism of Injury
4 Anterior Bankart Tear Soft Tissue Dominant >90%
5 How do we define the injury? + Stretch How can we measure: Translation Rotation Adjust tension? IGHL
6 Anterior Instability with Bone Loss
7 On Track, Off Track Courtesy of Giovanni Di Giacomo
8 Examination with Bone Loss
9 Fix Primary Direction, then Augment Repair Reliable Repair, Motion Recovery and Result
10 Portal Access Arthroscopy Apr;26(4): Four-quadrant approach to capsulolabral repair: an arthroscopic road map to the glenoid. Seroyer ST, Nho SJ, Provencher MT, Romeo AA Anterior - Superior Posterior Anterior Inferior (5 o clock) Posterior Inferior (7 o cclock)
11 Suspension of the Arm
12 Recurrence of Instability: Beach Chair Surgeons 14.7% Lateral Decubitus Surgeon 8.5% P = Lateral decubitus allows you to see ALL the pathology easier (level V)
13 Anterior Instability engaging Hill-Sachs Posterior Anterior
14 MLB Baseball Player
15 Major League Baseball Player Initial Injury Scope Repair
16 Anterior INFERIOR Stabilization Access Proper Fixation
17 Remplissage
18 Level of Evidence: IV 26 studies (n=1781) patients Mean: f/u 11 yrs, age 28, 81% male Mean of 11 dislocations before surgery 2013 AANA J Whit Ewing Award
19 No significant difference between: Open and Arthroscopic Suture Anchor Bankart Recurrence of instability (8% vs 8.5%; p=0.82) Rate of return to sport (89% vs 87%; p=0.43) Radiographic osteoarthritis (33% vs 26%; p=0.06) Constant score, Rowe score (p > 0.05 for both)
20 After Surgery Return to Sport Contact Athlete White et al. (OSJM 2015 abstract) Return to Play After Shoulder Stabilization in National Football League Athletes 60 NFL players underwent stabilization at single institution 11 open; 49 arthroscopic RTP definition at least one regular season NFL after surgery 54/60 (90%) RTP at average 8.6 months No differences between open and arthroscopic in RTP rates No differences in age, career length, or # of games before surgery in athletes who RTP verses those who did not Athletes selected before 4 th round of NFL draft 7.6x more likely to RTP Timing of surgery (in-season or off-season) unclear
21 Reduction in failure rate from 17.4 to 7.9 if lateral decubitus, <20% bone loss and 3 anchor minimum.
22 AOSSM Herodicus Award 2012 ONTARIO POPULATION COHORT Billing & hospital admission coding July 2003 December 2008; min >2 year f/u INCLUSION Age Elective surgery (no fractures) EXCLUSION Previous stabilization Posterior, inferior dislocation history (ICD-10) Bony reconstructions
23 Results N=5,904 surgeries (Population: 13+ million people) Median age 27 years (IQR 20-37) 80.6% male STABILIZATION = 4% REVISION After a mean 2.2 ± 1.3 years DISLOCATION= 6.9% POST-OP After a mean 2.0 ± 1.4 years
24 Percentage Younger Age = Higher Risk Revision Post op relocation Age (years)
25 More pre-op dislocations = Higher Risk
26 Recognize glenoid bone loss patients (101 contact athletes) Average 27 month follow-up Arthroscopic repair with suture anchors Bone loss #1 Reason for Failure 11 % recurrence overall No bone defect 4% recurrence Bone defect 67% recurrence Inverted Pear 61% recurrence
27 Recognize glenoid bone loss 2003
28 Why does Instability surgery fail? 2004 Anterior Glenoid Bone Loss (55%) Loose Capsule (22%) HAGL (5%)
29 Why does Instability surgery fail? 2006 Risk Factors: Bone loss (either HH or glenoid) Hyperlaxity Less than 4 anchors
30 Fix Bone Loss with Soft Tissue Operation? engaging Hill-Sachs
31 Critical size: ~20% (6-8mm) Revision case: 4mm is concerning or anything over 10%
32 JAAOS 2009
33 Estimate Amount of Glenoid Bone Loss XR, CT, MRI Arthroscopy? 0 to 15% 15% to 25% > 25% Arthroscopic Repair -Incorporate Bony Fragment -Liberal use of anchors -Consider posterior repair (contact athletes) -Arthroscopic Repair CAUTION! (>20%) -Best with bony fragment that is incorporated -Open procedures ± bone augmentation OPEN bone Augmentation procedures Provencher et al. J Bone Joint Surg Am Dec
34 Examples of 3D CT Scans Attritional Bone Loss Bone Fragment Bone Loss Inferior 2/3rds of Glenoid is Circle and can Measure
35 Results of Arthroscopic Revision Creighton et al Neri et al Arthroscopy patients 3 recurrences 5 failures (28%) Follow-up: 29 mos. JSES 07 No scientific assessment of bone loss 11 patients 3 recurrences (27%) g/ex results: 73%
36 Case Example 20yo male football player, RHD, with R shoulder instability Defensive back, hurt shoulder with tackle More shoulder subluxation events, may have been on other dislocation (self-reduced) PT, modified activities >6 months Wants to continue to play football
37 5/14/10 Pre-Op X-rays
38 Intraoperative
39 1 Year later Recurrent Dislocation with Football
40 2 nd Soft Tissue Stabilization + Augmentation?
41 Recurrence after Revision: 2 Failed Arthroscopic Repairs?
42 CT Scan After 2 Failures
43 AJSM patients failed bankart repair 88% good or excellent results Most pts able to return to sport at same level 11% recurrence Proper Fixation
44 Is there a role for revision arthroscopic bankart repair? Systematic Review 16 studies, 349 patients included Avg 12.7% recurrence after arthroscopic revision at avg 35 mo Most common reason for recurrence after revision was under appreciated bone loss either on glenoid or humerus
45 Arthroscopic Bankart Revision: May require ideal situation Overhead athlete Traumatic recurrence Inadequate initial repair Minimal Bone Loss Good tissue perfect standard Bankart repair + augmentation
46 Glenoid Bone Defects Coracoid Transfer Bristow-Helfet (1958): transfer tip of coracoid with conjoint tendon Latarjet (1954): transfer of larger portion of the coracoid
47
48 Latarjet, through Subscapularis Split The Sling resists anterior translation
49 Latarjet replaces bone loss with bone 10 studies with follow-up ranging from 6m to 14.3 years Recurrence rates 0% to 8% Satisfaction good to excellent in >90% of patients Patient reported outcomes variably reported, generally good when reported Complications variably reported, most often malunion or neuropraxia Surgical technique and coracoid fixation variable!
50 49 patients 38 months follow-up No recurrent dislocations No revision surgery Relationship between arthritis and suboptimal graft placment
51 Despite higher dislocation rates(10% v 0%), Arthroscopic Bankart repair had improved return to sport.
52 Latarjet lower recurrence, improved outcome scores improved external rotation No significant difference in complications requiring reoperation
53 The Rush Experience Clinical Outcomes Following Revision Anterior Shoulder Stabilization: Arthroscopic Revision Stabilization versus Latarjet Rachel M. Frank, MD; Chris Mellano, MD; Jason J. Shin, MD; Terrence F. Feldheim, BS; Randy Mascarenhas, MD; Adam B. Yanke, MD; Brian J. Cole, MD MBA; Gregory P. Nicholson, MD; Anthony A. Romeo, MD; and Nikhil N. Verma, MD Department of Orthopaedic Surgery, Rush University Medical Center 2016
54 Methods: Revision Anterior Shoulder Stabilization 91 shoulders 4 surgeons ( ) <10% bone loss Arthroscopic stabilization (n=63) >10% bone loss Latarjet (n=28) Inclusion Criteria Prior stabilization (min 15 months earlier) Exclusion Criteria Seizures, work-comp cases Prior open bone grafting
55 Methods Data Collection Minimum 18 month follow-up PROs ASES, SANE, VAS, WOSI Preoperative data imaging, PROs, exam Intraoperative data lesion size, concomitant pathology Postoperative data imaging, PROs, exam, RTP Failure recurrent dislocation or subluxation
56 Results Revision Arthroscopy 63 shoulders (74% males) Average age 23.2 years Average follow-up 46.9 months Sig improvements in ASES, SST, and VAS Average WOSI 80.1 Risk factors for failure 10 dislocation Recurrent instability 12/63 (19%) Progression to arthritis 0 Number of prior surgeries (P<0.001) 2 symptomatic subluxation Baseline hyperlaxity (P=0.04)
57 Results Latarjet 28 shoulders (75% male), average age 27.5 years Average follow-up 30.0 months Average glenoid bone loss 18.7% 14 (50%) with >1 prior stabilization attempt N=1 dislocation from motocross Significant improvements in ASES, SST, and VAS Average WOSI progressed 71.9 to rapid arthrosis converted to HA Recurrent instability 2/28 (7%) Progression to arthritis 2/28 (including 1 recurrent) N=1 symptomatic subluxation
58 Principal Findings Both revision arthroscopic stabilization and Latarjet result in satisfactory outcomes in patients with failed index stabilization Despite smaller degrees of glenoid bone loss, recurrent instability rates were higher in the arthroscopic group (19% versus 8%)
59 Conclusions Is there a role for revision arthroscopic stabilization? YES But with STRICT indications Technical failure that may be improved Good capsular tissue quality Caution in patients with >1 prior surgery and/or hyperlaxity, even if minimal bone loss
60 Thank you! Chicago
61 Anthony A. Romeo, MD Section Head, Shoulder and Elbow Service Professor, Dept. of Orthopaedic Surgery Rush University Medical Center 1611 W. Harrison St., Suite 300 Chicago, IL Chicago
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