RECURRENT SHOULDER DISLOCATIONS WITH ABSENT LABRUM D R. A M R I S H K R. J H A M S ( O R T H O ) A S S I S T A N T P R O F E S S O R M E D I C A L C O L L E G E, K O L K A T A
LABRUM Function as a chock-block, increasing the glenoid depth and resisting translation Concavity compression increase stability by 10-20% helps to maintain a negative intra-articular pressure
MORPHOLOGY OF LABRUM
STAGES OF SHOULDER INSTABILITY Single lesion: periosteal disintegration of A.I. labrum Double lesion: disinsertion of GHL complex Triple lesion: stress mechanism alters the detached structures through tissue damage Quadruple lesion: degeneration & destruction of labrum-ligaments complex
ARTHROSCOPIC CAPSULAR SHRINKAGE PROCEDURE an arthroscopic procedu re where the loose ligaments and capsule are tightened using a special radiofrequency heating probe Mainly for MDI not suitable for traumatic dislocations
THERMAL CAPSULORRRHAPHY END RESULT: Decrease capsular redundency Reduced glenohumeral translation Decrease joint volume High recurrence rate: 20-45% Excessive stiffness & Extensive chondrolysis Axillary nerve neuropathy: 21% in one series May play a role in augmenting other stabilisation construct
CAPSULORHHAPHY & ROTATOR INTERVAL CLOSURE May be attempted as a sole procedure in low demand patients??????? Controversial & unpredictable outcome
Arthroscopic Latarjet procedure` J Shoulder Elbow Surg. 2010 Mar;19(2 Suppl):2-12. doi: 10.1016/j.jse.2009.12.010. Lafosse L, Boyle S. The average patient age was 27.5 with 88% actively involved in sports. Mean return to work was 2 months (7 days-4 months) and return to sport at 10 weeks (21 days-6 months). At 26 months, patient-reported outcomes revealed 91% excellent scores and 9% good. Range of motion showed an average loss of external rotation of 18 degrees. Perioperative complications included 2 hematomas, 1 graft fracture, and 1 transient musculocutaneous nerve palsy. Late complications included 4 cases of graft non-union and 3 of graft lysis. Graft position was flush with the glenoid in 80%, vertical positioning was excellent in 78% (3-5 o'clock).
Arthroscopic absent labrum Surgeon should not hesitate to convert it into an open procedure as result is going to be inferior with arthroscopic procedures.
CONTRAINDICATIONS OF ARTHROSCOPIC PROCEDURES FOR RSD ABSENT LABRUM humeral avulsions of the glenohumeral ligaments (HAGL Lesion capsular ruptures/ loose capsule: drive through sign previous failed arthroscopic or open repair prior failed thermal capsulorrhaphy poor-quality capsulolabral tissue or even the complete capsular deficiency that can occur with capsular necrosis Significant bony defect in the glenoid (>21-30%), or the humeral head
OPEN TECHNIQUES OPEN TECHNIQUES WITH SOFT TISSUE REPAIR / AUGMENTATION OPEN TECHNIQUES WITH BONY AUGMENTATIONS
OPEN TECHNIQUES WITH SOFT TISSUE REPAIR / AUGMENTATION Open Bankart procedure: not for patients with degenerated / absent labrum Capsulolabral procedure Puttiplatt procedure Magnuson stack procedure
Capsulolabral procedure To reduce capsular redundancy T shaped incision in the capsule With horizontal limb, two separate flaps created: superior & inferior Two flaps are then imbricated on each other Labral defect is repaired if possible
Results : Good to excellent results : 92-96% Recurrence: 0-4% Loss of ER : MINIMAL, AS SUBSCAP IS NOT IMBRICATED
Puttiplatt procedure: "double-breasted" technique. nonanatomic procedure with promising initial outcomes Subscap tendon is devided 2-3 cm med. to lesser tuberosity lateral stump is sutured to the glenoid rim..the medial stump is then laid on top & repaired to the lateral stump.
Results : Good to excellent results : 55-855% Recurrence: 9-35% Loss of ER: 9-23 degrees Mild to moderate OA : 26-30%
Magnuson stack procedure The procedure is predicated on tightening of the subscapularis by altering the insertion site from the lesser tuberosity to a groove created lateral to the bicipital groove a sling effect on the humeral head
Results : Good to excellent results : 90-95% Recurrence: <5% Loss of ER: 5-10 degrees Early osteoarthrosis & damage to biceps tendon
OPEN BONY PROCEDURES Bristow procedure Laterjet procedure Eden- Hybbinette procedure
BRISTOW PROCEDURE Transfer of the coracoid process through the subscapularis tendon to the anteroinferior glenoid neck Serves as a bone block in front of the humeral head. The transferred short head of the biceps and coracobrachialis are placed so as to produce a strong dynamic buttress across the anterior and inferior aspects of the joint when the shoulder is in the vulnerable abducted and externally rotated position
Results : Good to excellent results : 80-97% Recurrence: 0-6% Loss of ER: 5-10 degrees Hard ware problems Graft nonunion
LATERJET PROCEDURE This procedure is mainly performed when there is some bone loss from the front of the glenoid (as a result of a bony bankart lesion or repeated dislocations wearing away the front of the glenoid Triple effect ( Patte) 1) increase or restore the glenoid contact surface area; 2) the conjoint tendon stabilises the joint when the arm is abducted and externally rotated, by reinforcing the inferior subscapularis and anteroinferior capsule; 3) repair of the capsule.
Larger portion of coracoid process Coracoid process is laid on its side & fixed with the neck of scapula
Results : Good to excellent results : 88-95% Recurrence: 2-10% including subluxation & dislocation GH arthrosis : very high rate: 30-70% Hard ware problems Graft nonunion
ARTHROSCOPIC REMPLISSAGE SURGERY FOR THE HILL SACH DEFECT The principle of remplissage surgery is to fill the gap of the hillsach lesion with the rotator cuff muscle. Hence it will act as a physical restraint when the provocative manoeuvres for dislocation are undertaken. The hill sach lesion can be easily made out as a dent in the back of the head of the arm bone (Posterolateral aspect). The dent is freshened with the help of mini tubular 4.2mm shavers and bone edges are burred with a special burr. Usually over the hill sach lesion one could visualise the infraspinatus muscle (a part of rotator cuff muscle). With a miniature drill two small holes are made in the dent. Absorbable screws with fibre wire are fixed in these holes. The fibrewires attached to these holes are retrieved through the infraspinatus muscle and the knot is applied to fix the infraspinatus muscle to the hill sach lesion.
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