Strategies for Failed Instability Repair

Strategies for Failed Instability Repair Robert E Hunter MD Director, Orthopedic Sports Medicine Center HRRMC Salida, Colorado CU Sports Medicine Course Sept 28, 2012

Conflict of Interest Paid Consultant: Smith & Nephew Biomet Institutional Support: Smith & Nephew Synthes Biomet Breg

Primary Arthroscopic Stabilization of Anterior Shoulder Instability 83 Consecutive Patients Bankart Repair With Anchor Technique F/U 24-49 Months Recurrence In 18% (13 Patients) Increase Recurrence With: Age <25 y/o Ligament Laxity Large Hill-Sachs Lesion Recurrence In Patients <20 y/o 37.5% HSS Sports Medicine Service Voos et al 10

Risk Factors For Recurrent Shoulder Instability After Arthroscopic Repair 91 Consecutive Patients F/U Mean 36 Months Mean Time to Recurrence 17.6 Months Risk For Recurrence Higher With: Presence of a Bone Defect on the Glenoid and/or Humerus Inferior Hyperlaxity and/or Anterior Hyperlaxity Glenoid Bone Loss and Inferior Hyperlaxity -75% Recurrence 3 Anchors Boileau et al 06

Failed = Redislocated Why Does A Reconstructed Shoulder Redislocate? The Correct Procedure Was Done Poorly The Wrong Procedure Was Done The Correct Procedure Was Done Well But Just Didn t Heal Perfect Surgery Was Re-stressed Through A New, Traumatic Injury (After All, You Dislocated A Normal Shoulder the First Time)

The Correct Procedure Bankart Reconstruction Potential Cross-Roads Release of Ant/Inferior Capsule Debridement of Ant Glenoid Placement of Anchors Number of Anchors Knot Tying Management of Associated Pathology

Release of Ant/Inferior Capsule Virtually All Chronic Instabilities Require Capsule Release View the Release From the Ant/Sup Portal Release From Superior Extent of Lesion to 6 Release Until: Labrum/Capsule Floats Up to the Glenoid Surface A Grasper Can Easily Mobilize the Capsule to the Desired Position On the Glenoid

Debridement of Ant Glenoid Remove All Soft Tissue See the Black Hole Debride the Ant Glenoid Neck to Raw Bone (Synovial Resector)

Placement of Anchors 1mm On the Glenoid Surface Lowest Anchor at 5-6 Anchor Below the Bone (Not Below the Cartilage)

Number of Anchors For a Simple Bankart Always More Than 1 Always Less Than 5 Generally 3 Space the Anchors About 8-10 mm Apart Place 3 Anchors From 3-6

Knot Tying There a Many Ways to Tie An Effective Knot There Are Even More Ways to Do it Wrong.

Management of Associated Pathology Inferior Laxity (Interval Closure?) SLAP (SLAP Repair) Biceps (Tenodesis vs Tenotomy) Posterior Laxity (Plication vs Reverse Bankart) ~25% Are Bankart+

The Wrong Procedure Where Will a Standard Bankart Reconstruction Fail? Associated Pathology Is Not Addressed Hyperlax Patients not Plicated (In Addition to a Bankart Repair) Hyperlax Patients Mobilized Too Early Anterior Glenoid Deficiency Exceeds ~20% Hill-Sachs Lesion That Easily Engages the Ant Glenoid Glenoid Deficiency + Hill-Sachs HAGL

Questions to Ask Why Did the First Surgery Fail? What Must I Do Differently or Better This Time? What Obstacles Stand In My Way? What Do I Need to Do Successful Surgery?

Why Did the First Surgery Fail? I Always Get Four Things: Op Report New X-Rays MRI CT (With 3D Reconstruction)

Why Did the First Surgery Fail? I Always Get Four Things: Op Report Findings Potential Problems Encountered Technique Used Type and Location of Anchors

Why Did the First Surgery Fail? I Always Get Four Things: New X-Rays Anchors: Numbers/Location Status of Articular Surfaces Information re. Glenoid Deficiency Hill-Sachs Lesion

Why Did the First Surgery Fail? I Always Get Four Things: MRI Capsule (R/O HAGL) Posterior Labrum/Capsule Cuff Information re. Bone

Why Did the First Surgery Fail? I Always Get Four Things: CT (With 3D Reconstruction) Anterior Glenoid Rim Posterior Humeral Head

Right MRI

Right Scapula

Right Humerus

Left MRI

Left Scapula

Left Humerus

What Must I Do Differently or Better This Time? Prepare For and Don t Be Afraid of Opening Address Bone Pathology Don t Be Myopic Look For Associated Pathology Address Associated Pathology Just Better Isn t Generally Enough

What Obstacles Stand In My Way? Incisions/Skin Anchors Heat Nerve Bone Scar

What Do I Need? Bone Resurface Options Allograft Non-Biologic Equipment to Open

My Approach EUA Motion Stability Arthroscopic Exam Posterior and Anterior/Superior Portals Complete Exam Determine Scope vs Open

Scope Revision If the Pathology Lends Itself to an Arthroscopic Approach, There is No Added Advantage to an Open Procedure.

IGHL Suture (#1 PDS) passed through the IGHL from the ant/inf. portal G

Open Revision I have a Very Low Threshold For Proceeding to an Open Approach Glenoid Deficiency Glenoid + Humeral Head Deficiency HAGL

R Shoulder Ant/Sup Portal H A IGHL Neck G P

Large Hill-Sachs Defect

Large Hill-Sachs Defect HemiCAP could plug the defect Can use 25, 30, or 35 mm components

Questions to Ask Why Did the First Surgery Fail? What Must I Do Differently or Better This Time? What Obstacles Stand In My Way? What Do I Need to Do Successful Surgery?

Subjective and Objective Outcome Following Arthroscopic Revision Shoulder Stabilization 20 Consecutive Revisions Compared to 20 Primary Sx s. Using the Same Technique F/U 24 Months (Minimum) No Recurrent Instability in Either Group Revisions Showed Consistently Lower Subjective Results Intra-articular Degenerative Changes Greater with Revisions Conclude: Revisions Don t Do As Well Krueger et al 11

Arthroscopic Revision of Failed 1 Reconstruction 15 Patients 14 Hill-Sachs Lesions 13 CM Ant Glenoid 10 Recurrent Bankart Lesions 9 Capsular Attenuation Revision With Anchors (Av= 2.5) 4 Failures (27%) Ryu and Ryu 11

Arthroscopic Revision of Failed 1 Reconstruction 56 Patients F/U 25-72 Months Anchor Technique- Minimum 3 in Ant/Inf Quadrant Recurrence 11% (6 Shoulders) Patient Rating- 86% Good or Excellent Bartl et al 11

The Latarjet Procedure for Failed Primary Reconstruction(s) 49 Consecutive Patients F/U Mean 38 Months No Recurrent Dislocations 2 Subluxations No Further Surgeries Patient Rating- 88% Good or Excellent Schmid et al 12

Thank You