Disclosure Royalities: Arthrosurface Consultant: medi Bayreuth, Med Park Stock option: - Research Support: Arthrex, DFG, AGA, Arthrosehilfe Editorial Board: Arthroskopie, AJSM, AOTS, DZS, EJTrauma, JSES, KSSTA, OBEX, OOTR, Operative Techniques, Sportorthopädie, ZOU OpenAccess Journal Sports Medicine 2018
Why do they dislocate again? n=190 (1996 - 2000) • RTS at preinjury level in 80% • Rowe, Constant, ASES increased • no complications due to 5:30h • overall 9% recurrence Imhoff AB et al., Am J Sports Med 2010 Tischer & Imhoff, Oper Orthop Traumatol. 2007
Epidemiology Overall incidence rate 23.9/100,000/year Zacchilli, Owens, JBJS, 2010 Owens et al., AJSM, 2007
Epidemiology Incidence of first-time anterior dislocation varies from 11 – 23 / 100,000 / year Male : Female = 3 :1 > 40% younger than 22 years High-risk sports • Contact sports (football, rugby, handball, wrestling...) • Boxing • Climbing (subluxations) Leroux et al., AJSM, 2014 Zacchilli, Owens, JBJS, 2010 Kirkley et al., Arthroscopy, 2005 Flatow et al., Orthop Clin North Am, 2000
First time anterior shoulder dislocation Why should we be concerned?
Natural History - Recurrence < 30 y.o. 30-40 y.o. > 40 y.o. Conservative Conservative Conservative < 18 a: ≈ 73% ≈ 20% ≈ 10% < 30 a: ≈ 50% Surgery Surgery Surgery < 18 a: ≈ 17 – 21% ≈ 7 – 15% ≈ 7 – 20% < 30 a: ≈ 7 – 13% Recurrence rate is highest in the young (male) population! Contact and throwing sports as important risk factors! Secondary pathologies with recurrence! Aboalata, Imhoff et al. 2017, Olds et al. 2015, Shymon et al. 2015, Longo et al. 2016, Privitera et al. 2014, Liavaag et al. 2011, Kim et al. 2009, Robinson et al. 2004, Hovelius et al. 1983, Imhoff et al. 2001
Specific Clinical Testing - Hyper-Laxity ? - Direction of Instability ? - SLAP / Pulley-Lesion ?
Specific Imaging - RX (3 Plains) - MRI (i.a. Contrast) - CT (3D Reconstruction)
Bankart Lesion Woertler & Waldt, Eur Radiol, 2006
SLAP V (Bankart- & SLAP-II-Lesion)
SLAP V (Bankart- & SLAP-II-Lesion)
SLAP V (Bankart- & SLAP-II-Lesion)
Concomitant lesions of the capsular-labral complex HAGL ALPSA GLAD Perthes Woertler und Waldt (2006) Eur Radiol
Imaging - MRI Gold standard to detect capsulo-labral tears • +/- contrast enhancement (not needed in the acute phase – hemarthrosis) HAGL Humeral avulsion of glenohumeral ligaments Woertler, Waldt, Eur Radiol, 2006 Bui-Mansfield et al., AJSM, 2007
Positioning of the 5: 30 - portal Coracoid 5:30- portal Acromion 8-10 cm • Via the inferior third x of the SSC 2,4 cm distance to • the axillary nerve • 1,4 cm distance to the circumflex artery Tischer, Imhoff et al, OOT, 2007
17
Imhoff, Feucht, Atlas sportorthopädisch-sporttraumatologische Operationen, Springer 2013
19 Imhoff, Feucht, Atlas sportorthopädisch-sporttraumatologische Operationen, Springer 2013
Munich - Results 1996-2000 • Ask. anteroinferiore Stabilisierung 1996 – 2000 190 patients; FU: 37,4 month; age at surgery: 28 y • ROWE: 32,2 88 • • High differences concerning redislocation in different anchors best: 6,5% in Fastak (9/138/190) • No complications due to the 5:30h portal • • Return to preop sporting level: >95% leisure level 50% professional level 80% returned to the same level
Munich-Results after Revision Surgery 2011 significant improvement in Rowe and Constant score (pre-OP vs. post-OP) improvement independent of index procedure (Asc. vs. open) 86% rated result as excellent or good no loss of external rotation or SSC-function after revision 80% achieved return to sports after mean of 9 months (5-13 months) 76% returned to previous level with little or no limitation Arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability. Bartl C, Schumann K, Paul J, Vogt S, Imhoff AB. Am J Sports Med. 2011, 39:511-8.
Imaging - CT +/- CT-Arthrography • To determine and evaluate glenoidal/humeral bone loss (3D-CT!) • Dysplasia, glenoid retroversion • CT-A for cartilaginous lesions
Glenoid bone loss Sizing CT (MRT) 20% = „small“ > 20% = „large“ Saliken et al., BMC Musculoskeletal Disorders, 2015 Spiegl, Braun, Imhoff et al., Unfallchirurg 2014 Sugaya et al., JBJS Am 2003
Glenoid bone loss Glenoid bone loss as small as 2-mm width of the anterior margin of the glenoid or average per cent bone loss of 7.5 % of the glenoid results in a significant decrease in force prior to dislocation Shin et al., KSSTA 2014
Glenoid bone loss n=8 cadaveric shoulders ... glenoid defects of 15% or more should be considered the critical bone loss amount at which soft tissue repair cannot restore glenohumeral translation , restricts rotational range of motion, and leads to abnormal humeral head position. Shin et al., Am J Sports Med. 2016
Glenoid Defect - Latarjet Snowboarder 23 y first dislocation 2011, 2 x a‘scopic stabilisation 2011/13 Again dislocation while snowboarding 2014 preoperative CT, A: parasagittal view glenoid defect (25%)
Glenoid Defect - Latarjet
Latarjet
Latarjet
Latarjet
Engaging or not ? Hill-Sachs-lesion 57,5% following index dislocation 94,5% following redislocation 77-100% following recurrent redislocation Engaging Non-Engaging Rowe et al., JBJS Am 1984 Burkhart et al., Arthroscopy 2000 Kim et al., AJSM 2010 7 % engaging – indication for surgery
Imaging – MRI – (Bipolar) Bone Loss Engaging Non-engaging Burkhart, DeBeer, Arthroscopy, 2000 Imhoff, Feucht, Surgical Atlas of Sports Orthopaedics and Sports Traumatology, 2015
Localisation ... the more medial, the more enganging ... Kurokowa et al., JSES 2013
Imaging – MRI – (Bipolar) Bone Loss Off-track On-track Locher, Imhoff et al., Arthroscopy, 2016; Gyftopolous et al, Am J Radiol, 2015, Di Giacomo, Arthroscopy, 2014
Risk factor: Off-track Arthroscopy. 2016 n=100 recurrence at 22 months FU
Glenoid defect & Hill-Sachs: Remplissage Imhoff, et al., Springer, 2012 Connolly et al. Instr. Course Lect 1972 Purchase, Wolf et al. Arthroscopy 2008 Zhu et al. AJSM 2011
Glenoid defect & Hill-Sachs: OATS / Allograft 28y male soccer player several dislocations since 3 years Tx: filled HillSachs + Latarjet Kropf und Sekiya Arthroscopy 2007 Shah et al. Arthroscopy 2011
Glenoid defect & Hill-Sachs: Partial Eclipse Epileptic 34y, 2 x asc. Stabilization, new dislocation Tx: 2 step procedure 1. Asc, Hemicap 2. Latarjet
Glenoid defect & Hill-Sachs: Partial Eclipse 11.11.15 30.03.16
Return to activity after arthroscopic bankart repair in chronic glenohumeral instability Inclusion: • Instability after traumatic dislocation • Time to surgery > 12 months • FU > 24 months Exclusion: • Bony deficiency glenoid > 20% • Rotator cuff lesion OA (> I ° Samilson) •
Return to activity after arthroscopic bankart repair in chronic glenohumeral instability • 66 / 81 patients with chronic instab. (> 12m) • 2/ 2008-8/ 2010 / / FU: 43 months • Tegner scale: 6,3 -> 6,1 ; DASH: 6,9 • Re-dislocation rate: 9% • Return to same level overhead sports: 79% contact-Sport: 82% • No increase of frequency, time, level or riskfactors (p> 0.05) • Reasons: 59% - not associated by the shoulder 22% - afraid about redislocation/ no appreh. 19% - some pain or instability Imhoff AB et al. Am J Sports Med. 2014
Return to activity after arthroscopic bankart repair in chronic glenohumeral instability Subjective sport activity • 66% - increased • 26% - equal • 8% - less Increase of Low risk sports: • Biking • Hiking • Fitness / Gym
13 y follow-up after Bankart Repair in 100 Sho. • 21% recurrent dislocation • 31% no signs OA, 41% mild signs, 16% moderate • 12% severe OA – no correlation with Constant Sc. Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Longterm Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13 years Follow-up Plath, Aboalata, Seppel, Juretzko, Waldt, Vogt, Imhoff Am J Sports Med. 2015: 1084-90
13 y follow-up after Bankart Repair in 100 Sho. OA sig. associated with • # of preop. disloc. • Age at initial disloc. • Age at surgery • Number of anchors (= amount of primary trauma) OA no significance • Time between disloc. and surgery ER deficit at 0 ° and 90 ° ABD • • Recurrent dislocation Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Longterm Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13 years Follow-up Plath, Aboalata, Seppel, Juretzko, Waldt, Vogt, Imhoff Am J Sports Med. 2015: 1084-90
Quality of Life – 2y after asc. Bankart Repair
Quality of Life – 2y after asc. Bankart Repair Weighted sum score [Reference: 65] preop 66 6w 57 * 12w 62 6m 73 12m 78 24m 75 *preop vs 12m postop p<.001 How satisfied are Patients with Asc. Bankart Repair? A 2y fup on Quality of Life outcome Saier T,.....Imhoff A., Arthroscopy 2017
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