Spero G. Karas, MD Head Team Physician- Atlanta Falcons Team Physician- Georgia Tech Baseball...

Spero G. Karas, MDHead Team Physician- Atlanta

FalconsTeam Physician- Georgia Tech Baseball

Associate Professor of OrthopaedicsDirector, Orthopaedic Sports Medicine Fellowship

Emory Healthcare Sports Medicine

Labral complex

“Bumper”- deepens glenoid

Attachment of glenohumeral ligaments

Glenohumeral ligaments

SGHL- Rotator intervalMGHL IGHLAnt and post bandsAxillary pouch

Rotator Interval

SGHLCHLBiceps

FOOSH

AbER injury

Direct Trauma

Subluxation vs Dislocation

ER reduction“Popped it in myself”

“Went in and out”

“Load and Shift”

Grade 1- up faceGrade 2- on rimGrade 3- over rim

AbER reproduces symptoms

Posterior force relieves symptoms

Inferior translation

Interval lesion

Resolves in external rotation?

Bankart Lesion

Caps-labral complex off glenoid

Classic lesionTraumatic Dislocators

Bony Bankart Lesion

Bankart lesion with anterior glenoid rim fracture

ALPSA lesion

Healed BankartTension off GH ligaments

Release and repair anatomically

Tear/deficiency of interval capsule

Restraint to inferior translation

Sulcus sign

Humeral Avulsion of Glenohumeral Ligaments

≈10% of patients

Pre-op MRI

Usually open Repair

Recently Arthroscopic

Karas, Spang Arthroscopy 2005

Glenolabral Articular Disruption

Superficial anterior-inferior labral tear

Associated with anterior-inferior articular cartilage injury

Posterior Humeral Head Defect

Increased Dislocation Rate

“Remplissage”

Fills defect with infraspinatus

Plain Film

Orthogonal viewsBony BankartHill Sachs lesion

MRI

Capsular anatomy Bankart v HAGL

Glenoid insufficiency (CT better)

Interval lesion SLAP Arthrogram improves

technique

Recurrence Rates

Skeletally immature: near 100%

<22: 50-85%23-40: 25-50%>40: low

Sling Management

External rotation?S

trengthening program

Bracing?

Indications

Age? Sport? Hill Sachs? In season / pre-season

athlete Full ROM and Strength Brace (If not a thrower) Recurrence:

1.4/athlete/seasonBuss, AJSM, 2004

External Rotation Immobilization

F/U 15 mos Recurrence IR- 30% ER- 0 Recent information not a

favorable… Probably does work better

than internal rotation (Hovelius 1996; Kiviluoto, 1980)

ResultsResults

StudyStudyNN

%f/u%f/uRecurrenceRecurrence

Surgery GroupSurgery GroupRecurrence Recurrence

Nonop.Nonop.GroupGroup

P-valueP-value ClinClinSignifSignif

KirkleyJARS, 1999

4095%

16%(3/19)

47%(9/19)

0.03 31%31%

YESYES

BottoniAJSM, 2002

2488%

10%(1/10)

64%(9/14)

NR 54%54%

YESYES

WintzellJSES, 1999

30100%

20%(3/15)

56%(9/15)

0.03 36%36%

YESYES

Nonoperative Treatment Has a Higher Recurrence

Rate than Arthroscopic Repair

Can arthroscopic instability procedures reproduce open results?

Yes:Caspari, Savoie,

Romeo, Gartsmann No:

Guanche, Walch

DiagnosisHill Sachs, HAGL,

Glenoid Insufficiency Address labral injury Treat capsular

redundancyPlication/ShiftETAC

Interval Closure? Rehabilitation

Open ShiftLubowitz, CORR,

’96○54-60%

Karas, et al, JSES, ‘04○51%

Miller, ASES, ’01○Lateral- 49%○ Vertical- 40%○Medial- 37%

Arthroscopic ShiftSuture Plication- 19%

ETAC- 33%Plication + ETAC- 41%

Used only four tucks and no interval closure

Glenoid deficiency

Bone GraftLaterjet

Multiple dislocations

Large HSL

Laxity ↑↑

Common Injury

Contact Athletes

High Recurrence Rates

Non-operative Management:

Older patients Sport dependent In-season athletes

Arthroscopy Decreases Recurrence Rates

Open Surgery

Multiple Recurrences Large Hill Sachs Glenoid Bone

Deficiency

Thank You ! Spero G. Karas, MDSKaras@emory.edu

www.sperokaras.com