- How common? - How to treat it? - Amazon Web …media-ns.mghcpd.org.s3.amazonaws.com/sports2018/2018...Sports: 87% able to resume the same sport Recurrence: 1.2% I once had an axillary

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

- How common?- How to treat it?

Jon “JP” Warner, MDChief, MGH Shoulder ServiceChair, Quality and Safety MGOAProfessor of OrthopedicsHarvard Medical School


Disclosures Wright Medical: Royalty on Rotator cuff implant; Consultant

IMASCAP: Stock

Smith and Nephew: Fellowship Funding

Arthrex: Fellowship funding

Breg: Fellowship Funding

San Diego Shoulder Institute: BOD


22 yo woman with seizure disorder (no sz in > 1yr)Multiple dislocations: “Too many to count”Worried to put arm away from bodyHad prior failed arthroscopic stabilization


Remplissage

BankartRepair

MRI? (This patient had treatment already….do you think it was successful?



CT SCAN…WITH/WITHOUT DYE?


CT Scan- Which is best view?


CT-Scan with3D reconstruction?


Shoulder Instability Bone Loss

1,720,000 results (0.49 seconds)


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511 publications


Shoulder stabilization in 1994most common stabilization procedures performed in 880 German clinics in 1994

◦ open Bankart 30%

◦ Eden-Hybbinette 28.6%

◦ Weber (Osteotomy) 27.1%

◦ Lange 15.5%

◦ Putti-Platt 13.6%

◦ arthroscopic stabilization 7.5%.

(Jerosch et al. Unfallchirurg. 1994)


Shoulder stabilization in 2008

(Owens et al. AJSM 2011)


1999-2006: 551 Cases

9%

All other instability Rx

2007-2011

30%



Conelly JF: Humeral Head Defects associated with Shoulder dislocation- Their Diagnostic & Surgical SignificanceICL, 1972. Recurrence with Infraspinatus Transfer = 1/15 (7%)


…around 20% (Provencher et al, JAAOS 2009

“”INSIGNIFICANT”“SIGNIFICANT”

“VERY SIGNIFICANT”


ALPSA Lesion has recurrence rate of 19% vs 5% in Bankart repair…- Ozbaydar, Arthroscopy 2008


Beren C. et al: Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review. JSES, 2010

Only 6 articles met inclusion criteria (quantitated bone loss & reported results )

“Chronic glenoid deficiency in the setting of recurrent anterior instability is an extremely challenging problem. There remains a lack of strong evidence guiding the surgeon in the decision-making process.”

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATIONCourtesy G. Wolf

Remplissage: “filling”Trans-tendinous transfer of infraspinatus

Into HS lesion = Arthroscopic “Conelly procedure”


- Courtesy G. Wolf

Wolf, JSES 2013:

2002-2010

59/270 (22%) = glenoid bone loss

4.4% recurrent instability

Rowe score = 95


JBJS-A, 2012 47/459 (10%) underwent Bankart + Remplissage

For Hill-Sachs lesion without glenoid bone loss.

90% return to sport; 9 deg avg loss E.R.



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Gillis Walch


Journées Lyonnaises de l’épaule LYON - 1993

n = 160 cases - FU 4 years

Subjective results: 97% satisfied or very satisfied

Sports: 87% able to resume the same sport

Recurrence: 1.2%

“I once had an axillaryNerve problem…thePatient was upset”- G. Walch


- Courtesy G. Walch


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Open Latarjet

Arthroscopic Bankart

N=26N=28

N=34 N=34

Total Traumatic Anterior Stabilizations = 122

2007 2008 2009 2010

27%

25%50% 62%




Butt C & Charalambous CP: Complications associated with open coracoid transfer

procedures for shoulder instability. JSES 2012

30 Studies reviewed including 1658 Coracoid Process transfers

Reoperation rate = 5%

Recurrent instability = 6%

Hardware complications = 6.5%

Nonunion rate of coracoid = 10%


Recurrent Instability = 8%

Neurologic Injury = 10%

Superficial Infection = 6%

Bone loss + prolonged

retraction


Neuromonitoring the Latarjet Procedure:

A Multicent Study

Annual ASES Meeting, Neer Award, 2014

Ruth Delaney M.D.Michael Freehill, M.D.D.R. Janfaza, M.D.K.V. Vlassakov, M.D.Laurence Higgins, M.D.Jon JP Warner, M.D.

76% HAD AN INTRAOPERATIVE NERVE ALERT

21% HAD A NERVE DEFICIT POSTOP.

All findings resolved within 28-165 days


Lafosse L & Boyle S: Arthroscopic

Latarjet Procedure. JSES, 2010

Early & Late Complications:

Graft Fx/non-union = 5 (5%)

“The all-arthroscopic Latarjet is a reliable but difficult technique, with a steep learning curve “



Warner JJP et al: Anatomical glenoid reconstruction for recurrent

anterior glenohumeral instability with glenoid deficiency using an

autogenous tricortical iliac crest bone graft. AJSM, 2005

11/264 Traumatic Instability Repairs over 3 years


PREOP. EVAL F/U POSTOP. EVAL.

ASES UCLA ROWE ASES UCLA ROWE

40 17 20 60 months 100 35 100

40 12 20 38 months 83 31 90

73 18 15 36 months 100 35 95

82 25 45 32 months 87 34 85

47 12 15 30 months 95 32 90

83 24 45 30 months 100 35 100

60 60 25 29 months 95 33 100

77 19 30 29 months 100 35 100

65 15 25 24 months 75 22 75

80 24 40 24 months 100 35 95

67 21 30 31 months 97 35 95

4 Pro Hockey Players


5 years postop.

5 years postop


JSES, 2014

2006-2011: 11 patients treated with J-Graft for glenoid bone loss < 5%

Rowe score = 85%

Glenoid surface area increased from 96% to 103%


Rim reconstruction with autogenous iliac crest for anterior

glenoid deficiency: forty-three instability cases followed for

5-19 years. Steffen & Hertel, R, JSES 2012

- 48 PATIENTS- Avg F/U = 9.2 years- 8/43 (19%) had residual pain- 4/43 (9%) recurrent instability


Bhatia et al: Comparison of glenohumeral contact pressures and contact areas after glenoidreconstruction with latarjet or distal tibial osteochondral allografts. AJSM 2013

Distal Tibial Osteochondral Allograft

improved joint Congruity…

NORMAL

Tibial allograft


“I am so clever that sometimes I don’t

Understand a single word of what I am saying”

- Oscar Wilde

Documents

- How common? - How to treat it? - Amazon Web …media-ns.mghcpd.org.s3.amazonaws.com/sports2018/2018...Sports: 87% able to resume the same sport Recurrence: 1.2% I once had an axillary